miR135a administration ameliorates brain ischemic damage by preventing TRPM7 activation during brain ischemia

BACKGROUND

miRNA-based strategies have recently emerged as a promising therapeutic approach in several neurodegenerative diseases. Unregulated cation influx is implicated in several cellular mechanisms underlying neural cell death during ischemia. The brain constitutively active isoform of transient receptor potential melastatin 7 (TRPM7) represents a glutamate excitotoxicity-independent pathway that significantly contributes to the pathological Ca2+ overload during ischemia.

AIMS

In the light of these premises, inhibition of TRPM7 may be a reasonable strategy to reduce ischemic injury. Since TRPM7 is a putative target of miRNA135a, the aim of the present paper was to evaluate the role played by miRNA135a in cerebral ischemia. Therefore, the specific objectives of the present paper were: (1) to evaluate miR135a expression in temporoparietal cortex of ischemic rats; (2) to investigate the effect of the intracerebroventricular (icv) infusion of miR135a on ischemic damage and neurological functions; and (3) to verify whether miR135a effects may be mediated by an alteration of TRPM7 expression.

METHODS

miR135a expression was evaluated by RT- PCR and FISH assay in temporoparietal cortex of ischemic rats. Ischemic volume and neurological functions were determined in rats subjected to transient middle cerebral artery occlusion (tMCAo) after miR135a intracerebroventricular perfusion. Target analysis was performed by Western blot.

RESULTS

Our results demonstrated that, in brain cortex, 72 h after ischemia, miR135a expression increased, while TRPM7 expression was parallelly downregulated. Interestingly, miR135a icv perfusion strongly ameliorated the ischemic damage and improved neurological functions, and downregulated TRPM7 protein levels.

CONCLUSIONS

The early prevention of TRPM7 activation is protective during brain ischemia.

Preconditioning in hypoxic-ischemic neonate mice triggers Na+-Ca2+ exchanger-dependent neurogenesis

To identify alternative interventions in neonatal hypoxic-ischemic encephalopathy, researchers’ attention has been focused to the study of endogenous neuroprotective strategies. Based on the preconditioning concept that a subthreshold insult may protect from a subsequent harmful event, we aimed at identifying a new preconditioning protocol able to enhance Ca²⁺-dependent neurogenesis in a mouse model of neonatal hypoxia ischemia (HI). To this purpose, we also investigated the role of the preconditioning-linked protein controlling ionic homeostasis, Na⁺/Ca²⁺ exchanger (NCX). Hypoxic Preconditioning (HPC) was reproduced by exposing P7 mice to 20’ hypoxia. HI was induced by isolating and cutting the right common carotid artery. A significant reduction in ischemic damage was observed in mice subjected to 20’ hypoxia followed,3 days later, by 60’ HI, thus suggesting that 20’ hypoxia functions as preconditioning stimulus. HPC promoted neuroblasts proliferation in the dentate gyrus mirrored by an increase of NCX1 and NCX3-positive cells and an improvement of behavioral motor performances in HI mice. An attenuation of HPC neuroprotection as well as a reduction in the expression of neurogenesis markers, including p57 and NeuroD1, was observed in preconditioned mice lacking NCX1 or NCX3. In summary, PC in neonatal mice triggers a neurogenic process linked to ionic homeostasis maintenance, regulated by NCX1 and NCX3.

Sodium/calcium exchanger as main effector of endogenous neuroprotection elicited by ischemic tolerance

The ischemic tolerance (IT) paradigm represents a fundamental cell response to certain types or injury able to render an organ more "tolerant" to a subsequent, stronger, insult. During the 16th century, the toxicologist Paracelsus described for the first time the possibility that a noxious event might determine a state of tolerance. This finding was summarized in one of his most important mentions: "The dose makes the poison". In more recent years, ischemic tolerance in the brain was first described in 1991, when it was demonstrated by Kirino and collaborators that two minutes of subthreshold brain ischemia in gerbils produced tolerance against global brain ischemia. Based on the time in which the conditioning stimulus is applied, it is possible to define preconditioning, perconditioning and postconditioning, when the subthreshold insult is applied before, during or after the ischemic event, respectively. Furthermore, depending on the temporal delay from the ischemic event, two different modalities are distinguished: rapid or delayed preconditioning and postconditioning. Finally, the circumstance in which the conditioning stimulus is applied on an organ distant from the brain is referred as remote conditioning. Over the years the "conditioning" paradigm has been applied to several brain disorders and a number of molecular mechanisms taking part to these protective processes have been described. The mechanisms are usually classified in three distinct categories identified as triggers, mediators and effectors. As concerns the putative effectors, it has been hypothesized that brain cells appear to have the ability to adapt to hypoxia by reducing their energy demand through modulation of ion channels and transporters, which delays anoxic depolarization. The purpose of the present review is to summarize the role played by plasmamembrane proteins able to control ionic homeostasis in mediating protection elicited by brain conditioning, particular attention will be deserved to the role played by Na⁺/Ca²⁺ exchanger.

