Liver regeneration of living donor after liver donation for transplantation: Disparity in the left and right remnant liver

Donor safety is crucial for living donor liver transplantation (LDLT), and sufficient liver regeneration significantly affects outcomes of living donors. This study aimed to investigate clinical factors associated with liver regeneration in living donors. The study retrospectively reviewed 380 living donors who underwent liver donation at Chang Gung Memorial Hospital in Linkou. The clinical characteristics and medical parameters of donors were analyzed and compared according to liver donation graft type. There were 355 donors (93.4%) with right hemi-liver donations and 25 donors (6.6%) with left hemi-liver donations. Left hemi-liver donors had a higher body mass index (BMI) and a larger ratio of remnant liver volume (RLV) to total liver volume (TLV). However, the 2 groups showed no significant difference in the liver regeneration ratio. The type of remnant liver (P < .001), RLV/body weight (P = .027), RLV/TLV (P < .001), serum albumin on postoperative day 7 and total bilirubin levels on postoperative day 30 were the most significant factors affecting liver regeneration in living donors. In conclusion, adequate liver regeneration is essential for donor outcome after liver donation. The remnant liver could eventually regenerate to an adequate volume similar to the initial TLV before liver donation. However, the remnant left hemi-liver had a faster growth rate than the remnant right hemi-liver in donors.

Optimal treatment strategy and prognostic analysis of salvage liver transplantation for patients with early hepatocellular carcinoma recurrence after hepatectomy

AIM

We aimed to investigate the prognostic factors for salvage liver transplant in patients with early hepatocellular carcinoma recurrence after hepatectomy.

METHODS

This retrospective analysis included 53 patients who underwent salvage living-donor liver transplantation between January 2007 and January 2018. There were 24 and 29 patients in the early (recurrence ≤24 months after primary liver resection) and the late recurrence groups, respectively.

RESULTS

In the multivariate Cox regression model, pre-liver transplant downstaging therapy, early recurrence (ER) after primary liver resection , and recurrence-to-liver-transplant ≥12 months were independent risks to predict recurrent hepatocellular carcinoma recurrence after salvage living-donor liver transplantation. Compared with the late recurrence group, the ER group showed lower disease-free survival rates (p < 0.001); however, the overall survival rates did not differ between the two groups (p = 0.355). The 1-, 3-, and 5-year disease-free survival rates were 83.3%, 70.6%, and 66.2%, and 96.0%, 91.6%, and 91.6% in the early and late recurrence groups, respectively. When stratified by recurrence-to-liver transplant time and pre-liver transplant downstaging therapy in the ER group, disease-free survival and overall survival rates were significantly different.

CONCLUSION

ER after primary liver resection with advanced tumor status and a longer period of recurrence-to-liver-transplant (≥12 months) have a negative impact on salvage liver transplant. Our findings provide novel recommendations for treatment strategies and eligibility for salvage liver transplant candidates.

Converting from Tenofovir Disoproxil Fumarate to Tenofovir Alafenamide in Patients with Hepatitis B Following Liver Transplantation

BACKGROUND Taiwan has a high prevalence of hepatitis B virus (HBV) infection. HBV-related end-stage liver disease is the leading cause of liver transplantation (LT). Tenofovir alafenamide (TAF) is a recently approved agent for the treatment of chronic HBV infection that improves renal profiles compared with tenofovir disoproxil fumarate (TDF) in phase III trials. This study aimed to assess the outcomes of TAF treatment in LT recipients. MATERIAL AND METHODS This retrospective study analyzed 17 LT recipients who underwent treatment with TDF and TAF. Changes in baseline renal function were compared. RESULTS Seventeen LT recipients received TDF for ≥48 weeks and were switched to TAF. During TDF treatment, estimated glomerular filtration rate (eGFR) (using the Modification of Diet in Renal Disease [MDRD] formula) decreased significantly at weeks 24 and 48. At week 48, only 2 patients (11.8%) displayed improved renal function, whereas the other patients showed decreased eGFR ranging from 5.48% to 62.84%. After switching to TAF, the median eGFR increased by 3.01% at week 24 and decreased by 0.31% at week 48. Seven patients (47%) showed improved renal function at week 48 after TAF treatment. CONCLUSIONS Switching from TDF to TAF was associated with fewer short-term renal impairment while maintaining the antiviral efficacy in LT recipients.

Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Gastric Cancer with Peritoneal Carcinomatosis: Additional Information Helps to Optimize Patient Selection before Surgery

(1) Background: The prognosis of gastric cancer-associated peritoneal carcinomatosis (GCPC) is poor, with a median survival time of less than six months, and current systemic chemotherapy, including targeted therapy, is ineffective. Despite growing evidence that cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for GCPC improves overall survival (OS), optimal patient selection remains unclear. We aimed to evaluate preoperative clinical factors and identify indicative factors for predicting postoperative OS in patients with GCPC undergoing CRS-HIPEC. (2) Methods: We retrospectively reviewed 44 consecutive patients with GCPC who underwent CRS-HIPEC between May 2015 and May 2021. Data on demographics and radiologic assessment were collected and analyzed. (3) Results: Elevated preoperative serum neutrophil-to-lymphocyte ratio > 4.4 (p = 0.003, HR = 3.70, 95% CI = 1.55–8.79) and number of computed tomography risks > 2 (p = 0.005, HR = 3.26, 95% CI = 1.33–7.98) were independently indicative of OS post-surgery. A strong correlation was observed between intraoperative peritoneal cancer index score and number of computed tomography risks (r = 0.534, p < 0.0001). Two patients after CRS-HIPEC ultimately achieved disease-free survival for more than 50 months. (4) Conclusions: Our experience optimizes GCPC patients’ selection for CRS-HIPEC, may help to improve outcomes in the corresponding population, and prevent futile surgery in inappropriate patients.

Significance of Physical Status and Liver Function Reserve for Outcome of Patients with Advanced Hepatocellular Carcinoma Receiving Lenvatinib Treatment

Background

Tyrosine kinase inhibitors (TKIs) remain the primary therapeutic option for patients with advanced-stage hepatocellular carcinoma (HCC). However, the selection of a suitable TKI is an issue in real-world clinical practice. Thus, this study aimed to identify patients most likely to benefit from lenvatinib treatment.

Methods

A retrospective review of 143 patients with unresectable advanced-stage HCC treated with lenvatinib between January 2020 and December 2021 was performed. Outcomes related to lenvatinib treatment were measured, and the clinical parameters affecting prognosis were analyzed.

Results

Overall, the median time of progression-free survival (PFS) and overall survival (OS) were 7.1 months and 17.7 months, respectively. Prognostic analyses found that Child-Pugh score > 5 (hazard ratio [HR] = 2.43, 95% confidence interval [CI] = 1.55-3.80, p = 0.001) was a significant factor affecting the PFS of HCC after lenvatinib treatment. Child-Pugh score > 5 (HR = 2.12, 95% CI = 1.20-3.74, p = 0.009), body weight ≥ 60 kg (HR = 0.54, 95% CI = 0.32-0.90, p = 0.020), and additional trans-arterial chemoembolization (TACE) treatment (HR = 0.38, 95% CI = 0.21-0.70, p = 0.003) were significant prognostic factors for OS. However, early α-fetoprotein reduction was not significantly correlated with patient outcomes. Additionally, patients with pre-treatment neutrophil-lymphocyte ratio > 4.07 showed a significant worse PFS and OS than other patients.

Conclusion

The outcome of patients with advanced-stage HCC remains poor. However, the host condition, including good physical status and better functional liver preservation, largely affected the outcome of patients receiving lenvatinib treatment. Moreover, additional locoregional therapy for intrahepatic HCC, other than TKI treatment, can be considered in certain patients to achieve a favorable outcome.

Elevation of Lipid Metabolites in Deceased Liver Donors Reflects Graft Suffering

Liver transplantation can be performed with deceased or living donor allografts. Deceased liver grafts are donated from brain- or circulation-death patients, and they have usually suffered from a certain degree of damage. Post-transplant graft function and patient survival are closely related to liver allograft recovery. How to define the damage of liver grafts is unclear. A total of 47 liver donors, 23 deceased and 24 living, were enrolled in this study. All deceased donors had suffered from severe brain damage, and six of them had experienced cardio-pulmonary-cerebral resuscitation (CPR). The exploration of liver graft metabolomics was conducted by liquid chromatography coupled with mass spectrometry. Compared with living donor grafts, the deceased liver grafts expressed higher levels of various diacylglycerol, lysophosphatidylcholine, lysophosphatidylethanolamine, oleoylcarnitine and linoleylcarnitine; and lower levels of cardiolipin and phosphatidylcholine. The liver grafts from the donors with CPR had higher levels of cardiolipin, phosphatidic acid, phosphatidylcholine, phatidylethanolamine and amiodarone than the donors without CPR. When focusing on amino acids, the deceased livers had higher levels of histidine, taurine and tryptophan than the living donor livers. In conclusion, the deceased donors had suffered from cardio-circulation instability, and their lipid metabolites were increased. The elevation of lipid metabolites can be employed as an indicator of liver graft suffering.

Modified preoperative score to predict disease-free survival for hepatocellular carcinoma patients with surgical resections

BACKGROUND

No prognostic models specific to hepatocellular carcinoma patients receiving surgical resection have been considered strong and convincing enough for survival prediction thus far, and there are no models including only preoperative predictors. We derived a nomogram to predict disease-free survival in a previous study.

AIM

To simplify our score and compare research outcomes among other scoring systems.

METHODS

We retrospectively reviewed data from 1106 patients with hepatocellular carcinoma who underwent liver resection at the Linkou Chang Gung Memorial Hospital between April 2003 and December 2012. Multivariate analyses were conducted to identify the significant survival predictors. Homogeneity, Harrell’s C-index, and Akaike information criterion were compared between our score, AJCC 8^th edition, Tokyo score, and Taipei Integrated Scoring System (TTV-CTP-AFP model).

