The long-term effects of immune suppression on liver transplant recipients with recurrent hepatitis C viral infection.

INTRODUCTION: Adequate immune suppression following liver transplantation in recipients with recurrence of hepatitis C virus (HCV) is not standardized. The aim of this study was to evaluate the association between immune suppression protocol and the clinical/histological parameters in HCV transplant recipients with an HCV recurrence. METHODS: A retrospective analysis was performed on recipients of liver transplants from June 1998 to October 2003 who experienced HCV recurrence. Only patients with liver biopsies at 3 to 5 years following liver transplantation were included in the analysis. The data set included: patient demographics, immune suppression, antiviral therapies, as well as histology to evaluate ductopenia and chronic rejection. Patients divided into groups of high, medium, and low immune suppression were subdivided by treatment with versus without interferon. A control group with similar demographics suffering from cryptogenic cirrhosis was used for comparison. RESULTS: During this period 45 patients had liver biopsies at 3 to 5 years posttransplantation. Their mean age was 56.5 years and mean time from transplant to biopsy was 1543 days. Their average posttransplant survival was 1964 days. There was no difference among the three groups with respect to HCV RNA levels (log(10) IU/mL), age, gender, time from transplant, donor age, and UNOS status. Median HCV RNA levels within the three groups were comparable at various time periods pre- and posttransplant. CONCLUSION: The development of chronic allograft damage following transplantation in recipients with recurrent HCV tended to be worse among patients with low levels of immune suppression, suggesting the importance of therapy to maintain allograft function.

Topical testosterone treatment for chronic allograft failure in liver transplant recipients with recurrent hepatitis C virus.

INTRODUCTION: Liver transplant recipients with allograft failure due to recurrent hepatitis C virus (HCV) infection often develop marked muscle wasting and ascites prior to death and are denied repeat liver transplantation. We sought to determine whether topical testosterone therapy is associated with improved muscle mass and survival in patients with chronic allograft failure post-liver transplant. METHODS: We performed a retrospective review of liver transplant recipients with chronic allograft failure. Group 1 patients were treated for >6 months with testosterone gel 1%; group 2 patients were untreated. RESULTS: Fourteen patients were identified with stage 3 or 4 fibrosis, muscle wasting, and allograft failure due to recurrent HCV. Group 1 (n=9) patients had statistically significant improvement in albumin, testosterone, muscle strength, well-being, and MELD/CTP scores, while there was no improvement seen for any of these parameters in group 2 (n=5). There were no deaths in group 1, while four of five patients in group 2 died on average 84 days posttransplant. Adverse effects of testosterone treatment included lower extremity edema (which resolved upon dose adjustment), hypertension, and pruritus. CONCLUSIONS: Topical testosterone gel appears to increase muscle strength, stimulate albumin synthesis, and improve survival in patients with allograft failure post-liver transplant.

Preservation injury patterns in liver transplantation associated with poor prognosis.

Preservation injury (PI) is defined as hepatic dysfunction that occurs within 10 days of liver transplantation (OLT) but spontaneously resolves. However, we noted two new patterns: one characterized by histologic evidence of preservation injury that occurs at later than 10 days post-OLT (late PI), and a second, of persistent charge in liver biopsies > 10 days post-OLT (persistent PI). To characterize these new patterns, we performed a retrospective study of patients who underwent liver biopsies for hepatic dysfunction post-OLT from September 1993 to March 1998. The outcome of the 61 patients with preservation injury on liver biopsy after OLT was followed until the last clinic visit or death. Thirty patients had early PI, 16 patients had persistent preservation injury and 15 patients, late onset preservation injury. There were no significant differences in the age (P =.28), sex (P =.77), follow-up time (P =.78), cold ischemia (P =.3), or warm ischemia time (P =.16) between these groups. There was also no significant association between early preservation injury or persistent preservation injury with the development of acute or chronic rejection (P =.19). The overall survival rates at 1, 3, and 5 years was 52%, 45%, and 45%, respectively. There was no significant difference in survival between early, persistent, and late PI patterns (P =.59), although there was a trend toward better survival for patients with early preservation injury. The survival of OLT patients with persistent or late preservation injury is poor and should prompt consideration for retransplantation.