Triple-layer Mesh Plasty for Re-recurrent Ventral Hernia in a Liver Transplant Patient: A Case Report

Ventral hernias often occur in transplanted patients because of weakness of the abdominal wall, poor muscle mass, and ascitis. In this report we describe the case of a re-recurrent ventral hernia seen emergently in a liver transplant recipient, who was treated using a singular 3-layer approach by placement of an intraperitoneal mesh, stressing technical aspects of the plasty as well as the importance of a sublay technique in the reinforcement of a previous prosthetic plasty.

Antifungal prophylaxis with liposomal amphotericin B and caspofungin in high-risk patients after liver transplantation: impact on fungal infections and immune system

Antifungal prophylaxis may be required in high-risk patients undergoing liver transplantation and for that reason we aimed to verify its role and its related impact on the graft. From January 2006 throughout 2012, 250 liver transplants were evaluated and 54 patients identified as being at higher risk were randomly selected to undergo the following schedule: 28 patients received liposomal amphotericin B and 26 received caspofungin. We evaluated, throughout 12 months, renal and liver function tests, bacterial and fungal infection episodes, and intensive care unit (ICU) stay, as well as the Th1 and Th2 cytokine network. Differences were analyzed according to non-parametric tests (two-tailed p values). Neither of the groups showed episodes of invasive fungal infection during the 12 months follow-up; however, patients receiving prophylaxis with liposomal amphotericin B had reduced episodes of bacterial infections coupled with an improved immune system response compared with those receiving caspofungin. Finally, a reduced stay in the ICU was also observed. In conclusion, even if the results of liposomal amphotericin B and caspofungin prophylaxis strategies did not differ in terms of invasive fungal infection rate, patients receiving prophylaxis with liposomal amphotericin B had a reduced ICU stay and an improved Th2 status, as well as a reduced number of post-transplant bacterial infections. Further studies are required to better address and evaluate these findings.

Genetic ablation of homeodomain-interacting protein kinase 2 selectively induces apoptosis of cerebellar Purkinje cells during adulthood and generates an ataxic-like phenotype

Homeodomain-interacting protein kinase 2 (HIPK2) is a multitalented coregulator of an increasing number of transcription factors and cofactors involved in cell death and proliferation in several organs and systems. As Hipk2^−/− mice show behavioral abnormalities consistent with cerebellar dysfunction, we investigated whether Hipk2 is involved in these neurological symptoms. To this aim, we characterized the postnatal developmental expression profile of Hipk2 in the brain cortex, hippocampus, striatum, and cerebellum of mice by real-time PCR, western blot analysis, and immunohistochemistry. Notably, we found that whereas in the brain cortex, hippocampus, and striatum, HIPK2 expression progressively decreased with age, that is, from postnatal day 1 to adulthood, it increased in the cerebellum. Interestingly, mice lacking Hipk2 displayed atrophic lobules and a visibly smaller cerebellum than did wild-type mice. More important, the cerebellum of Hipk2^−/− mice showed a strong reduction in cerebellar Purkinje neurons during adulthood. Such reduction is due to the activation of an apoptotic process associated with a compromised proteasomal function followed by an unpredicted accumulation of ubiquitinated proteins. In particular, Purkinje cell dysfunction was characterized by a strong accumulation of ubiquitinated β-catenin. Moreover, our behavioral tests showed that Hipk2^−/− mice displayed muscle and balance impairment, indicative of Hipk2 involvement in cerebellar function. Taken together, these results indicate that Hipk2 exerts a relevant role in the survival of cerebellar Purkinje cells and that Hipk2 genetic ablation generates cerebellar dysfunction compatible with an ataxic-like phenotype.

A Bayesian methodology to improve prediction of early graft loss after liver transplantation derived from the liver match study

BACKGROUND

To generate a robust predictive model of Early (3 months) Graft Loss after liver transplantation, we used a Bayesian approach to combine evidence from a prospective European cohort (Liver-Match) and the United Network for Organ Sharing registry.

METHODS

Liver-Match included 1480 consecutive primary liver transplants performed from 2007 to 2009 and the United Network for Organ Sharing a time-matched series of 9740 transplants. There were 173 and 706 Early Graft Loss, respectively. Multivariate analysis identified as significant predictors of Early Graft Loss: donor age, donation after cardiac death, cold ischaemia time, donor body mass index and height, recipient creatinine, bilirubin, disease aetiology, prior upper abdominal surgery and portal thrombosis.

