Increased soluble leptin receptor levels in morbidly obese patients with insulin resistance and nonalcoholic fatty liver disease

The adipocyte hormone, leptin has been demonstrated to have profibrogenic actions in vitro and in animal models. However, no correlation was found between plasma leptin levels and fibrosis stage in humans. Thus, our aim was to study whether soluble leptin receptor (SLR) or free leptin index (FLI; calculated as the ratio of leptin to SLR), may correlate better with the features of metabolic syndrome and with the histological grade and stage of nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH). We studied a population (n = 104) of morbidly obese patients undergoing bariatric surgery. Data including BMI, type 2 diabetes mellitus, hypertension, and hyperlipidemia were obtained. Plasma fasting leptin and SLR, fasting glucose and insulin were measured, and homeostasis model of assessment insulin resistance (HOMA(IR)) index and FLI were calculated. All patients had intraoperative liver biopsies. Leptin levels correlated with the BMI. The multiple regression analysis indicated that increasing HOMA and decreasing FLI were predictors of steatosis in the liver (P < 0.0003). SLR levels were positively correlated with the presence of diabetes mellitus and the stage of fibrosis. In conclusion, increased SLR levels in morbidly obese patients with diabetes are correlated with the stage of liver fibrosis, and may reflect progressive liver disease.

De novo nonalcoholic fatty liver disease after liver transplantation

Hepatic steatosis is a recognized problem in patients after orthotopic liver transplant (OLT). However, de novo development of nonalcoholic fatty liver disease (NAFLD) has not been well described. The aim of this study was to determine the prevalence and predictors of de novo NAFLD after OLT. A retrospective analysis was performed on 68 OLT patients with donor liver biopsies and posttransplantation liver biopsies. Individual medical charts were reviewed for demographics, indication for OLT, serial histology reports, genotypes for hepatitis C, comorbid conditions, and medications. Liver biopsies were reviewed blindly and graded according to the Brunt Scoring System. Multivariate logistic regression analysis was used to study the risk factors for developing NAFLD. The interval time from OLT to subsequent follow-up liver biopsy was 28 +/- 18 months. A total of 12 patients (18%) developed de novo NAFLD, and 6 (9%) developed de novo NASH. The regression model indicated that the use of angiotensin-converting enzyme inhibitors (ACE-I) was associated with a reduced risk of developing NAFLD after OLT (odds ratio, 0.09; 95% confidence interval, 0.010-0.92; P = 0.042). Increase in body mass index (BMI) of greater than 10% after OLT was associated with a higher risk of developing NAFLD (odds ratio, 19.38; 95% confidence interval, 3.50-107.40; P = 0.001). In conclusion, de novo NAFLD is common in the post-OLT setting, with a significant association with weight gain after transplant. The use of an ACE-I may reduce the risk of developing post-OLT NAFLD.

Symptoms, gastric function, and psychosocial factors in functional dyspepsia

INTRODUCTION

The classification of functional dyspepsia into meaningful subgroups remains an important goal. The aim of this investigation was to determine correlations between dyspeptic symptoms with gastric physiology and psychologic distress.

METHODS

Consecutive patients with functional dyspepsia were evaluated with electrogastrography (EGG), drink test, and solid phase gastric emptying. Subjects also completed the Nepean Dyspepsia Index, Psychologic General Well-Being Index, SCL-90R, and SF-36.

RESULTS

Eighty-one patients were evaluated. Gastric emptying was performed in 29 of 81 patients and was abnormal in 21%, but no correlation existed between symptoms and T1/2 or TLAG. EGG was abnormal in 42% and drink test was abnormal in 40% of patients. Both were significantly associated with nausea but not with other symptoms. Significant correlations existed with 10 of 15 assessed symptoms and various subscales of the SCL-90R. Somatization was associated with abdominal burning, chest pain, abdominal pressure, abdominal discomfort, bad breath, chest burning, excessive fullness, bloating, abdominal pain, and regurgitation. Anxiety was associated with abdominal burning, chest pain, abdominal pressure, and abdominal discomfort. Anger-hostility was associated with abdominal burning and abdominal pressure. Increased interpersonal sensitivity was associated with abdominal burning and chest burning. SCL-90R Global Symptom Score was associated with abdominal burning, chest pain, abdominal discomfort, and bad breath.