A pilot trial of recombinant interleukin-12 in patients with chronic hepatitis C who previously failed treatment with interferon-alpha.

OBJECTIVE: Interleukin-12 is a cytokine with a multitude of immunomodulatory actions. Currently, interferon-alpha (IFN-alpha) monotherapy and combination treatment with IFN and ribavirin are the only therapies with proven efficacy against chronic hepatitis C infection. The purpose of this study was to assess the safety and antiviral activity of recombinant interleukin-12 (rhIL-12) in adults with chronic hepatitis C who did not achieve a sustained response to previous IFN-alpha therapy. METHODS: This was a randomized, placebo-controlled, double-blind trial. We randomized 24 patients to one of three dose groups: 30 ng/kg, 100 ng/kg, and 300 ng/kg. Within each group, six patients received rhIL-12, and two patients received placebo administered s.c. twice a week for 12 wk. RESULTS: Three of six patients treated with rhIL-12 at a dose of 300 ng/kg had loss of detectable hepatitis C RNA by reverse transcription-polymerase chain reaction compared with the placebo group (p = 0.05). All patients relapsed at the end of the 3-month treatment period. No other dose group demonstrated a loss of detectable hepatitis C RNA. CONCLUSIONS: RhIL-12 at 300 ng/kg can suppress hepatitis C RNA to undetectable levels by reverse transcription-polymerase chain reaction, although relapse occurred when treatment was stopped. RhIL-12 was well tolerated with the most common side effects being flu-like symptoms and headaches.

The first case report of the use of a zoom videoendoscope for the evaluation of small bowel graft mucosa in a human after intestinal transplantation.

BACKGROUND: Control of allograft rejection remains the most difficult dilemma in intestinal transplantation. Standard endoscopic surveillance to date has not been always accurate in the diagnosis of rejection. We describe the first application of a zoom video endoscope in monitoring graft mucosa in humans after intestinal transplantation. METHOD: A zoom video endoscope, which can magnify the image up to 100-fold, was used in this study. The patient was a 31-year-old man who received an isolated intestinal transplant. Surveillance endoscopy with the zoom video endoscope was performed through the ileostomy. Endoscopic biopsies were done at the same time. RESULTS: The zoom video endoscope showed the microscopic architecture of the graft mucosa such as villi and crypts with outstanding quality. We found that an enlargement of the crypt areas appeared to correlate with morphologic changes of early rejection. This finding was reversed with the treatment of rejection. CONCLUSIONS: The zoom video endoscope successfully showed the detailed information of intestinal mucosa. The ability to visualize a more representative view of the graft mucosa could lead to better detection of early rejection. A greater experience with this unique method will provide more accurate assessment of the intestinal allograft.

Extracorporeal photopheresis alone and with interferon-alpha2a in chronic hepatitis C patients who failed previous interferon therapy.

Extracorporeal photopheresis (ECP) is approved for treatment of cutaneous, T-cell lymphoma. Evidence suggests that ECP can induce an immune response against tumor antigens expressed by malignant T lymphocytes. We theorized that if HCV-infected PBMCs express viral antigens, ECP could demonstrate antiviral activity by eliciting an immune response against these antigens. Fifteen cirrhotic patients with genotype-1 HCV, who had previously relapsed or not responded to interferon-alpha (IFN-alpha) therapy were stratified by their HCV RNA titer into one of three treatment groups: (1) ECP alone, (2) ECP + 3 MIU IFN-alpha2a subcutaneously three times a week and (3) ECP + 6 MIU IFN-alpha2a subcutaneously three times a week. All patients received treatment for 24 weeks. Group 1 had no significant decrease in HCV RNA. Two patients in group 2 had undetectable HCV RNA at the end of treatment. One patient in group 3 had undetectable HCV RNA at the end of treatment. However, HCV RNA was detected in all three patients during follow-up. ECP alone or with IFN-alpha was well tolerated. ECP alone demonstrated no clear antiviral activity. The combination of ECP and IFN-alpha resulted in an end-of-treatment response (ETR) in three of 10 patients. All responders had elimination of serum HCV RNA by three months, although no patient had a sustained response. More intensive therapy for a longer duration may result in sustained responses. A multicenter trial is now underway.