RESULTS

Among the 1106 patients, 731 (66.1%) had tumor recurrence at a median follow-up of 83.9 mo. Five risk factors were identified: platelet count, albumin level, indocyanine green retention rate, multiplicity, and radiologic total tumor volume. Patients were divided into three risk groups, and the 5-year survival rates were 61.7%, 39%, and 25.7%, respectively. The C-index was 0.617, which was higher than the Tokyo score (0.613) and the Taipei Integrated Scoring System (0.562) and equal to the value of the AJCC 8^th edition (0.617).

CONCLUSION

The modified score provides an easier method to predict survival. Appropriate treatment can be planned preoperatively by dividing patients into risk groups.

Enhancement of dendritic cell immunotherapy by recalling antigens for hepatocellular carcinoma in mice

Background: The therapeutic efficacy of dendritic cell (DC)-immunotherapy for large hepatoma in mice is unsatisfactory. Materials & methods: DC-based immunotherapy was used to treat Hepa1-6 tumors measuring 6 ± 1 mm in diameter, enhanced by boosting tumor antigens. Results: CD4⁺ and CD8⁺ T-cells were contracted and transformed into memory phenotypic cells after DC-based vaccination. When T-cells were re-stimulated, T-cells obtained from mice boosted by tumor antigen injection showed highest proliferation capacity. When mice with large tumors were treated, DC-based vaccination boosted by tumor antigen and an additional DC-infusion yielded curative rates of 50% and 23.1%, respectively. Conclusion: DC vaccination induced effector memory cells. Antigen presentation recalled by DC or tumor antigens increased the curative rate in mice with large tumors.

Individualized Selection Criteria Based on Tumor Burden in Future Remnant Liver for Staged Hepatectomy of Advanced CRLM: Conventional TSH or ALPPS

Staged hepatectomy is a promising strategy for curative resection of advanced colorectal liver metastasis (CRLM) to prevent inadequate future remnant liver (FRL). However, the selection criteria for conventional two-stage hepatectomy (cTSH) and associating liver partitioning and portal vein ligation for staged hepatectomy (ALPPS) remain unclear. This study aimed to propose a selection criterion for determining the optimal staged hepatectomy for patients with advanced CRLM. A selection criterion based on the degree of metastatic tumors within the FRL was established to determine staged hepatectomy approaches. Generally, ALPPS is recommended for patients with ≤3 metastatic nodules and whose nodules do not measure >3 cm in the FRL. cTSH is performed for patients whose tumor burden in FRL beyond the selection criteria. Data of 37 patients who underwent staged hepatectomy and curative intent of CRLM were analyzed. The clinical characteristics and outcomes of the two approaches were compared. Overall, cTSH and ALPPS were performed for 27 (73.0%) and 10 (27.0%) patients, respectively. Of those, 20 patients in the cTSH group and all patients in the ALPPS group had completed staged hepatectomy. The 1-, 3-, and 5-year survival rates were 91.6%, 62.4%, and 45.4% for all patients, respectively. The outcomes of patients who had successfully completed the staged hepatectomy were significantly better than those of other patients who failed to achieve staged hepatectomy. However, no significant difference was observed in the overall survival of patients who underwent staged hepatectomy between the two groups, but those in the ALPPS group had 100% survival at the end of this study. The individualized selection criteria based on tumor burden in the FRL that could balance the operative risk and oncologic outcome appear to be a promising strategy for achieving complete staged hepatectomy in patients with advanced CRLM.

Recurrence Patterns After Hepatectomy With Very Narrow Resection Margins for Hepatocellular Carcinoma

Background

The extent of hepatic resection In HCC depends on the remnant liver reserve or the proximity of the tumor to major vessels. In this study, we evaluated the effects of very close resection margins on postoperative recurrence.

Methods

Consecutive LR for HCC between 2003 and 2009 were studied. Patients were divided into groups with very narrow (≤1 mm) or wider (>1 mm) resection margins. Propensity score matching (PSM) was used to balance demographic, surgical, and pathological factors.

Results

983 patients were included in the study. After PSM, 173 patients were analyzed in each group. 5-year tumor recurrence and survival rates were comparable. Most recurrences were multiple intrahepatic. Section margin recurrences were similar in both groups. By multivariate analysis, tumor size >5 cm was associated with a very narrow resection margin, whereas low platelet count and tumor macrovascular invasion were significant factors related to tumor recurrence.

Conclusions

Patients with very narrow surgical margins showed outcomes comparable to those with wider surgical margins. Most recurrences were multiple intrahepatic and associated with the degree of portal hypertension and adverse tumor biology. Although wide surgical margins should be aimed whenever possible, a narrow tumor-free margin resection still represents an effective therapeutic strategy.

Preferred Treatment with Curative Intent for Left Lateral Segment Early Hepatocellular Carcinoma under the Era of Minimal Invasive Surgery

Background: Hepatocellular carcinoma (HCC) occurring at the left lateral segment (LLS) is relatively susceptible to treatment with curative intent in terms of tumor location. However, outcomes might vary depending on the selection of treatment modalities. This study aimed to analyze patients who had undergone curative treatment for early HCC at LLS. Methods: A retrospective analysis of 179 patients who underwent curative treatment for early HCC at LLS was performed. Patients were grouped based on treatment modalities, including radiofrequency ablation (RFA) and liver resection (LR). The long-term outcomes of the two groups were compared. Additionally, the impact of the LR approach on patient outcomes was analyzed. Results: Among these patients, 60 received RFA and 119 underwent LR as primary treatment with curative intent. During follow-up, a significantly higher incidence of HCC recurrence was observed in the RFA group (37/60, 61.7%) than in the LR group (45/119, 37.8%) (p = 0.0025). The median time of HCC recurrence was 10.8 (range: 1.1–60.9 months) and 17.6 (range: 2.4–94.8 months) months in the RFA and LR groups, respectively. In addition, multivariate analysis showed that liver cirrhosis, multiple tumors, and RFA treatment were significant risk factors for HCC recurrence. The 1-, 2-, and 5-year overall survival rates in the RFA and LR groups were 96.4%, 92.2%, and 71.5% versus 97.3%, 93.6%, and 87.7%, respectively. (p = 0.047). Moreover, outcomes related to LR were comparable between laparoscopic and conventional open methods. The 1-, 2-, and 5-year recurrence free survival rates in the laparoscopic (n = 37) and conventional open (n = 82) LR groups were 94.1%, 82.0%, and 66.9% versus 86.1%, 74.6%, and 53.1%, respectively. (p = 0.506) Conclusion: Early HCC at LLS had satisfactory outcomes after curative treatment, in which LR seems to have a superior outcome, as compared to RFA treatment. Moreover, laparoscopic LR could be considered a preferential option in the era of minimally invasive surgery.

GALNT14 genotype-guided chemoembolization plus sorafenib therapy in hepatocellular carcinoma: a randomized trial

BACKGROUND

GALNT14-rs9679162 "TT" genotype is associated with favorable clinical outcomes in hepatocellular carcinoma (HCC) treated by transarterial chemoembolization (TACE). We investigated whether patients with GALNT14-rs9679162 "non-TT" unfavorable genotype benefited from chemoembolization plus sorafenib combination therapy.

METHODS

Intermediate stage HCC patients were recruited for GALNT14-rs9679162 genotyping before TACE. Patients with "TT" genotype received only TACE, labeled as TT (TACE) group. Patients with "non-TT" genotype ("GG" or "GT") were randomized to receive either TACE alone, labeled as Non-TT (TACE) group, or TACE plus sorafenib, labeled as Non-TT (TACE + Sora) group. The latter group received sorafenib 400 mg daily plus TACE.

RESULTS

From October 2015 to April 2019, 103 HCC patients scheduled to receive chemoembolization were screened. Of them, 84 met inclusion criteria and were assigned to TT (TACE) (n = 25), Non-TT (TACE) (n = 30) and Non-TT (TACE + Sora) (n = 29) groups according to their GALNT14 genotypes. Repeated TACE sessions were performed on-demand and patients were followed until November 2020. It was found that TT (TACE) and Non-TT (TACE + Sora) patients had shorter time-to-complete response compared with that in Non-TT (TACE) patients (p < 0.001 and 0.009, respectively). These two groups also had longer time-to-TACE progression (p < 0.001 and 0.006, respectively) and longer progression-free survival (p = 0.001 and 0.021, respectively). However, TT (TACE) patients harbored longer overall survival compared with those in non-TT (TACE + Sora) and non-TT (TACE) patients (p = 0.028, < 0.001, respectively).

CONCLUSION

Combination of sorafenib and TACE for "non-TT" patients partially overcame the genetic disadvantage on treatment outcomes in terms of time-to-complete response, time-to-TACE progression and progression-free survival.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02504983.

Reconstruction of Separated Intrahepatic Ducts Using the Cystic and Common Hepatic Ducts in Right-Lobe Living-Donor Liver Transplantation: Experiences of Surgical Techniques, Biliary Complications, and Outcomes in a Single Institution

Background

Duct-to-duct biliary reconstruction has been increasingly used in living-donor liver transplantation. Information regarding dual duct-to-duct biliary anastomoses is limited. We present the largest case series to date on the use of the cystic and common hepatic ducts as dual-ductal anastomosis, along with long-term follow-up results.

Material/Methods

In this study, 740 patients underwent right-lobe living-donor liver transplantation; 56 of them were documented as dual-ductal anastomoses. We analyzed recipient and donor characteristics, surgical procedures, appearance of biliary complications, corresponding interventions, and long-term biliary outcomes.

Results

Cystic and common hepatic ducts were utilized in 56 cases of dual-ductal biliary reconstruction, which we categorized into 2 types: A (78.6%), in which the right anterior intrahepatic duct was anastomosed to the common hepatic duct and the right posterior intrahepatic duct to the cystic duct; and B (21.4%), which was the reverse of A. After a median follow-up period of 46.4 months, 23 patients (41.1%) experienced complications, including biliary leakage and biliary stricture. However, after aggressive intervention (patent biliary anastomosis in most of them), 50 of 56 patients (89.3%) had patent biliary anastomosis and restored normal liver function at the end of follow-up. A small graft (graft-to-recipient weight ratio <0.9%) was the only predictor of biliary complications after multivariate analysis.