RESULTS

A Bayesian Cox model was fitted to Liver-Match data using the United Network for Organ Sharing findings as prior information, allowing to generate an Early Graft Loss-Donor Risk Index and an Early Graft Loss-Recipient Risk Index. A Donor-Recipient Allocation Model, obtained by adding Early Graft Loss-Donor Risk Index to Early Graft Loss-Recipient Risk Index, was then validated in a distinct United Network for Organ Sharing (year 2010) cohort including 2964 transplants. Donor-Recipient Allocation Model updating using the independent Turin Transplant Centre dataset, allowed to predict Early Graft Loss with good accuracy (c-statistic: 0.76).

CONCLUSION

Donor-Recipient Allocation Model allows a reliable donor and recipient-based Early Graft Loss prediction. The Bayesian approach permits to adapt the original Donor-Recipient Allocation Model by incorporating evidence from other cohorts, resulting in significantly improved predictive capability.

Conjunctival instillation of plasminogen eliminates ocular lesion in B6.129P2-Plg(tm1Jld) transgenic mice, a model of ligneous conjunctivitis

Ligneous conjunctivitis is a severe and rare chronic "idiopathic membraneous" conjunctivitis, characterized by the formation of pseudomembranes mostly on the palpebral surfaces that progressively replace the normal mucosa. Evidence has been provided that ligneous conjunctivitis is caused by a severe systemic plasminogen deficiency with decreased plasminogen antigen and decreased plasminogen functional activities. Objective of the present study is to verify the hypothesis that a topical eye application of plasminogen is able to ameliorate the consequences of this disease. Here we report the results of pre-clinical studies performed to investigate the therapeutic effectiveness of an eye-drop plasminogen preparation in B6.129P2-Plg(tm1Jld) transgenic mice, a model of ligneous conjunctivitis. The entity of protection mediated by plasminogen was evaluated by measuring the extent of the eye lesion by means of a computerized system and dedicated software. The results of the present study clearly showed that the administration for six times a day of plasminogen eye-drop solution in the lesioned eye of animals knock-out for plasminogen gene and developing ligneous conjunctivitis caused a dose and time related reduction of the extent of the ocular lesion. These findings may pave the road for the pharmacological treatment of the ocular lesion associated to the ligneous conjunctivitis that at the present is surgically treated by removing the pseudomembranes generated on the eye.

Side-to-side cavocavostomy in adult piggyback liver transplantation

OBJECTIVE

Our objective was to perform a retrospective study that described the anastomosis technique as well as the complications of side-to-side cavo-caval reconstruction.

PATIENTS AND METHODS

From June 1998 to April 2011, we performed 284 liver transplantations including 10 adults with live donor organs. In all cases but 2 (272), cavo-caval reconstruction was performed using side-to-side cavo-caval (STSCC) anastomosis. In 19 cases (6.9%), we also carried out an end-to-side temporary porto-caval shunt (TPCS). In 17 cases (6.2%) the technique was performed for retransplantation.

RESULTS

STSCC anastomosis was technically feasible in all but 2 cases, regardless of the recipient's vena cava, anatomic factors, or graft size. Mean operative time for the STSCC was 13 minutes (range, 6-25). Routine Doppler ultrasonography was performed intraoperatively at the end of the surgery. There was no case of cava stump thrombosis. Complications associated with this technique were limited to 2 patients. One complication was torsion due to donor graft/recipient mismatch, which was successfully treated surgically by falciform ligament fixation. The second complication was only evident by sinusoidal congestion and was managed nonoperatively. Seventeen cases were uneventful for retransplant recipients.

CONCLUSIONS

STSCC during piggyback liver transplantation is safe and can be performed in the retransplantation setting, with a low incidence of venous outflow obstruction that can be associated with the traditional piggyback technique. Our data suggest that donor graft to recipient mismatch is not an absolute contraindication when proper body size match is considered. A wide anastomosis with typical recipient hepatic vein inclusion is warranted with routine postanastomotic Doppler ultrasonography.

[Traumatic rupture of hepatic hydatid cyst]

Hydatid disease is endemic in some areas of the world. It is located mostly in the liver. The cysts rupture is possible after a trauma, or spontaneously by the increase of intracystic pressure. Rupture of the hydatid cyst requires urgent surgical intervention. We report our experience in treatment of traumatic rupture of hepatic hydatid cyst.

Elevated CD4+/CD25+ T-cell frequency and function during hepatitis C virus recurrence after liver transplantation

BACKGROUND/AIM

Factors involved in hepatitis C virus (HCV) recurrence versus acute cellular rejection are not fully understood. The aim of the present study was to investigate whether patients with recurrence after liver transplantation (OLT) showed similar CD4(+)/CD25(+) cell frequency and function as those who became chronically infected.