Quantitative assessment of hepatitis C virus RNA in peripheral blood mononuclear cells during therapy with interferon-alpha2a.

A significant number of patients with hepatitis C (HCV) treated with interferon (IFN) will initially clear their serum of HCV RNA, but will then have recurrence of viraemia either during or after therapy. One proposed mechanism for relapse is that HCV may persist in peripheral blood mononuclear cells (PBMCs) and that the PBMCs serve as a 'viral reservoir' that is resistant to IFN. To address this hypothesis, we performed serial, quantitative polymerase chain reaction (PCR) of HCV RNA in serum and PBMCs from 26 consecutive patients treated with IFN-alpha2a. Of the 26 patients, 11 (42%) did not clear virus from their serum during therapy and were termed non-responders. Five patients (19%) had sustained clearance of virus from serum and were termed complete responders. The remaining 10 patients (39%) initially eliminated HCV RNA from their serum, but had relapse of viraemia. They were termed partial responders. In all 10 partial responders HCV RNA was undetectable in PBMCs at the same time that it was undetectable in serum. When virus recurred in serum, it was preceded by or occurred at the same time as the return of virus in PBMCs. The results of our study indicate that PBMCs did not serve as an IFN-resistant 'viral reservoir' during therapy. Partial responders who transiently cleared virus from serum also cleared virus from PBMCs and the presence or titre of HCV RNA in PBMCs at the initiation of therapy did not predict response to therapy.

cDNA sequencing of the 5' noncoding region (5' NCR) to determine hepatitis C genotypes in patients with chronic hepatitis C.

Reports suggest that response to interferon-alpha therapy is influenced by both hepatitis C viral genotype and titer. Our aim was to determine if direct, automated, cycle sequencing of the PCR product from an HCV RNA detection assay could be used to reliably determine HCV genotype. In addition, the approach was used to determine the HCV genotype distribution in our patient population and to learn if there was a correlation between HCV genotype and RNA titer that could be used to predict response to treatment. In all 143 consecutive patients were tested for both HCV RNA titer and genotype. Automated, cycle sequencing of PCR product was highly effective and failed to yield a genotype in only 3 (2%) patients. The distribution of HCV genotypes was: 1a (40%), 1b (39%), 2a (2%), 2b (6%), 3a (4%). There were significant differences in the median HCV RNA titers between genotypes 1, 2, and 3. High HCV RNA titers >4.4 x 10(6) copies/ml were only seen in genotype 1. However, the HCV RNA level should not be used as a surrogate marker of genotype because of a significant overlap of titers within the genotypes.

Fatal hyperammonemia following orthotopic lung transplantation.

There have been anecdotes of unexplained coma and death in patients after otherwise successful orthotopic lung transplantation. A patient with primary pulmonary hypertension who underwent a technically uncomplicated single orthotopic lung transplantation is described. The patient developed intractable status epilepticus 4 days after surgery in association with the presence of a markedly elevated plasma ammonium level. Despite multiple therapeutic interventions, the hyperammonemia ultimately resulted in the patient's death. Both metabolic and enzymatic studies showed that the unique physiological disturbance in this disorder results at least in part from defective in vivo conversion of waste nitrogen to urea and increased production of waste nitrogen. Although the rate of hepatic ureagenesis was therefore insufficient to prevent accumulation of ammonium, the cause was not severe liver disease. Liver histology showed widespread, microvesicular steatosis on light-microscopic examination, but only electron-microscopic examination showed severe microvesicular steatosis with severe mitochondrial injury. As in Reye's syndrome, it was unclear whether the hepatic mitochondrial injury played a role in development or if it was the result of hyperammonemia. We recommended that any patient with an unexplained alteration of mental status after solid organ transplantation be evaluated for hyperammonemia.