Conclusions

Dual-ductal biliary reconstruction in adult right-lobe living-donor liver transplantation is challenging but feasible. Our findings support the use of the cystic duct for reconstruction in selected patients. Good long-term results can be achieved with adequate management of patients with biliary complications.

Quick preparation of ABO-incompatible living donor liver transplantation for acute liver failure

Acute liver failure is life-threatening and has to be treated by liver transplantation urgently. When deceased donors or ABO-compatible living donors are not available, ABO-incompatible (ABO-I) living donor liver transplantation (LDLT) becomes the only choice. How to prepare ABO-I LDLT urgently is an unsolved issue. A quick preparation regimen was designed, which was consisted of bortezomib (3.5mg) injection to deplete plasma cells and plasma exchange to achieve isoagglutinin titer ≤ 1: 64 just prior to liver transplantation and followed by rituximab (375mg/m² ) on post-operative day one to deplete B-cells. Eight patients received this quick preparation regimen to undergo ABO-I LDLT for acute liver failure from 2012 to 2019. They aged between 50 and 60 years. The median MELD score was 39 with a range from 35 to 48. It took 4.75 ± 1.58 days to prepare such an urgent ABO-I LDLT. All the patients had successful liver transplantations, but one patient died of antibody-mediated rejection at post-operative month 6. The 3-month, 6-month, and 1-year graft/patient survival were 100%, 87.5%, and 75%, respectively. In conclusion, this quick preparation regimen can reduce isoagglutinin titers quickly and make timely ABO-I LDLT feasible for acute liver failure. This article is protected by copyright. All rights reserved.

The Impact of Multidisciplinary Team Approach on Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a therapeutic approach used to achieve curative treatment in intra-abdominal malignancy with peritoneal carcinomatosis (PC). However, it is a complicated procedure with high post-operative complication rates. Thus, we analyzed our preliminary data to establish whether multidisciplinary teamwork (MDT) implementation is beneficial for CRS-HIPEC outcomes.

METHOD

A series of 132 consecutive patients with synchronous or recurrent PC secondary to gastrointestinal or gynecologic cancer who received CRS-HIPEC operation between May 2015 and September 2017 were included. Ninety-nine patients were categorized into the MDT group, with the 33 other patients into the non-MDT group.

RESULTS

The mean PCI score was 16.3 ± 8.8. Patients in the MDT group more often presented a higher PCI score (p value = 0.038). Regarding CRS completeness (CCR 0-1), it was distributed 81.8% and 57.6% in the MDT and the non-MDT group, respectively (p value = 0.005). Although post-operative complications were common (n = 62, 47.0%), post-operative complication rates did not differ between the two groups. The cumulative OS survival rate at the first year was 75.5%. Older age (p = 0.030, HR = 4.58, 95% CI = 1.16-18.10), ECOG 2 (p = 0.030, HR = 6.41, 95% CI = 1.20-34.14), and incomplete cytoreduction (p = 0.048, HR = 2.79, 95% CI = 1.04-8.27) were independent prognostic factors for survival.

CONCLUSIONS

Our experience suggests that the CRS-HIPEC performed under MDT cooperation may result in higher complete cytoreduction rates without increasing post-operative complications and hospital mortalities.

Improving outcomes of liver resection for hepatocellular carcinoma associated with portal vein tumor thrombosis over the evolving eras of treatment

BACKGROUND

The outcomes and management of hepatocellular carcinoma (HCC) have undergone several evolutionary changes. This study aimed to analyze the outcomes of patients who had undergone liver resection for HCC with portal vein tumor thrombosis (PVTT) in terms of the evolving era of treatment.

MATERIALS AND METHODS

A retrospective analysis of 157 patients who had undergone liver resection for HCC associated with PVTT was performed. The outcomes and prognostic factors related to different eras were further examined.

RESULTS

Overall, 129 (82.1%) patients encountered HCC recurrence after liver resection, and the median time of recurrence was 4.1 months. Maximum tumor size ≥ 5 cm and PVTT in the main portal trunk were identified as the major prognostic factors influencing HCC recurrence after liver resection. Although the recurrence-free survival had no statistical difference between the two eras, the overall survival of patients in the second era was significantly better than that of the patients in the first era (p = 0.004). The 1-, 2-, and 3-year overall survival rates of patients in the second era were 60.0%, 45.7%, and 35.8%, respectively, with a median survival time of 19.6 months.

CONCLUSION

The outcomes of HCC associated with PVTT remain unsatisfactory because of a high incidence of tumor recurrence even after curative resection. Although the management and outcomes of patients with HCC and PVTT have greatly improved over the years, surgical resection remains an option to achieve a potential cure of HCC in well-selected patients.

A review of split liver transplantation with full right/left hemi-liver grafts for 2 adult recipients

Liver transplantation has become a routine operation in many transplantation centers worldwide. However, liver graft availability fails to meet patient demands. Split liver transplantation (SPLT), which divides a deceased donor liver into 2 partial liver grafts, is a promising strategy for increasing graft availability for transplantation and ameliorating organ shortage to a certain degree. However, the transplantation community has not yet reached a consensus on SPLT because of the variable results. Specifically, SPLT for 2 adult recipients using full right/left hemi-liver grafts is clinically more challenging in terms of surgical technique and potential postoperative complications. Therefore, this review summarizes the current status of SPLT, focusing on the transplantation of adult recipients. Furthermore, the initiation of the SPLT program, donor allocation, surgical aspects, recipient outcomes, and obstacles to developing this procedure will be thoroughly discussed. This information might help provide an optimal strategy for implementing SPLT for 2 adult recipients among current transplantation societies. Meanwhile, potential obstacles to SPLT might be overcome in the near future with growing knowledge, experience, and refinement of surgical techniques. Ultimately, the widespread diffusion of SPLT may increase graft availability and mitigate organ donation shortages.

Immunological discrepancy in aged mice facilitates skin allograft survival

More and more aged people are undergoing organ transplantation. Understanding aging effects on immunity will be helpful for post-transplantation care and adjustment of immunosuppressants for aged recipients. A mouse model, using C3H mice as donors and aged/young C57BL/10J mice as recipients, was employed to study aging effects on immunity. The results showed that frequency of myeloid-derived suppressor cells (MDSC) and level of TGF-β was higher in aged mice than in young mice (4.4 ± 1.4% versus 1.6 ± 1.1%, p = 0.026 for MDSC; 21.04 ± 3.91 ng/ml versus 15.26 ± 5.01 ng/ml, p = 0.026 for TGF-β). In vivo, skin allograft survived longer on the aged than on young mice (19.7 ± 5.2 days versus 11.9 ± 4.1 days, p = 0.005). When entinostat was applied to block MDSC, the survival of skin allografts on aged mice was shorten to 13.5 ± 4.7 days which was not different from the survival on young mice (p = 0.359). In conclusion, allogeneic immunity was different in aged from young mice in high frequency of MDSC and high serum level of TGF-β. Blocking the function of MDSC reversed the low immunity in aged mice and caused skin allograft rejection similar to young recipients.

Plasma cytomegalovirus DNA load predicts outcomes in liver transplant recipients

Objective

Cytomegalovirus (CMV) infection has a significant negative impact on liver transplant (LT) recipients. We aimed to evaluate the efficacy of real‐time DNA quantitative polymerase chain reaction (qPCR) in the early detection of CMV and predicting post‐transplant outcomes.

Materials and Methods

This was a retrospective study that enrolled a total of 49 adult LT recipients between December 2016 and October 2019. Serial CMV qPCR were tested weekly. We used operating characteristic curve analysis to quantify qPCR replication numbers to decide the optimal threshold to predict posttransplant complications and overall survival.

Results

The optimal cut‐off value of 180 copies/ml (=164 IU/ml) was determined. We had 40 patients in the low qPCR group (<180 copies/ml) and nine patients in the high qPCR group (≥180 copies/ml). Higher qPCR was associated with more severe CMV disease, early allograft dysfunction, major posttransplant complications, longer ICU stays, and lower 2‐year overall survival (OS; all p < .05). In the univariate logistic regression model, persistent DNAemia ≥ 4 weeks after anti‐CMV treatment, coexisted bacterial and/or fungal infection, and high CMV qPCR ≥ 180 copies/ml with p < .100. High CMV qPCR ≥ 180 copies/ml (p = .016; hazard ratio [HR] = 19.5; 95% confidence interval [CI] = 1.73–219.49) remained to be the only independent risk factors for major complication by the multivariate analysis. The overall 2‐year OS rates were 92.5% and 66.7% in the low and the high qPCR group, respectively (p = .030).

Conclusion

Our findings support evidence that qPCR is effective in detecting CMV infection provides an objective perspective in predicting posttransplant outcomes. High plasma CMV DNA load (defined as CMV qPCR ≥ 180 copies/ml or 164 IU/ml) not only indicates a hazard in developing major posttransplant complications but also associates with prolonged and refractory treatment courses.

Treatment strategy of adding transcatheter arterial chemoembolization to sorafenib for advanced stage hepatocellular carcinoma

Background

Therapeutic effect and immunosuppressor cell alteration in adding transcatheter arterial chemoembolization (TACE) to sorafenib for advanced stage hepatocellular carcinoma (HCC) remain unclear.

Aims

To examine the therapeutic effect and immunosuppressor cell alteration in adding TACE to sorafenib.

Methods

Forty‐four advanced stage HCC patients were divided into group A (n = 17) treated by sorafenib (400‐600 mg/day) alone and group B patients (n = 27) treated by sorafenib and TACE. The frequency of regulatory T‐cells and myeloid‐derived suppressor cells (MDSC), and patients' outcomes were examined. Advanced HCC patients' survival was improved by adding TACE to sorafenib if N/L was reduced from ≥2.5 to <2.5 by TACE.