CONCLUSIONS

Abnormal gastric physiology as measured in this study was not associated with symptoms other than nausea. Significant associations existed between measures of psychiatric distress and digestive symptoms. Symptoms in functional dyspepsia had greater associations with psychologic distress than with commonly employed tests of gastric physiology.

A systematic review of surgical therapy for gastroparesis

Gastroparesis is characterized by delayed gastric emptying in the absence of obstruction. Common symptoms include nausea, vomiting, and abdominal pain. Severe gastroparesis might result in recurrent hospitalizations, malnutrition, and significant mortality. Patients failing medical therapy are often considered for a variety of surgical interventions, the efficacy of which is not well studied. This review summarizes available literature on surgical interventions in gastroparesis. A MEDLINE search for the period from 1966 to 2002 was performed to identify all English language literature regarding surgical interventions in gastroparesis. Therapies reviewed were gastrostomy, jejunostomy, gastric pacing/stimulation, and gastrectomy or surgical drainage procedures. Candidate studies involved human subjects and included surgical series or trials. The search was conducted independently by two authors and discrepancies resolved by consensus opinion. Seventeen articles met inclusion criteria. These included series reporting on gastrostomy (2), jejunostomy (3), gastric stimulation (2), and gastrectomy for postsurgical (6), diabetic (3), and idiopathic (1) gastroparesis. All trials were unblinded, uncontrolled case series or retrospective reviews. Methodologic differences did not allow for pooled analysis. Completion gastrectomy seems to provide symptom relief in postsurgical gastroparesis. Benefits of gastric surgery for other forms of gastroparesis are not adequately studied. Gastrostomy might provide symptom improvement, but only 26 subjects in two trials were evaluable. Jejunostomy improved symptoms and nutrition in 32 evaluable subjects in three trials but had significant complications. Gastric neurostimulation improves symptoms of nausea and vomiting, but therapeutic gain beyond placebo has not been demonstrated. Limited data exist concerning surgical therapies of gastroparesis. Completion gastrectomy seems effective for postsurgical gastroparesis, but a cautious approach is warranted before surgical therapies in diabetic or idiopathic gastroparesis are used.

Oral erythromycin and symptomatic relief of gastroparesis: a systematic review

OBJECTIVE

Erythromycin is a motilin agonist that greatly increases the fractional rate of gastric emptying. Although a number of studies document the efficacy of erythromycin in improving gastric emptying, little information exists concerning symptom improvement in patients with gastroparesis. The aim of this study was to review clinical trials of erythromycin to determine the efficacy of this agent in producing symptom relief in patients with gastroparesis.

METHODS

A MEDLINE search from 1966 to 2001 was performed to identify all clinical trials using erythromycin in patients with gastroparesis. The search was further limited to clinical trials using symptom assessment as an endpoint. References from index citations were reviewed to identify additional studies. The search was conducted independently by two authors, and discrepancies were resolved by consensus opinion.

RESULTS

Thirty-five clinical trials were identified, and five met inclusion criteria. One study each involved gastroparesis caused by surgery and systemic sclerosis. Three studies evaluated patients with diabetic or idiopathic gastroparesis. No study used symptoms as a primary endpoint. Improvement was reported in 26 of 60 (43%) patients. Individual symptom scores were available for 23 of 60 subjects in these studies, and symptom improvement was seen in 11 of 23 (48%) patients. One study compared erythromycin and metoclopromide in an open-label, crossover fashion, and found no difference between the two agents. All studies were methodologically weak and highly subject to bias. Four of five studies were open-label trials. Sample sizes in all studies were < or =13 subjects, and treatment duration was < or =4 wk in all studies.