PATIENTS AND METHODS

After written informed consent, we enrolled 20 patients (group A) who underwent OLT with HCV recurrence within 6 months. HCV-RNA and hypertransaminasemia were used to assess the reactivation of viral hepatitis. CD4(+)/CD25(+) T cells were enumerated using a flow cytometry assay, gated on CD3 cells, stained for FoxP3. After immunomagnetic sorting (Dynal, Oslo, NW), Treg suppressor activity was measured, as the ability to inhibit proliferation of autologous CD4(+)/CD25(-) T cells (anti-CD3/CD28 stimulation-1:2, 1:20 ratio). Eight patients with acute hepatitis C who evolved to a chronic infection after 6 months (group B) were used as positive controls, while 10 healthy individuals were negative controls (group C).

RESULTS

We did not observe any difference in CD4(+)/CD25(+) frequency or function among group A compared with group B (CD4(+)/CD25(+) = 14% +/- 2% versus CD4(+)/CD25(+) = 16% +/- 3%), although both groups were significantly increased with respect to group A (CD4(+)/CD25(+) = 6% +/- 3%; Mann-Whitney U test, P < .01).

CONCLUSION

Patients developing HCV recurrence after OLT have the same immunoregulatory network as patients with acute hepatitis C evolving to persistent infection, likely suggesting that CD4(+)/CD25(+) numbers may be a marker to predict recurrence of HCV after OLT.

Model for End-Stage Liver Disease (MELD) score system to evaluate patients with viral hepatitis on the waiting list: better than the Child-Turcotte-Pugh (CTP) system?

BACKGROUND

The Model for End-Stage Liver Disease (MELD), based on creatinine, bilirubin, and International normalized ratio (INR), has been shown to be superior to the Child-Turcotte-Pugh (CTP) score in predicting 3-month mortality among patients on the transplant waiting list due to end-stage liver disease (ESLD). An additional advantage of MELD is the possibility to add "adjustment points" for exceptional patients at risk for death because of liver disease not identified by changes in the used parameters, as occurs in the case of hepatocellular carcinoma (HCC). Although it is useful, MELD has some important limitations: There are no differences for patients with or without ascites, and for the absence of other laboratory parameters involved in the etiology of disease. In this study, we evaluated dropouts of patients on the waiting list for orthotopic liver transplantation (OLT) based upon the characteristics of these subjects before and after introduction of the MELD score.

METHODS

All patients on the OLT waiting list from June 1, 2006 to June 30, 2007 were enrolled in the MELD group (A) and evaluated with CHILD and MELD score, while those listed from January 1, 2004 to May 31, 2005 were enrolled in pre-MELD group (B) to be evaluated with CHILD. In these subjects we assessed the drop out frequency and waiting time and we compared the results to assess possible differences (U Mann-Whitney Test; P<.05).

RESULTS

The total number of patients included in this study was 176: 116 patients in Group A and 60 in Group B. We had a drop-out frequency of 21% with a median of 9+/-6 S.E. months in Group A, while 9% with a median of 15+/-8 months S.E. in Group B. The dropout frequencies were as follows: Group A--16 deaths (1 HCC--15 disease complications) while in Group B we had 13 drop outs, 10 exitus (4 HCC and 6 disease complications) and three exclusions for nonmedical reasons. In Group A we had a higher number of deaths due to disease complications than in group B (P<.05). Further, we had 32 OLTx in Group A and 45 in Group B. Survival rate did not show any differences between the two groups while number needed to harm was 11.

CONCLUSIONS

The use of MELD score in this group of patients produced an advantage for HCC, but seemed to cutoff patients with viral hepatitis complications during the waiting time. Particularly, about one in every 11 patients may receive an harm using this score system. Other parameters should be introduced as adjustment points to make the MELD score suitable also for patients with infectious liver diseases.

Evidence of liver histological alterations in apparently healthy individuals evaluated for living donor liver transplantation

BACKGROUND

Living donor liver transplantation (LDLT) represents an important therapeutic option for patients with end-stage liver disease (ESLD). It has been reported that steatosis may be a serious problem in patients who donate a part of their liver. Liver biopsy represents an accepted method to assess the rate of steatosis and the possible risk to the donor. Nonetheless, some histological abnormalities have been documented in the specimens from potential donors. The aim of this study was to evaluate the possible hepatic histological alterations among apparently healthy candidates for liver donation who did not show serological or ultrasound (US) evidence.

MATERIALS AND METHODS

From January 1, 2005 until October 15, 2006, we performed virological, biochemical, and tumor marker evaluations and liver biopsies on 20 LDLT donor candidates. At histological evaluation we classified the evidence of steatosis (5%-10% or 10%-20%), fibrosis (absent or 1-3 portal space), inflammation, iron deposition, biliary neoductulation, and portal vein vascular alterations.