Results

The median (interquartile) follow‐up for all patients was 8.5 (3.5 to 15.5) with a range from 1 to 71 months. The median (interquartile) survival was 5.0 (2.3‐11.3) months for group A and 11.0 (5.0‐19.0) months for group B patients (P = .024). In group A, the patients (n = 8) with neutrophil‐to‐lymphocytes ratio (N/L) < 2.5 had better survival than the patients (n = 9) with N/L ≥ 2.5 (P = .006). In group B, 6 of 13 patients with N/L ≥ 2.5 had N/L reduction to <2.5 after combination therapy of sorafenib and TACE, and their 6‐month, 1‐year and 2‐year survival were improved (P = .013). For immune cell examination, the frequency of CD4⁺ and CD8⁺ T‐lymphocytes, regulatory T‐cell and MDSC were not altered by sorafenib treatment. However, actual number of lymphocytes had a tendency to increase (from 978.5 ± 319.4/mm³ prior to treatment to 1378.0 ± 403.3/mm³, P = .086) for the patients with N/L reduction.

Conclusion

Immunosuppressor cells were not altered by sorafeinb. Patients' survival was improved if N/L ≥ 2.5 was reduced to <2.5 by TACE.

Models to predict disease-free survival for hepatocellular carcinoma patients with surgical resections

BACKGROUND AND OBJECTIVES

Precise prognostic prediction for an individual hepatocellular carcinoma (HCC) patient before and after liver resection is important. We aimed to establish simple prognostic models to predict disease-free survival (DFS) for these patients.

METHODS

Six hundred and ninety-eight HCC patients with liver resections were reviewed. Preoperative (model 1) and postoperative (model 2) nomogram-based scoring systems were constructed by multivariate analyses, and DFS was estimated.

RESULTS

Among 698 patients, 490 (70.2%) patients had tumor recurrence at a median follow-up of 84.4 months. Risk factors of tumor recurrence in model 1 included viral hepatitis, platelet count, albumin, indocyanine green retention rate, multiplicity of tumor, and radiologic total tumor volume (TTV). Prognostic variables identified in model 2 were viral hepatitis, platelet count, multiplicity of tumor, cirrhosis, microvascular invasion, and pathologic TTV. By nomogram in model 1, the patients were classified into three groups with 5-year DFS of 61.0%, 35.7%, and 21.1%, respectively (P < .0001). In model 2, the patients were divided into five groups with 5-year DFS of 58.0%, 43.7%, 24.0%, 15.4%, and 0.0%, respectively (P < .0001).

CONCLUSION

Based on nomogram models, DFS for the patients who had liver resection for HCC can be predicted before liver resection and re-assessed after liver resection.

COX5B-Mediated Bioenergetic Alteration Regulates Tumor Growth and Migration by Modulating AMPK-UHMK1-ERK Cascade in Hepatoma

The oxidative phosphorylation machinery in mitochondria, which generates the main bioenergy pool in cells, includes four enzyme complexes for electron transport and ATP synthase. Among them, the cytochrome c oxidase (COX), which constitutes the fourth complex, has been suggested as the major regulatory site. Recently, abnormalities in COX were linked to tumor progression in several cancers. However, it remains unclear whether COX and its subunits play a role in tumor progression of hepatoma. To search for the key regulatory factor(s) in COX for hepatoma development, in silico analysis using public transcriptomic database followed by validation for postoperative outcome associations using independent in-house patient cohorts was performed. In which, COX5B was highly expressed in hepatoma and associated with unfavorable postoperative prognosis. In addressing the role of COX5B in hepatoma, the loss- and gain-of-function experiments for COX5B were conducted. Consequently, COX5B expression was associated with increased hepatoma cell proliferation, migration and xenograft growth. Downstream effectors searched by cDNA microarray analysis identified UHMK1, an oncogenic protein, which manifested a positively correlated expression level of COX5B. The COX5B-mediated regulatory event on UHMK1 expression was subsequently demonstrated as bioenergetic alteration-dependent activation of AMPK in hepatoma cells. Phosphoproteomic analysis uncovered activation of ERK- and stathmin-mediated pathways downstream of UHMK1. Finally, comprehensive phenotypic assays supported the impacts of COX5B-UHMK1-ERK axis on hepatoma cell growth and migration.

Performance of ceftazidime/avibactam susceptibility testing methods against clinically relevant Gram-negative organisms

OBJECTIVES

To ensure the accuracy of susceptibility testing methods for ceftazidime/avibactam.

METHODS

The performances of the Etest (bioMérieux), 30/20 μg disc (Hardy diagnostics) and 10/4 μg disc (Mast Group) were evaluated against the reference broth microdilution (BMD) method for 102 clinically relevant Gram-negative organisms: 69 ceftazidime- and meropenem-resistant Klebsiella pneumoniae and 33 MDR non-K. pneumoniae. Essential and categorical agreement along with major and very major error rates were determined according to CLSI guidelines.

RESULTS

A total of 78% of isolates were susceptible to ceftazidime/avibactam. None of the three methods met the defined equivalency threshold against all 102 organisms. The Etest performed the best, with categorical agreement of 95% and major errors of 6.3%. Against the 69 ceftazidime- and meropenem-resistant K. pneumoniae, only the Etest and the 10/4 μg disc met the equivalency threshold. None of the three methods met equivalency for the 33 MDR isolates. There were no very major errors observed in any analysis. These results were pooled with those from a previous study of 74 carbapenem-resistant Enterobacteriaceae and data from the ceftazidime/avibactam new drug application to define optimal 30/20 μg disc thresholds using the error-rate bound model-based approaches of the diffusion breakpoint estimation testing software. This analysis identified a susceptibility threshold of ≤19 mm as optimal.

CONCLUSIONS

Our data indicate that the Etest is a suitable alternative to BMD for testing ceftazidime/avibactam against ceftazidime- and meropenem-resistant K. pneumoniae. The 30/20 μg discs overestimate resistance and may lead to the use of treatment regimens that are more toxic and less effective.

ABO-Incompatible Liver Transplantation: State of Art and Future Perspectives

ABO-incompatible (ABO-I) liver transplantation (LT) has been limited due to the increased rate of complications, including severe cellular and antibody-mediated rejection, hepatic necrosis, hepatic artery thrombosis, and biliary complications. However, several strategies for reducing preformed anti-donor ABO antibodies and B cell desensitization have improved the outcomes of ABO-I LT. As a result, ABO-I LT has become a routine procedure and is a feasible option in countries with a scarce deceased-organ donation or in cases without an available compatible organ donor. In this review, we describe past and present desensitizing protocols as well as emergent therapies for depleting B cell and anti-ABO antibodies with the objective of identifying approaches that could lead to new, refined strategies for maximizing the results of ABO-I LT.

Protein S for Portal Vein Thrombosis in Cirrhotic Patients Waiting for Liver Transplantation

Portal vein thrombus (PVT) is a challenge in liver transplantation. How PVT develops in cirrhotic patients who already have coagulopathy is unclear. This study aimed to investigate possible contributing factors to PVT in cirrhotic patients. A total of 349 cirrhotic patients who waited liver transplantation were included in this study and 48 of them had PVT. For all the patients, the mean age was 53.5 ± 9.0 year old, and 75.9% of the patients were male. There were 233 (66.8%) patients who had either hepatitis B or C. The mean Model For End-Stage Liver Disease (MELD) score was 16.4 ± 7.5. Eighteen of 48 patients with PVT and 145 of 301 patients without PVT received liver transplantation. Multivariate analysis showed that low protein S level (hazard ratio = 2.46, p = 0.017) was the only independent risk factor for PVT development. Protein S deficiency also demonstrated prognostic value on short-term survival, not only for cirrhotic patients awaiting liver transplantation (69.9% versus 84.1% at 1 year survival, p = 0.012), but also for the patients having liver transplantation (70.4% versus 84.8% at 1 year survival, p = 0.047). In conclusion, protein S level was an independent risk factor for PVT development in decompensated cirrhotic patients, and protein S deficiency was also a prognostic factor for the patients waiting for liver transplantation.

Inferior Outcomes Associated with the Coexistence of Hepatocellular Carcinoma Recurrence and Hepatic Virus Reinfection After Living Donor Liver Transplantation

BACKGROUND

Chronic viral hepatitis remains a major etiology of liver cirrhosis and hepatocellular carcinoma. Liver transplantation has been considered an effective treatment for this condition. This study aims to analyze living donor liver transplantation for patients with hepatocellular carcinoma and its relationship with hepatitis virus status.

METHODS

A retrospective analysis of 268 patients who received living donor liver transplantation for hepatocellular carcinoma was performed. Patients were analyzed according to their serologic status of hepatitis virus; clinicopathologic features, operative parameters, and outcomes were also assessed and compared.

RESULTS

Twenty-three patients (8.6%) had hepatocellular carcinoma recurrence following liver transplantation; the most common pattern of recurrence was systemic spreading (n = 10). Hepatitis B virus relapse was encountered in 41 out of 188 patients (21.8%) with hepatitis B virus-positive, and hepatitis C virus reactivation was noted in 48 (60.8%) patients among 79 hepatitis C virus-positive patients. Incidence of hepatitis C virus reactivation was significantly higher than that of hepatitis B virus relapse (p < 0.0001). Hepatocellular carcinoma recurrence and overall survival were not significantly different in relation to hepatitis virus; however, patients who had hepatocellular carcinoma recurrence combined with hepatitis virus reinfection had the significantly lowest survival rate compared with other groups (p < 0.0001).

CONCLUSION

Living donor liver transplantation based on expanded hepatocellular carcinoma criteria achieved a satisfactory result, but reinfection of hepatic virus remains a great concern particularly in patient with hepatitis C. Moreover, hepatocellular carcinoma recurrence accompanied with reinfection of hepatic virus after liver transplantation is associated with inferior outcomes.