CONCLUSIONS

Although clearly a potent prokinetic, limited data exist concerning efficacy of erythromycin in treating gastroparesis. Small sample sizes, uncontrolled designs, short duration, and inadequate symptom assessment limit available studies. Well-designed trials designed to assess symptom relief in gastroparesis are needed.

Viral hepatitis and other infectious diseases in a homeless population

GOALS

To determine the prevalence of four common infectious diseases-hepatitis B, hepatitis C, human immunodeficiency virus (HIV), and tuberculosis-as well as co-infection rates and risk factors in a homeless population.

BACKGROUND

The prevalence of infectious diseases, especially viral hepatitis, among the homeless population is largely unknown.

STUDY

This study consists of a retrospective analysis of the history and laboratory data collected from all homeless veterans admitted to a Veterans Administration (VA) domiciliary from May 1995 to March 2000.

RESULTS

Of the homeless veterans admitted to a VA domiciliary program, 597 of 829 were screened for markers of all four infectious diseases. The overall prevalence of anti-hepatitis C virus (HCV) antibody, and positive result for purified protein derivative (PPD), anti-HIV antibody, and hepatitis B surface antigen (HbsAg) were 41.7%, 20.6%, 1.84% and 1.17%, respectively. At least one of the four markers was positive in 52.6% and more than one in 12%. Co-infection with HCV occurred commonly in veterans who were positive for anti-HIV (72.7%) and HBsAg (57.1%). Four self-reported major risk factors (intravenous drug use, alcohol abuse, previous imprisonment, and prior stay in a shelter) were evaluated. Multivariate analysis indicates that intravenous drug use and anti-HBs reactivity are independent risk factors for HCV infection, HCV infection for anti-hepatitis B surface antibody reactivity, and older age for PPD positivity.

CONCLUSIONS

Chronic hepatitis C and co-infections are common among the homeless population. Patients infected with HIV and hepatitis B virus frequently are co-infected with HCV. Infections frequently are associated with certain identifiable risk factors.

Transcoronary and pulmonary vascular dynamics of endothelin-1 in heart transplant recipients

BACKGROUND

Endothelin-1, a potent endothelium-derived vasoconstrictor peptide, has recently been shown to be elevated in heart transplant recipients and may be a participant in posttransplantation vasculopathy.

METHODS

We measured peripheral venous endothelin-1 concentrations in eight heart transplant recipients and eight age- and gender-matched healthy controls. Subsequently, in 21 transplant recipients, right atrial, aortic, and coronary sinus plasma was obtained and endothelin-1 levels were measured. Potential correlations to donor and recipient age, cyclosporine levels, hemodynamic parameters, donor heart ischemic time, time from transplantation, and serum creatinine were examined. In eight more patients, right atrial levels of endothelin-1 were measured before and after endomyocardial biopsy to examine the effect of this procedure on endothelin-1 concentrations.

RESULTS

Peripheral endothelin-1 concentrations were significantly higher in heart transplant recipients (45.6 +/- 1.8 versus 25.8 +/- 2.3, p < 0.001). Multiple regression analysis showed a significant correlation between right atrial endothelin-1 and pulmonary artery systolic pressure (r = 0.48), as well as serum creatinine (r = 0.52). No relation to blood pressure, right atrial pressure, pulmonary vascular resistance, recipient age, cyclosporine levels, or donor heart ischemic time was observed. In 11 patients, a 38% +/- 7% fall in endothelin-1 levels across the pulmonary bed was observed, suggesting extraction across the lung in these subjects. Nine patients had net release of endothelin-1 (95% +/- 26% rise) across the coronary vascular bed, whereas 12 patients showed net extraction (24% +/- 4% fall). Endomyocardial biopsy had no influence on endothelin-1 levels (prebiopsy: 48.3 +/- 1.7; postbiopsy: 42.3 +/- 2.34; p = Not significant).

CONCLUSION

These findings suggest that endothelin-1 levels in transplant recipients may be influenced by renal function and may contribute to pulmonary hypertension. The significance of transcardiac release of endothelin in some patients is unclear: further studies are needed to determine the pathophysiologic significance of endothelin-1 in heart transplant recipients.