RESULTS

Among the 20 subjects, serological markers did not show any pathological alterations. At liver biopsy we found: steatosis (5%-10%) in 6 individuals (about 30%) with 1 ranging from 10% to 20%; iron deposition in 4 (20%); biliary neoductulation in 3 (about 16%); fibrosis in 4 (20%); inflammation in 5 (25%); and portal vein dilatation in 10 (50%).

CONCLUSIONS

Our data showed that apparently healthy individuals who did not display serological markers or US evidence of pathology had liver histological abnormalities. This result suggested that in absence of clinical or laboratory alterations, liver biopsy may represent a useful diagnostic tool for living donor candidates. Long-term follow-up results for the laboratory data among those patients should be performed even though they were not qualified for LDLT.

ncx1, ncx2, and ncx3 gene product expression and function in neuronal anoxia and brain ischemia

Over the last few years, although extensive studies have focused on the relevant function played by the sodium-calcium exchanger (NCX) during focal ischemia, a thorough understanding of its role still remains a controversial issue. We explored the consequences of the pharmacological inhibition of this antiporter with conventional pharmacological approach, with the synthetic inhibitory peptide, XIP, or with an antisense strategy on the extent of brain damage induced by the permanent occlusion of middle cerebral artery (pMCAO) in rats. Collectively, the results of these studies suggest that ncx1 and ncx3 genes could be play a major role to limit the severity of ischemic damage probably as they act to dampen [Na+]i and [Ca2+]i overload. This mechanism seems to be normally activated in the ischemic brain as we found a selective upregulation of NCX1 and NCX3 mRNA levels in regions of the brain surviving to an ischemic insult. Despite this transcript increase, NCX1, NCX2, and NCX3 proteins undergo an extensive proteolytic degradation in the ipsilateral cerebral hemisphere. All together these results suggest that a rescue program centered on an increase NCX function and expression could halt the progression of the ischemic damage. On the basis of this evidence we directed our attention to the understanding of the transductional and transcriptional pathways responsible for NCX upregulation. To this aim, we are studying whether the brain isoform of Akt, Akt1, which is a downstream effector of neurotrophic factors, such as NGF can, in addition to affecting the other prosurvival cascades, also exert its neuroprotective effect by modulating the expression and activity of ncx1, ncx2, and ncx3 gene products.

Acute rejection after liver transplantation: Is there a specific immunological pattern?

The aim of the study was to assess various T-cell subsets and cytokine secretion patterns both in liver tissue and in the peripheral blood of 24 liver transplant patients to assess possible specific immunological involvement in early acute rejection episodes after liver transplantation. Particularly, we studied CD4+ CD7+, CD8+ CD38+, and CD4+ CD25+ T cells by flow cytometry, as well as contemporaneously, interleukin (IL)-2 and IL-10 secretion by ELISpot to determine possible Th1-like immune responses and the immunomodulation expressed by Treg cells in acute liver rejection, respectively. As a control group we included patients transplanted without acute rejection. Early acute rejection within the first 4 weeks was proven histologically in 42% of patients. It was associated with a greater expression of CD4+ CD7+ and CD8+ CD38+ T cells in the liver than in the blood (P < .001). A contemporaneous reduced expansion of liver Treg cells was evident in patients with acute rejection (P < .001). Our data suggested that a preferential Th1-like immune mechanism operated in local fashion as characterized by a decreased presence in the liver and blood of Treg cells.

Living Donor Liver Transplantation: Early Single-Center Experience

Adult living donor liver transplantation (ALDLT) is an accepted procedure to overcome the organ shortage. The advantages of ALDLT must be balanced against the first concern of donor safety. We analyzed the results of our early experience among a series of eight ALDLT performed between April 2001 and October 2003. All patients were listed as United Network for Organ Sharing UNOS status 2b and 3. Transplant recipients consisted of four men and four women. The living donors included four sons, three daughters, and one son-in-law (ages 20 to 45 years). One donor was anti-HBc-positive and negative for hepatitis B virus-DNA by polymerase chain reaction analysis in serum and in liver tissue. GR/WR >0.8 and fatty liver <10% were considered suitable for the hepatectomy. Residual left lobe volume was at least 33%. No exogenous blood and blood products were transfused into the donors and a cell-saver device was used in all donors (blood loss 490 +/- 160 mL). All procedures were right lobe hepatectomy; in one case the middle hepatic vein was withdrawn with the right graft. The mean ischemia time was 1.5 +/- 0.5 hours. All donors survived the procedure. Median hospital stay was 8.5 +/- 2.1 days in all donors but one who had a long stay because of drug-related hepatitis. One graft was lost and one donor aborted because of preoperative overestimated volumetry. Complications were experienced by two donors (25%). Five recipients (62.5%) experienced major complications; one patient underwent retransplantation because of donor graft loss. Two biliary and two vascular complications (33.3%) occurred in three patients. No perioperative death occurred. Two patients died at 9 and 10 months after transplant because of heart and respiratory failure in the first case and tumor recurrence in the second. One-year actuarial survival is 75%. ALDLT using right lobe has gained acceptance to overcome the organ shortage. Donor selection criteria must be stringent with respect to residual donor hepatic volume, steatosis, and liver function.