Outcomes associated with the intention of loco-regional therapy prior to living donor liver transplantation for hepatocellular carcinoma

BACKGROUND

Loco-regional therapy for hepatocellular carcinoma (HCC) during the period awaiting liver transplantation (LT) appears to be a logical approach to reduce the risk of tumor progression and dropout in the waitlist. Living donor LT (LDLT) offers a flexible timing for transplantation providing timeframe for well preparation of transplantation.

AIM

To investigate outcomes in relation to the intention of pre-transplantation loco-regional therapy in LDLT for HCC patients.

METHODS

A total of 308 consecutive patients undergoing LDLTs for HCC between August 2004 and December 2018 were retrospectively analyzed. Patients were grouped according to the intention of loco-regional therapy prior to LT, and outcomes of patients were analyzed and compared between groups.

RESULTS

Overall, 38 patients (12.3%) were detected with HCC recurrence during the follow-up period after LDLT. Patients who were radiologically beyond the University of California at San Francisco criteria and received loco-regional therapy as down-staging therapy had significant inferior outcomes to other groups for both recurrence-free survival (RFS, P < 0.0005) and overall survival (P = 0.046). Moreover, patients with defined profound tumor necrosis (TN) by loco-regional therapy had a superior RFS (5-year of 93.8%) as compared with others (P = 0.010).

CONCLUSION

LDLT features a flexible timely transplantation for patient with HCC. However, the loco-regional therapy prior to LDLT does not seem to provide benefit unless a certain effect in terms of profound TN is noted.

P5644Hypoglycemic episodes increase the risk of ventricular arrhythmias and sudden cardiac arrest in patients with type 2 diabetes - a nationwide cohort study

Background

Hypoglycemic episode (HE) increases the risk of cardiovascular mortality. The impact of HE on the risk of sudden death remains unclear. We hypothesized that HE increases the risks of ventricular arrhythmia (VA) and sudden cardiac arrest (SCA), and that anti-diabetic agents (ADAs) causing hypoglycemia also increase the risks of VA and SCA.

Methods

Patients aged ≥20 years with newly diagnosed diabetes were identified from the Taiwan National Insurance Database. HE was defined as the presentation of hypoglycemic coma or specified/unspecified hypoglycemia. For control group, we included diabetic patients without HE, and they were frequency-matched to the HE group at a 4:1 ratio. The primary outcome was the occurrence of any event of VA (including ventricular tachycardia and fibrillation) and SCA during the defined follow-up periods. Multivariate Cox hazards regression model was used to evaluate the hazard ratio (HR) for VA or SCA.

Results

A total of 54,303 diabetic patients were screened with 1,037 of them in the HE group, and 4,148 in the control group. During a mean follow-up period of 3.3±2.5 years, 29 VA/SCA events had occurred. Compared to the control group, the HE group had a higher incidence of VA/SCA (adjusted HR: 2.42, p=0.04). Diabetic patients medicated with insulin for glycemic control increased the risk of VA/SCA compared to those without insulin (adjusted HR: 3.05, p=0.01).

Kaplan-Meier survival curves

Conclusions

HEs in patients with diabetes increased the risks of VA and SCA compared to those without. Their use of insulin also independently increased the risk of VA/SCA.

P6204Oral vaccination of Lactococcus lactis expressing Ling Zhi 8 protein prevents nonalcoholic fatty liver and early atherogenesis in cholesterol-fed rabbits

Background

Atherosclerosis is an inflammatory disease characterized by lipid deposits in the subendothelial space leading to severe inflammation. Nonalcoholic fatty liver disease (NAFLD) shares several risk factors with atherosclerosis. Epidemiology studies have indicated that NAFLD may be an independent risk factor for atherosclerosis. Anti-inflammation therapy by inhibiting IL-1β led to a significantly lower cardiovascular event rate in recent clinical trial (CANTOS trial). Ling Zhi 8 (LZ8) is an immunomodulatory protein that possesses a broad range of pharmacological properties, including anti-inflammatory activities.

Methods and findings

In this study, we developed an oral vaccination of Lactococcus lactis expressing LZ8 protein in a nisin-controlled gene expression system and investigated its anti-inflammation properties. Experimental rabbits received commercial rabbit chow supplemented with 2% cholesterol for 5 weeks and recombinant LZ8 L. lactis vaccine once a day on weekdays. The expression of IL-1β in the aorta (Figure A) was significantly suppressed after LZ8 vaccination. Moreover, in hematoxylin and eosin staining of the aorta, the intima-medial thickness was decreased, and foam cells were significantly reduced in the sub-endothelial space (Figure C). LZ8 also inhibited the expression of IL-1β in the liver (Figure B), decreased fat droplet deposits and infiltration of inflammatory cells (Figure D), and improved liver function by decreasing liver enzymes.

Figure 1

Conclusions

Our results suggest that LZ8 could be used as a therapeutic tool to improve both atherosclerosis and NAFLD due to its anti-inflammatory effect.

Acknowledgement/Funding

TCVGH-1067317C, TCVGH-1063108C

P2564Levosimendan shortens action potential duration, decreases alternans threshold and prevents ventricular arrhythmia during therapeutic hypothermia in isolated rabbit hearts

Background

Therapeutic hypothermia (TH) increases the susceptibility to ventricular arrhythmias (VA) by prolonging action potential duration (APD) and facilitating arrhythmogenic spatially discordant alternans (SDA). The calcium sensitizer levosimendan has been reported to shorten APD by enhancing ATP-sensitive K current. We hypothesize that levosimendan might shorten the already prolonged APD during TH, decreasing SDA threshold, and prevent the occurrence of VA.

Methods

Langendorff-perfused isolated rabbit hearts were subjected to 15-min TH (30°C) followed by 30-min treatment with levosimendan (0.5 μM, n=9) or vehicle (n=8). Using an optical mapping system, epicardial APD was evaluated by S1 pacing. SDA threshold was defined as the longest pacing cycle length (PCL) that induced SDA phenomenon. Ventricular fibrillation (VF) inducibility was evaluated by burst pacing for 30 s using the shortest PCL that achieved 1:1 ventricular capture.

Results

Levosimendan shortened the ventricular APD (at PCL 300 ms, from 229±9 ms to 211±18 ms, p=0.02) and decrease the SDA threshold (from 327±88 ms to 311±68 ms, p=0.001) during TH. The VF inducibility was decreased by levosimendan from 39±30% at 30°C to 14±12% after levosimendan infusion. In control hearts, the APD (p=0.75), SDA threshold (p=ns) and VF inducibility (p=0.12) were not changed by vehicle during TH.

Conclusions

Levosimendan protects the hearts against VA during TH by shortening APD and decreasing SDA threshold. Enhancing ATP-sensitive K current with levosimendan might be a novel approach to prevent VA during TH.

Salvage living donor liver transplantation for posthepatectomy recurrence: a higher incidence of recurrence but promising strategy for long-term survival

Background

The scarcity of deceased donor organ donation has led to increasing utilization of living donor liver transplantation (LDLT), which is an optimal treatment for cirrhosis associated with hepatocellular carcinoma (HCC). The study thus aims to analyze prognostic factors and beneficial effects of LDLT for patients with HCC.

Methods

All patients who underwent LDLT for HCC were included in this study. A multivariate analysis of patients’ clinicopathologic parameters was performed to determine prognostic factors. Subsequently, the type of LDLT was further analyzed and compared based on the result of multivariate analysis.

Results

Overall, 36 (11.9%) of 303 patients were identified as having HCC recurrence after LDLT. Salvage LDLT (sLDLT) defined by liver transplantation for those patients with recurrent HCC after primary liver resection (LR) was identified as the major prognostic factor of HCC recurrence following the transplantation (HR=2.49 [1.12–5.54], p=0.025). The HCC recurrence incidence and recurrence-free survival after LDLT were significantly inferior in the salvage group than the other group. The pre-transplantation factors were further evaluated and resulted in only maximum tumour size ≥5 cm at primary LR(HR=10.79 [2.10–55.43], p=0.004) affecting post-transplantation HCC recurrence in those patients who had been performed sLDLT. However, patients receiving salvage LDLT had 5- and 10-year overall survival of 86.7% and 52.9%, respectively, measured from the time of initial HCC diagnosis.

Conclusion

Overall, LDLT achieves a satisfactory result with low incidence of HCC recurrence based on certain transplantation criteria. Despite the higher incidence of HCC recurrence after sLDLT, it remains a promising strategy to improve long-term outcomes.

"Left at right" liver transplantation with heterotopic implantation of left liver graft in the right subphrenic space: Reappraisal and technical concerns for decision making

Conventional orthotopic implantation of left liver grafts is technically demanding and requires consideration of limited space and vascular complications. The study proposed a modified approach termed "left at right" liver transplantation (LAR-LT), wherein left liver grafts were rotated and implanted in right subphrenic spaces. The selection of recipients for this approach is based on the measurement of the right subphrenic space width and left liver graft length, in which a rotated left liver graft could be comfortably placed in the right subphrenic space. A total of 36 recipients who had undergone LAR-LT between July 2006 and December 2017 were retrospectively reviewed. None of recipients died of complications related to this approach immediately after operation. All grafts showed remarkable increment in liver volume and bi-directional regeneration to fit well within the right abdominal cavity. Meanwhile, the alignment of the biliary tree in LAR-LT is quite straight, making no difficulty in both anastomosis during operation and dealing with biliary stenosis afterward. As such, long-term outcome of LAR-LT is satisfactory. Keeping in mind certain technical concerns, a heterotopic LAR-LT might be safely applied as an alternative with an easier reconstruction procedure for select patients.