Anaesthetic management and outcome in right-lobe living liver-donor surgery

BACKGROUND AND OBJECTIVE

We reviewed retrospectively the anaesthetic management and perioperative course of eight right hepatectomies for living liver donation.

METHODS

After preoperative psychiatric evaluation, eight ASA I-II individuals donated the right lobe of their liver to a family member. A graft-recipient body weight ratio of 0.8-1.0% was required for patient selection. Indications for liver transplantation were: hepatitis C viral-related cirrhosis in six patients; combined hepatitis C and B viral cirrhosis in one patient; multifocal hepatocellular carcinoma--four lesions, involving both liver lobes--of hepatitis C viral-related cirrhosis in another patient. Indication for adult-to-adult living-donor liver transplantation was retained in the latter because of rapid deterioration of liver disease, rare recipient's blood group and extended, unresectable hepatocellular carcinoma. Hepatitis C viral-related cirrhosis was casually the primary indication for adult-to-adult living-donor liver transplantation in this group. The condition of the donated hepatic lobe was optimized by appropriate drug and perfusion management. Preoperative investigations included: blood tests (full cell count and film, thyroid function tests, pregnancy tests, full virological tests and bacteriological cultures, and immunological typing), chest radiograph, electrocardiogram plus Doppler cardiac ultrasound, spirometry, aminopyrine breath test, liver Doppler examination, magnetic resonance imaging, angiography and cholangiography and a volumetric study of the whole liver and the right lobe. Haemoglobin and lactate concentrations, liver function tests and international normalized ratio were measured before and after operation. The volume and weight of the resected right lobe was calculated. Anaesthesia was induced with propofol 300 mL h(-1) and sufentanil 0.3 microg kg(-1) intravenously; cisatracurium, 0.15 mg kg(-1), was given to facilitate tracheal intubation. Anaesthesia was maintained during normocapnic ventilation of the lungs with oxygen 40% in air, isoflurane 1-1.5 MAC and sufentanil. Routine anaesthetic monitoring included electrocardiography, pulse oximetry, invasive blood pressure, central venous pressure, urine output, state of neuromuscular blockade and core temperature. Periods of hypotension (<80% of the preoperative blood pressure) or haemodynamic instability (requiring inotropic or vasoactive support) were registered. Total blood loss and transfusion (homologous, autologous or cell-saver blood) requirements were measured; volume replacements were derived.

RESULTS

Data are presented as mean (range). There was no morbidity or mortality and no periods of intraoperative hypotension or haemodynamic instability. The operation time averaged 619 (525-780)min. Four donors were extubated in the operating room immediately after surgery; the others were extubated in the intensive care unit, where the mean extubation time was 16.3 (5-25)h after arrival. The estimated blood loss was 967 (550-1,600)mL. No homologous blood was administered; five donors received autologous blood, intraoperatively; three donors received a cell-saver blood transfusion. Intraoperative fluid replacement was with crystalloids, colloids and 4% albumin. Total urine output was 1,472 (700-3100)mL. Although intraoperative hypothermia occurred all subjects were normothermic at the end of operation. The pre- and immediately postoperative haemoglobin concentration averaged 13.6 (9.8-15.6) and 10.5 (6.9-13.0)gdL(-1), respectively. On the first postoperative day, the haemoglobin was 11.7 (8.4-15.1)gdL(-1). The donors' liver function tests were transiently elevated in the initial postoperative period. The intensive care unit discharge time was 2 (1-3) days. The hospital stay was 13 (7-17) days. There was no morbidity or mortality.

CONCLUSIONS

The study demonstrates that right-lobe living-donor surgery was well tolerated, without intraoperative hypotension or haemodynamic instability, without perioperative anaesthetic or surgical complications, and with an excellent general outcome.

HCV and cancer: a case-control study in a high-endemic area

BACKGROUND/AIMS

HCV is a RNA virus that cannot be integrated with the host genome; it can, however, exert its oncogenic potential indirectly by contributing to the modulatory effects of the host immune system, probably through a capacity to elude the immune system. We have carried out a case-controlled study on the different oncological pathologies which have, to date, been shown to have a relationship with HCV.

METHODS

We screened 495 patients with different types of cancer: 114 cases of liver cancer, 41 of multiple myeloma, 111 non-Hodgkin's lymphomas, 130 thyroid cancers, 63 cases of Hodgkin's disease. The controls were 226 patients with no history of cancer. The relationship between each cancer and HCV infection was assessed by means of odds ratios (OR) and corresponding 95% confidence intervals.

RESULTS

Risks were greater for liver cancer (OR=32.9 95% CI 16.5-65.4, p<0.0001), multiple myeloma (OR=4.5 95% CI 1.9-10.7, p=0.0004) and B-cell non-Hodgkin's lymphoma (OR=3.7 95% CI 1.9-7.4, p=0.0001). For Hodgkin's disease there was no significant association (p=0.3). An association between HCV and thyroid cancer was noted (OR=2.8 95% CI 1.2-6.3, p=0.01).

CONCLUSION

Our study is particularly important for public health since the high prevalence of HCV in the South of Italy gives reason to expect increases in not only liver cancer, but also tumors associated with the immune system and thyroid cancer in years to come.

Role of immunosuppression in recurrence after liver transplantation for diethylnitrosamine-induced tumors in rats

Hepatocellular carcinoma is one of the world's most common malignant diseases, with an increasing incidence related to liver cirrhosis. The purpose of the study was to evaluate the role of immunosuppression in recurrence in rats transplanted after liver tumor induction by diethylnitrosamine (DENA), which has proved to be a reliable carcinogen. In 14-week-old Lewis rats weighing 200 g, tumors were induced by the oral administration (5 mg/100 ml in drinking water ad libitum) of DENA for 13 weeks. Orthotopic liver transplantation (OLT) was performed after 4 weeks' latency. In the Lewis/Lewis rats weighing 200 g, tumors sporin A (CsA) treatment, median survival was 199-days with no recurrence or metastasis. In the BN/Lewis group with no CsA (5 ats) median survival was 144 days. All rats died due to rejection. In the other BN/Lewis group (10 rats), OLT was followed by CsA administration (7.5 mg/kg). Median survival was 161 days. In three rats (218 days), there was liver tumor recurrence; in two rats (137.5 days), kidney and lung metastases were found. The remaining rats died of septic complications. In the Lewis/Lewis + CsA group (10 rats), median survival was 131 days with 5 recurrencies and/or metastases. Two rats are still surviving at 84 and 88 days. Our results suggest that the DENA model is reliable; it proved to have a similar carcinologic pattern to HCC in man. Moreover, immunosuppression seems to play an important role in determining recurrence. Further studies are needed to investigate the efficacy of chemotherapy agents pre- and post-transplantation.

HCV and hepatocellular carcinoma: A case-control study in an area of hyperendemicity

HCV is an RNA virus that cannot be integrated with the host genome; it can, however, exert its oncogenetic potential indirectly by contributing to the modulator effects of the host immune system probably through a capacity to escape the immune system. We have carried out a case controlled study in a hyperendemic area on HCV infection and liver cancer. We screened 114 liver cancer and 226 controls. All patients were at first diagnosis and examined. For liver cancer the risk was (OR=32.9, 95% CI 16.5-65.4, p<0.0001). Our study is particularly important for public health since it shows that in the South of Italy, because of the high prevalence of HCV and the high life expectancy, there are good reasons to suppose that the incidence rate of liver cancer will continue to increase in the next few years.

Late biliary tract complications after orthotopic liver transplantation: diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography

BACKGROUND

Biliary tract complications are frequent after orthotopic liver transplantation. Late biliary tract complications occurring after T-tube removal mostly include stones and strictures which may be associated with sepsis and worsening of the liver function. Endoscopic retrograde cholangiopancreatography (ERCP) has a role in the diagnosis and therapy of these complications. The aim of our study was to report our experience of endoscopic diagnosis and treatment of late biliary tract complications in liver-transplanted patients.

METHODS AND RESULTS

One hundred and thirty-six adult liver-transplanted patients have been followed since 1988. Seventeen patients (12.5%) needed a total of 30 ERCP because of evidence of clinical and/or biochemical cholestasis: eight with biliary stricture; six with biliary stones; one with both stricture and stones; and two with normal ERCP findings. Interventional endoscopic procedures included 14 sphincterotomies, six stone removals, seven biliary balloon dilatations, seven biliary stent placements, 11 biliary stent replacements, seven nasobiliary catheter placements and one mechanical lithotripsy. No complications were seen. In all cases, ERCP was able to identify the location, entity and dimension of the late biliary tract complication, thus allowing a therapeutic strategy to be used. Two patients had medical cholestasis. Forty-seven per cent of patients with late biliary tract complications could definitely be cured by ERCP alone. The ERCP improved the patients' condition to allow subsequent surgery in five patients (33%).