SAT-032 In Vitro Characterization Of GPR101 Transcriptional Regulation

Background: X-linked acrogigantism (X-LAG) is a novel syndrome of early childhood-onset gigantism caused by duplications of GPR101, a gene that is strongly upregulated in the pituitary adenomas (PAs) of the patients. Aim: To study the human GPR101 promoter. Methods:GPR101 promoter annotation was carried out in silico using the Genomatix and MPromDb softwares and by querying specific tracks in the UCSC Genome Browser. The identified sequences were cloned into reporter vectors and transiently transfected into HEK293 cells. Promoter activity was assessed by luciferase assays and quantitative PCR (qPCR) under normal growth conditions and after treatments with forskolin (10 μM, 6h) and β-estradiol (E2, 100 nM, 24h). Putative binding sites for cAMP responsive elements (CREs) were functionally evaluated by mutagenesis studies. GPR101-specific primers were used for an open chromatin assay. Results:In silico characterization of the GPR101 promoter revealed two putative promoter regions, each overlapping a CpG island. The proximal sequence partially extends into the coding sequence (CDS), is marked by a promoter-specific histone modification (H3K4me3), and harbors one CRE; the distal sequence is located 2 Kb upstream of the start codon and harbors three CREs. In vitro reporter assays confirmed that both sequences were functional (3-fold change over mock for both, P<0.001) and that activation of the cAMP signaling pathway further stimulates GPR101 transcription only via the distal promoter (1.8-fold change over basal, P<0.05). Mutation of two CREs within the distal promoter significantly reduced basal transcription rates and forskolin stimulation could not restore normal expression. Treatment with E2 inhibited basal transcription rates of both promoter sequences (0.3 and 0.4-fold change, respectively, P<0.01). qPCR in cells transfected with a promoterless vector containing only GPR101 CDS showed strong GPR101 levels, suggesting that sequences within the CDS can drive its transcription. However, mutation of a CDS-located CRE did not affect basal or forskolin-stimulated transcription. No endogenous GPR101 transcripts were detected in HEK293 cells. We determined that the lack of correlation between reporter activities and endogenous expression was due to the location of the GPR101 locus in a heterochromatin region. Conclusions: These results show that GPR101 is a gene endowed with a complex promoter that likely allow varying levels of expression as required. Unraveling the transcriptional regulation of GPR101 is an important step towards understanding how this gene is regulated during physiological (development) and pathological (X-LAG) states. The finding that cAMP (a pathway commonly deregulated in PAs) stimulates GPR101 expression and that mutations disrupting CREs negatively impact this expression warrants screening of GPR101 promoter in patients with PAs.

Impact of donor with evidence of bacterial infections on deceased donor liver transplantation: a retrospective observational cohort study in Taiwan

OBJECTIVE

The shortage of available donor organs is an unsolvable concern leading to an expansion in the donor criteria for organ transplantation. Here, we describe our experience and assess the outcomes in recipients who obtained a graft from a donor with bacterial infections in deceased donor liver transplantation (DDLT).

METHODS

All DDLTs between January 1991 and February 2017 were retrospectively reviewed. Patients were categorised into two groups based on the recipients who obtained a graft from a donor with (group I) or without (group II) evidence of bacterial infections. Outcomes and bacterial infections were compared between the two groups of recipients.

RESULTS

Overall, a total of 285 DDLTs were performed from 248 donors consisting of 48 split liver grafts and 208 whole liver grafts. Of those, 98 recipients (group I, 34.3%) were transplanted with a graft from 78 donors with positive bacterial cultures. Donor sputum cultures had the highest rate of positive bacterial growth, accounting for 26.6% of donors. Overall survival (OS) was not significantly different between the two groups (p=0.9746). The OS rates at 1 and 3 years were 73.5% and 69.2%, respectively, in the group I recipients versus 68.8% and 62.4% in the group II recipients. Importantly, no hospital mortality was related to donor-derived bacterial infections.

CONCLUSION

Transmission of bacteria from the donor to the recipient is infrequent in DDLT. Therefore, potential donors with positive bacterial infections should not be excluded for organ transplantation to increase organ availability and ameliorate the organ shortage.

Clinical relevance of alpha-fetoprotein in determining resection margin for hepatocellular carcinoma

Liver resection for hepatocellular carcinoma (HCC) is associated with high recurrence rates. Adequate resection margin which is carried out by surgeons may reduce tumor recurrence. Nevertheless, the margin width remains controversial particularly in cirrhotic patients where optimal parenchymal preservation is necessary. This study aims to find a reference for proposing the resection margin when liver resection is planning.Totally, 534 patients who received liver resection for HCC were included. The clinical profiles of the patients, tumor characteristics and patients' survival were all collected. The patients were classified according to resection margin (<0.5 cm, 0.5-0.99 cm, and ≥1 cm) and preoperative α-fetoprotein (AFP) levels (<15 ng/ml, 15-200 ng/ml, and >200 ng/ml), then survival was calculated.Most of the patients had hepatitis B (52.4%) and hepatitis C (24.0%) infection. Multivariate analysis showed that narrow resection margin (<0.5 cm) (hazard ratio [HR]: 1.323, P = .024), high AFP level (≥15 ng/ml) (HR: 1.305, P = .039), major extent of resection (≥3 segments) (HR: 1.507, P = .034), and underlying cirrhosis (HR: 1.404, P = .009) were independent risk factors for disease-free survival. In further survival analysis, resection margin was not significant for disease-free survival if serum AFP levels were <15ng/ml. However, for the patients with AFP level between 15 and 200 ng/ml, resection margin ≥0.5 cm was significant to improve 5-year disease-free survival from 24.6 months to 38.7 months (P = .040). For the patients with AFP >200 ng/ml, resection margin had to be extended to ≥1 cm to improve 5-year disease-free survival from 33.9 months to 48.8 months (P = .012). When the patients meeting AFP <15 ng/ml with tumor-free margin, AFP between 15 and 200 ng/ml with margin ≥0.5 cm, and AFP level >200 ng/ml with margin ≥1 cm were compared, their survival rates were not different.Adequate resection margin can be guided by pre-operative AFP levels. Tumor-free margin is enough for patients with normal AFP level. A resection margin ≥0.5 cm is advised for the patients with AFP between 15 and 200 ng/ml, and ≥1 cm for the patients with AFP over 200 ng/ml.

Implementation of sorafenib treatment for advanced hepatocellular carcinoma: an illustration of current practice in Taiwan

Background

Sorafenib is the first regimen listed in the treatment algorithm for hepatocellular carcinoma (HCC) worldwide. This study aimed to assess the efficacy of sorafenib treatment for advanced HCC in a clinical practice using a nationwide population study.

Methods

All patients registered with a diagnosis of primary HCC and identified as having been prescribed sorafenib between August 2012 and December 2015 were selected from a national database and retrospectively reviewed. Outcomes related to prescription of sorafenib for these patients were further assessed.

Results

A total of 9,738 patients were enrolled and analyzed. As a result, 32.33% of patients had an initial treatment response and were eligible for the prescribed second term (240 tablets/ term) of sorafenib and 8.91% of patients received more than three terms of sorafenib. Meanwhile, the duration of sorafenib usage beyond 6 months was noted in 15.49% of patients, including 10.59% of patients with a period of usage between 6 and 12 months and 4.9% of patients with more than 12 months usage. Survival analysis showed that patients who received locoregional therapy plus sorafenib had significantly better survival rates than those who underwent only sorafenib treatment. Certain patients who underwent hepatectomy (n=12) or liver transplantation (n=13) were subsequently free of HCC.

Conclusion

The disease control rate of sorafenib in advanced HCC patients in this study seemed similarly poorer as what has been previously reported by clinical trials. The combination of sorafenib and additional treatments could perhaps provide survival benefits and possibly cure disease in combination with surgical management.

Low-dose anti-hepatitis B immunoglobulin regimen as prophylaxis for hepatitis B recurrence after liver transplantation

BACKGROUND

Combination of anti-hepatitis B immunoglobulin (HBIg) and antiviral nucleotide/nucleoside is the most common regimen for prophylaxis against hepatitis B virus (HBV) recurrence. However, what the optimal regimen is for HBIg administration remains subject to debate.

METHODS

Two hundred and thirty-two HBV patients who had liver transplantation were included in this study. According to the decline rate of HBIg, the patients were divided into quick (group Q, n = 95) and slow decline groups (group S, n = 137). Quick HBIg decline was defined as anti-HBs titer <200 IU/mL at postoperative month (POM) 1, when 24 000 IU of HBIg was given perioperatively. HBV recurrence was defined as reappearance of hepatitis B surface antigen (HBsAg).

RESULTS

After a mean (range) follow-up of 42.2 (24.1-76.8) months, the HBV recurrence rate was 12.1% for all 232 patients. The median (interquartile) HBIg titer was 96.2 (41.0-158.0) IU in group Q patients, compared to 418.0 (298.8-692.8) IU in group S patients at POM 1 (P < .001). For the patients in group Q, 18 patients (18.9%) had HBV recurrence; this was higher than the 10 (7.3%) patients in group S (P = .013). Multivariate analysis showed that quick HBIg decline and hepatocellular carcinoma recurrence were the risk factors for HBV recurrence.

CONCLUSION

Perioperative low-dose HBIg and antiviral nucleotide/nucleoside can effectively prevent HBV recurrence in patients with slow HBIg decline. For patients with quick HBIg decline, the idealized HBIg and antiviral agent regimen should be adjusted to establish an effective regimen as prophylaxis against HBV recurrence.

Targeting HSP60 by subcutaneous injections of jetPEI/HSP60-shRNA destabilizes cytoplasmic survivin and inhibits hepatocellular carcinoma growth

Heat shock protein 60 (HSP60) overexpresses in various types of cancer, but its expression levels and functions in hepatocellular carcinoma (HCC) are still in dispute. We aim to clarify this issue and examine whether HSP60 could be a therapeutic target for HCC. We found drastically enhanced cell apoptosis and suppressed cell proliferation in two HCC cell lines with HSP60-silencing, and also indicated survivin was involved in this regulatory process in vitro and in vivo. However, HSP60-silencing in normal human hepatocytes only resulted in a minimal reduction of cell proliferation but without effects on cell apoptosis. We also showed HSP60 interacted with cytosolic but not mitochondrial survivin by immunoprecipitation assay. A rigorous method was used to standardize quantification from immunoblot assay to obtain more precise expression levels of HSP60 and survivin. The expression of HSP60 and survivin positively correlated in both cancerous and non-cancerous liver tissues (P < 0.001) after analyzing 145 surgically removed HCC tissues. A total of 56.6% of HCC patients overexpressed HSP60 in cancerous tissues, and 40.0% under-expressed HSP60. Higher expression of HSP60 and survivin in non-cancerous tissues both correlated with shorter overall survival (P = 0.029 and P < 0.001, respectively). Finally, we evaluated the therapeutic potential of HSP60 using extraneous delivery of jetPEI/shHSP60 complexes. The treatment results showed significant reduction of tumor weight by 44.3% (P < 0.05), accompanied by under-expression of survivin. These studies suggested that HSP60 not only served as a prognostic marker but also served as a novel therapeutic target for HCC.

Clinical relevance of oncologic prognostic factors in the decision-making of pre-hepatectomy chemotherapy for colorectal cancer hepatic metastasis: the priority of hepatectomy

Background

Although liver resection (LR) provides the best chance of long-term survival for patients with colorectal cancer (CRC) hepatic metastasis, concerns regarding chemotherapy before liver resection remain unresolved.

Methods

A retrospective review of patients who underwent curative LR for CRC hepatic metastasis between January 2008 and February 2016 was performed. Outcome relevance based on oncologic prognostic factors and chemotherapy prior to liver resection was assessed.

Results

Patients who had received pre-hepatectomy chemotherapy for CRC hepatic metastasis and delayed liver resection had a worse outcome in terms of CRC recurrence following liver resection. The hazard ratio (HR) of pre-hepatectomy chemotherapy in patients with minor oncologic prognostic factors was 1.55 (confidence interval, CI = 1.07–2.26, p = 0.021) for CRC recurrence after liver resection for hepatic metastasis, whereas the HR of pre-hepatectomy chemotherapy was 1.34 (CI = 0.99–1.81, p = 0.062) for CRC recurrence in patients with multiple oncologic prognostic factors.

Conclusion

The administration of pre-hepatectomy chemotherapy and delaying liver resection seems not to be an optimal strategy to provide a clinical benefit for patients with CRC hepatic metastasis. Hence, liver resection should be attempted without delay at the initial detection of CRC hepatic metastasis whenever possible.

Impact of neutrophil to lymphocyte ratio on survival for hepatocellular carcinoma after curative resection

BACKGROUND

Neutrophil-lymphocyte ratio (NLR) represents a pro-tumor inflammatory environment and host immunity. The aim of this study was to examine the effect of subsequent NLR for hepatocellular carcinoma (HCC) after liver resection.

METHODS

A total of 672 patients had liver resection for HCC were included in this study. NLR at diagnosis of HCC and HCC recurrence were collected. NLR at 2.5 was used as cut-off value to calculate its prognostic effect.

RESULTS

According to NLR cut-off value, the patients with NLR >2.5 had larger tumor size, higher histology grade, and higher rates of tumor multiplicity and vascular invasion. After a median follow-up of 76.3 months, 437 (65.0%) patients had tumor recurrence. The 1-, 3- and 5-year recurrence-free survival were 77.4%, 55.2% and 44.8% in NLR ≤2.5 group, compared to 64.1%, 45.2% and 35.5% in NLR >2.5 group (P = 0.016). When patients had tumor recurrence, 5-year post-recurrent survival was best in the patients staying with NLR ≤2.5 all the time and decreased from 45.9% to 24.6% if NLR was ≤2.5 at resection and became >2.5 at recurrence (P = 0.013).

CONCLUSION

High NLR was an independent unfavorable prognostic factor. Subsequent change of NLR between liver resection and HCC recurrence could predict post-recurrent survival.

Down-regulation of metabolic proteins in hepatocellular carcinoma with portal vein thrombosis

BACKGROUND

Hepatocellular carcinoma is an aggressive malignancy with poor prognosis and easy to recur even the tumor is totally removed by surgery. Portal vascular invasion is one of the major factors contributing to tumor recurrence and poor prognosis. However, why hepatocellular carcinoma is easy to grow into vessels is unclear.

METHODS

Surgical specimens from seven hepatocellular carcinoma patients with portal vein thrombosis and seven patients without vascular invasion were utilized to analyze protein expression by proteomic technique. The proteins in the tumors were separated by 2-dimensional electrophoresis. Protein patterns in the gels were recorded as digitalized images. The differences of expression in hepatocellular carcinoma with or without portal vein thrombosis were identified by mass spectrometry.

RESULTS

Clinically, the tumors with portal vein thrombosis were larger than those without portal vein thrombosis. The median survival time for the patients with portal vein thrombosis was much shorter [4 (ranged 2.5-47) vs. 53 (ranged 33-85) months, p = 0.002]. By analyzing the protein expression in cancer tissues with or without portal vein thrombosis, the differences of protein expression were mainly metabolic enzymes. Carbonic anhydrase I, betaine-homocysteine S-methyltransferase 1, fumarate hydratase, isovaleryl-CoA dehydrogenase, short-chain specific acyl-CoA dehydrogenase and arginase-1 were all down-regulated in the tumors with portal vein thrombosis.

CONCLUSION

Metabolic enzymes and cytosol carbonic anhydrases were downregulated in hepatocellular carcinoma with portal vein thrombus. The deficiency of metabolic enzymes and cytosol carbonic anhydrases may alter cellular metabolisms and acid-base balance in hepatocellular carcinoma, which may facilitate to invade portal vein.

Prognostic impact and risk factors of low body mass index in patients undergoing liver transplantation

We aimed to investigate the effect of body mass index (BMI) on the overall survival rates and to identify the risk factors associated with adverse outcomes. A total of 381 adult-to-adult living donor liver transplantations performed were retrospectively analyzed. These patients were classified according to the BMI categories established by the World Health Organization: The underweight group (BMI<18.5 kg/m² ) and the non-underweight group (BMI≥18.5 kg/m² ). The underweight group had significantly worse outcomes, compared with that of the non-underweight group (5-year overall survival: 45.6% vs 74.6%, P<.001). Underweight patients with CD4/CD8 ratio <1.4 had a significant worse prognosis, compared with those with CD4/CD8 ratio ≥1.4. (The 1-, 3-, and 5-year overall patient survival rates in both groups were 71.0% vs 20%, 58.9% vs 0%, and 53.6% vs 0%, respectively, P=.002.) In the multivariate analysis, only CD4/CD8 ratio <1.4 was an independent poor prognostic factor (hazard ratio=7.063, 95% confidence interval=1.329-37.547, P=.022).

CONCLUSIONS

Pre-operative CD4/CD8 ratio <1.4 is an independent poor prognostic indicator for underweight patients undergoing liver transplantation. Early intervention in replenishing the nutrient deficit and cautious use of immunosuppressive regimens are essential to prepare this high-risk population for a more successful liver transplantation.

Abstract 3133: NF-κB-dependent inflammatory responses offset sorafenib cytotoxicity in hepatocellular carcinoma via TIFA

Sorafenib is the promising first-line drug to treat advanced hepatocellular carcinoma (HCC), with the acquired resistance within 6 months in most treated patients. The epithelial-mesenchymal transition (EMT)-driven cancer metastasis contributes to sorafenib resistance via multiple signaling pathways, but the underlying molecular mechanism remains elusive. Recent studies showed that inflammatory cytokines TNF-α functionally initiates EMT through NF-κB mediated Snail activation in HCC, and that TRAF-interacting protein TIFA sustains the positive feedback loop between TNF-α and NF-κB that enhances chemoresistance in AML. Here we investigated the functional link between TIFA-regulated NF-κB inflammatory signaling and sorafenib resistance as a potential therapeutic target in the treatment of HCC. We showed that severe hepatitis induced in HCC mice promoted intrahepatic metastasis concurrently with NF-κB-driven EMT via Snail, and that HCC patients with hepatitis displayed poorer responses to sorafenib and unfavorable clinical outcome. In support, inflammatory TNF-α stimulation promoted levels of TIFA, NF-κB signaling factors, and EMT axis independent of sorafenib treatment, while silencing of TIFA or RelA perturbed sorafenib-dependent cytokine secretion in HCC cells. In addition, silencing of TIFA or RelA suppressed pro-survival factors Bcl-2 and Bcl-XL, and promoted pro-apoptotic factor BAX in response to sorafenib treatment in vitro. Consequently, HCC cells regained sorafenib chemosensitivity upon silencing of TIFA or RelA through promoted apoptosis. To further explore the therapeutic relevance, shRNAs were delivered using the liver-tropic adeno-associated virus serotype 8 in mice with orthotopic HCC xenografts, and results showed that targeting TIFA or RelA specifically enhanced sorafenib chemotoxicity resulting in more prominent tumor regression. Our results collectively showed that TIFA and NF-κB support inflammatory responses to offset sorafenib cytotoxicity, and that their targeting are therapeutically effective concomitant with sorafenib treatment in HCC.

Citation Format: Tong-You Wade Wei, Pei-Yu Wu, Ting-Jung Wu, Ming-Daw Tsai. NF-κB-dependent inflammatory responses offset sorafenib cytotoxicity in hepatocellular carcinoma via TIFA [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3133. doi:10.1158/1538-7445.AM2017-3133

Abstract 3123: Identification of TIFA as a novel therapeutic target in acute myeloid leukemia

Aurora A-dependent NF-κB signaling portends poor prognosis of cancers including acute myeloid leukemia (AML). Our previous study demonstrated that phosphorylation-dependent oligomerization of TRAF-interacting protein with FHA domain (TIFA) triggers the activation of NF-κB. The present study identifies that Aurora A is an essential kinase for the Thr9 phosphorylation of TIFA, and that TIFA functionally mediates the Aurora A-driven NF-κB survival pathway in AML. Overexpression of TIFA occurred concurrently with Aurora A and NF-κB signaling factors in de novo AML patients but not healthy individuals, and also correlated with poor prognosis. Silencing of TIFA specifically attenuated leukemic cell growth and enhanced chemosensitivity of AML cells via down-regulation of pro-survival factors Bcl-2 and Bcl-XL that support NF-κB-dependent anti-apoptotic events. In addition, molecular targeting of TIFA perturbed leukemic cytokine secretion and significantly lowered the IC50 of chemotherapeutic drugs to treat AML cells. Furthermore, in vivo delivery of TIFA-inhibitory fragments potentiates the clearance of leukemic myeloblasts in the bone marrow of xenograft-recipient mice via enhanced chemotoxicity, similar to the effect of anti-inflammatory drug treatments. Collectively, we proposed that TIFA functionally supports the positive feedback between TNF-α, Aurora A, and NF-κB to facilitate AML survival signaling, and impairment in this pathway can enhance the efficacy of AML treatments.