CONCLUSIONS

These results confirms that ERCP is a valuable diagnostic tool and should be considered as the first step in the non-surgical management of late biliary tract complications after orthotopic liver transplantation.

Adult-to-adult living-related liver transplantation using the right lobe. Case report

In the last few years an increase in the number of candidates for liver transplantation has been observed. However, the donor pool has not increased proportionally so that the lack of available donor organs remain a major concern. Living-related liver transplantation is actually one of the strategies to maximize donor organ use not only for paediatric but also for the adult patient population. The authors report their experience with the first adult-to-adult living-related liver transplantation using the right lobe. Despite a donor portal anomaly, the donor operation and the transplantation were uneventful. After six months' follow-up, donor and recipient are in excellent clinical state.

Immune response in liver transplantation: is there a preferential pattern in acute rejection?

To determine the immune factors involved in liver graft rejection, a study on 14 liver transplants was conducted. We have, in particular, studied CD4+CD7+ and CD8+CD38+ T cells in both liver tissue and blood of patients with and without acute rejection. Contemporarily, IL-2 and IL-4 secretion in both plasma and stimulated culture supernatants from hepatic T cells was evaluated. Early acute rejection was characterized by a higher expression of CD4+CD7+ and CD8+CD38+ T lymphocytes in the liver than in blood (p&#x003C;0.001). Moreover, a preferential proinflammatory (Thl) cytokine profile was related to liver resident T cells in comparison with corresponding plasma (p&#x003C;0.001). Conversely, in the patients without acute rejection CD4+CD7+ was higher in blood than in liver and the Th2-like cytokine profile characterized these subjects. Our data suggest that a preferential Th1 immune mechanism operates in a local fashion and may be involved in acute rejection.

Improved survival with splenic autotransplantation and fibronectin therapy following endotoxin administration in rats

The risk of overwhelming infections is greatly increased after splenectomy. In this experimental study in rats, we investigated whether the administration of fibronectinrich cryoprecipitate can improve the survival rate of splenectomized autotransplanted rats subjected to an intravenous challenge with endotoxin. Inbred Lewis rats were divided into four groups: A, splenectomy; B, splenectomy + splenic autotransplantation; C, splenectomy, splenic autotransplantation + fibronectin treatment, and D, sham. Five months after surgery, rats were challenged intravenously with Escherichia coli endotoxin. Immunoglobulin (IgG, IgM, IgA), complement and fibronectin levels were measured before surgery and endotoxin challenge, and 48 h after endotoxin challenge. The survival rate of splenectomized rats was not significantly improved by autotransplantation of splenic tissue, but was significantly (p less than 0.05) improved by autotransplantation and fibronectin treatment. The levels of fibronectin, immunoglobulins and/or complements were significantly decreased after endotoxin challenge in control and in autotransplanted fibronectin-treated rats. The survival improvement of autotransplanted rats treated by fibronectin is probably due to increased endotoxin phagocytosis and clearance.

Delayed rejection of heart allografts after extracorporeal donor-specific liver hemoperfusion. Role of Kupffer cells

Liver allografts have a privileged status in regard to acute rejection. In this experimental study, we have analyzed the immunosuppressive effects of an extracorporeal liver hemoperfusion. In the LEW-to-BN combination of inbred rats, donor-specific liver hemoperfusion can significantly delay acute rejection of heart allografts. Analysis of the immunological status of these animals revealed a significant decrease in donor-specific lymphocytotoxic antibodies and in cytotoxic T lympholysis. Reactivity in mixed lymphocyte culture was normal. After third-party (DA) liver hemoperfusion or after donor-specific (LEW) splenic hemoperfusion, prolongation of heart allograft survival was moderate. Previous blockade of Kupffer cells suppressed the effects of donor-specific liver hemoperfusion. These results suggest that the sequestration by Kupffer cells of a clone of cytotoxic T cells and/or lymphocytotoxic antibodies may explain the immunosuppressive effects of donor-specific liver hemoperfusion.

Recent advances in diagnostic techniques in Caroli's disease

Preoperative diagnosis of congenital dilatation of the intrahepatic bile ducts (Caroli's disease) is difficult. The best techniques for this diagnosis are endoscopic retrograde cholangiopancreatography, abdominal ultrasonography and computerized tomography. The authors present a case of Caroli's disease diagnosed using ultrasonography and computerized tomography. They discuss the usefulness and the real possibilities of existing techniques in the diagnosis of intra- and extrahepatic bile duct disease.