Citation Format: Pei-Yu Wu, Tong-You Wade Wei, Ting-Jung Wu, Ming-Daw Tsai. Identification of TIFA as a novel therapeutic target in acute myeloid leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3123. doi:10.1158/1538-7445.AM2017-3123

GALNT14 genotype-guided, sorafenib in combination with transarterial chemoembolization in hepatocellular carcinoma: An interim report of a prospective randomized controlled trial

e15657

Background: Sorafenib is the only approved targeted agent for treatment of unresectable hepatocellular carcinoma (HCC). Transarterial chemoembolization (TACE) is the mainstay of treatment for advanced HCC patients in Barcelona Clinical Liver Cancer (BCLC) stage B. Previous randomized controlled trials did not show definite beneficial effect for TACE + sorafenib combination therapy in Asian HCC patients. Recently, an SNP marker on GALNT14gene, rs9679162, was found associated with therapeutic outcomes in HCC patients receiving chemotherapy or chemoembolization, wherein rs9679162-TT genotype was associated with a favorable therapeutic response. In this study, we examined whether this marker could be used as a guide for TACE + sorafenib therapy. Methods: From 2015-Aug, HCC patients in BCLC stage B were genotyped for GALNT14-rs9679162. Patients with genotype TT were treated with TACE alone. Patients with non-TT (CT or CC) were randomized 1:1 to receive TACE + sorafenib treatment or TACE treatment alone (NCT02504983). Results: Interim analysis was performed on 2017-Jan. Totally 40 patients were enrolled. Of them, 16 and 24 patients had GALNT14-TT and non-TT genotypes, respectively. Of the non-TT patients, 11 and 13 patients were randomized into TACE alone (TACEA) and TACE + sorafenib (TACE+S) group. TACEA patients had significant shorter time-to-tumor progression compared with TACE+S (P = 0.019) and GALNT14-TT patients (P < 0.001). No significant difference was found for time-to-therapeutic response (CR + PR) between the three groups. However, when evaluating the time-to-therapeutic response occurring > 3 m of the first TACE (excluding early response), it was found that TACEA patients had significant longer time-to-therapeutic response compared with TACE+S (P = 0.046) and GALNT14-TT patients (P = 0.034). Conclusions: The interim analysis confirmed that patients with GALNT14-TT genotype had a favorable TACE response compared with the non-TT genotype. In addition, in patients with non-TT genotype, TACE + sorafenib combination therapy had a significantly better therapeutic response compared with TACE alone. Clinical trial information: NCT02504983.

Metformin confers risk reduction for developing hepatocellular carcinoma recurrence after liver resection

BACKGROUND

Hepatocellular carcinoma recurrence following liver resection remains a great concern. The study aims to examine the chemopreventive effect of metformin in patients undergoing liver resection for hepatocellular carcinoma from a population-based study.

METHODS

All patients registered as having hepatocellular carcinoma between January 1995 and December 2011 in a nationwide database were retrospectively analysed. Outcomes related to liver resection and the presence of diabetes mellitus were assessed. Prognosis in terms of the use of metformin was further explored, in which only patients in the long-term follow-up starting at 2 years were included for analysis.

RESULTS

Patients with diabetes mellitus had a significantly poorer outcome than patients without diabetes mellitus. Among diabetes mellitus patients, metformin users had significantly better survival curves in both recurrence-free survival (P<.0001) and overall survival (P<.0001) after liver resection. The hazard ratio of metformin use in hepatocellular carcinoma patients with diabetes mellitus was 0.65 (P<.05, 95% CI=0.60-0.72) for hepatocellular carcinoma recurrence and 0.79 (P<.05, 95% CI=0.72-0.88) for overall survival after liver resection. The risk reduction in hepatocellular carcinoma recurrence after liver resection was significantly associated with a dose/duration dependent of accumulated metformin usage.

CONCLUSION

Diabetes mellitus has an adverse effect on patients with hepatocellular carcinoma regardless of treatment modality. The use of metformin significantly reduces the risk of hepatocellular carcinoma recurrence and improves the overall outcome of patients after liver resection if patients survives the initial 2 years. Nonetheless, a prospective controlled study is recommended for validating the metformin use on preventing postoperative hepatocellular carcinoma recurrence.

Aurora A and NF-κB Survival Pathway Drive Chemoresistance in Acute Myeloid Leukemia via the TRAF-Interacting Protein TIFA

Aurora A-dependent NF-κB signaling portends poor prognosis in acute myeloid leukemia (AML) and other cancers, but the functional basis underlying this association is unclear. Here, we report that Aurora A is essential for Thr9 phosphorylation of the TRAF-interacting protein TIFA, triggering activation of the NF-κB survival pathway in AML. TIFA protein was overexpressed concurrently with Aurora A and NF-κB signaling factors in patients with de novo AML relative to healthy individuals and also correlated with poor prognosis. Silencing TIFA in AML lines and primary patient cells decreased leukemic cell growth and chemoresistance via downregulation of prosurvival factors Bcl-2 and Bcl-X_L that support NF-κB-dependent antiapoptotic events. Inhibiting TIFA perturbed leukemic cytokine secretion and reduced the IC₅₀ of chemotherapeutic drug treatments in AML cells. Furthermore, in vivo delivery of TIFA-inhibitory fragments potentiated the clearance of myeloblasts in the bone marrow of xenograft-recipient mice via enhanced chemotoxicity. Collectively, our results showed that TIFA supports AML progression and that its targeting can enhance the efficacy of AML treatments. Cancer Res; 77(2); 494-508. ©2016 AACR.

Peripheral and Central Mechanisms Involved in the Hormonal Control of Male and Female Reproduction

Reproduction involves the integration of hormonal signals acting across multiple systems to generate a synchronised physiological output. A critical component of reproduction is the luteinising hormone (LH) surge, which is mediated by oestradiol (E2 ) and neuroprogesterone interacting to stimulate kisspeptin release in the rostral periventricular nucleus of the third ventricle in rats. Recent evidence indicates the involvement of both classical and membrane E2 and progesterone signalling in this pathway. A metabolite of gonadotrophin-releasing hormone (GnRH), GnRH-(1-5), has been shown to stimulate GnRH expression and secretion, and has a role in the regulation of lordosis. Additionally, gonadotrophin release-inhibitory hormone (GnIH) projects to and influences the activity of GnRH neurones in birds. Stress-induced changes in GnIH have been shown to alter breeding behaviour in birds, demonstrating another mechanism for the molecular control of reproduction. Peripherally, paracrine and autocrine actions within the gonad have been suggested as therapeutic targets for infertility in both males and females. Dysfunction of testicular prostaglandin synthesis is a possible cause of idiopathic male infertility. Indeed, local production of melatonin and corticotrophin-releasing hormone could influence spermatogenesis via immune pathways in the gonad. In females, vascular endothelial growth factor A has been implicated in an angiogenic process that mediates development of the corpus luteum and thus fertility via the Notch signalling pathway. Age-induced decreases in fertility involve ovarian kisspeptin and its regulation of ovarian sympathetic innervation. Finally, morphological changes in the arcuate nucleus of the hypothalamus influence female sexual receptivity in rats. The processes mediating these morphological changes have been shown to involve the rapid effects of E2 controlling synaptogenesis in this hypothalamic nucleus. In summary, this review highlights new research in these areas, focusing on recent findings concerning the molecular mechanisms involved in the central and peripheral hormonal control of reproduction.

Validation of the Model for End-Stage Liver Disease Score Criteria in Urgent Liver Transplantation for Acute Flare Up of Hepatitis B

Acute flare up of hepatitis B in noncirrhotic liver with rapid liver function deterioration is a critical condition. This flare up of hepatitis B may be subsided under medical treatments, otherwise urgent liver transplantation is needed. However, the necessity of urgent liver transplantation is hard to decide. In this institute, the indications of urgent liver transplantation for acute flare up of hepatitis B in noncirrhotic liver were settled according to the model for end-stage liver disease (MELD) scores: once upon MELD scores ≥35 (criterion 1) or MELD score < 35 at beginning and increased in the subsequent 1 to 2 weeks (criterion 2). This study was to examine whether MELD score criteria for liver transplantation were valid in such an urgent condition. Eighty-three patients having acute flare up of hepatitis B virus with total bilirubin ≥17.5 mg/dL were included in this study. Among 83 patients, 20 patients met criterion 1. Five patients were transplanted and 15 patients died of liver failure with a median survival of 17 days. Fifty-one patients met criterion 2. Nineteen were transplanted, 30 patients died of liver failure with a median survival of 23.5 days, and 2 patients recovered from this critical condition. The other 12 patients did not meet criteria 1 and 2, and urgent liver transplantation was spared although 5 patients needed liver transplantation in subsequent 2 to 3 months. Therefore, the sensitivity of MELD score criteria for urgent liver transplantation was 100% and specificity was 85.7%. In conclusion, determination of urgent liver transplantation for hepatitis B with acute liver failure is crucial. MELD score criteria are valid to make a decision of urgent liver transplantation for hepatitis B patients with acute flare up and liver failure.