Transjugular intrahepatic portosystemic shunting: decreased survival for patients with high APACHE II scores.

OBJECTIVES: To determine which clinical characteristics are associated with decreased survival after transjugular intrahepatic portosystemic shunting (TIPS). METHODS: Forty-nine consecutive patients were treated with TIPS; 46 of them had refractory variceal bleeding. Univariate statistics and logistic regression analyses were used to determine the relationship between clinical, biochemical, and hemodynamic variables and 30-day) survival. RESULTS: Shunt insertion was successful in 48 (98.0%) of 49 cases. Median portal-systemic gradient was reduced from 22.5 (range 9-36) [median (5th-95th percentile)] to 12 (range 4-20) mm Hg. Thirty (61.2%) of 49 patients survived more than 30 days; four patients died more than 30 days after TIPS in mean follow-up of 8.4 months. Significant differences (p < 0.05) were found between those who survived more than 30 days and those who did not, with respect to preprocedural prothrombin time, bilirubin, albumin, alanine aminotransferase, and treatment with vasopressin and nitrates, balloon tamponade, or mechanical ventilation. Whereas there were no significant differences between the pre- and post-TIPS portal vein pressures and portal-systemic gradients in survivors and non-survivors, the pre- and post-TIPS hepatic vein pressures were significantly lower in survivors. Survival was inversely proportional to Child-Pugh class (p < 0.01) and to APACHE II score (p < 0.01). The single determinant most closely associated with decreased survival in the month after TIPS was the APACHE II score, a score of 18 stratifying patients into those at low and high risk of mortality [odds ratio 21.7 (CI 3.6-131.7)]. Only 1 (7.7%) of 13 patients with Child-Pugh C cirrhosis and an APACHE II score exceeding 18 survived more than 30 days. CONCLUSIONS: Patients with advanced cirrhosis, especially those with high pre-TIPS APACHE II scores, are at high risk for reduced survival after TIPS, despite adequate portal decompression.

Effect of long-term treatment with ursodiol on clinical and biochemical features and biliary bile acid metabolism in patients with primary biliary cirrhosis.

The effect of ursodiol on the clinical and biochemical features, serum, urinary, and biliary bile acids was investigated over a 2-yr treatment period in 14 patients with primary biliary cirrhosis (stages II-IV). Pruritus and fatigue improved, and alkaline phosphatase and liver transferases declined significantly in all patients during therapy. In four patients, less inflammation was noted by liver biopsy after 2 yr, but histology of disease did not change. Serum and urinary bile acids were increased several-fold before treatment, with cholic acid predominating. Ursodiol accounted for 30% of biliary bile acids after administration (gallstone subjects approximately 50%), and was conjugated with glycine and taurine in a ratio of 7.3:1. However, in the endogenous bile acids, the ratio increased from 1.2:1 to only 2.1:1. About 6% unconjugated bile acids were secreted into the bile (healthy controls < 1%). Thus, in patients with primary biliary cirrhosis, a larger fraction of free bile acids and a higher proportion of taurine-conjugated bile acids are secreted into the bile, compared with healthy controls. Ursodiol improves symptoms and histology with lower biliary enrichment with this bile acid.

Ursodeoxycholic acid for the treatment of primary sclerosing cholangitis: a 30-month pilot study.

We investigated the effects of once-daily oral administration of 10 mg/kg ursodeoxycholic acid (generic name, ursodiol) on elevated serum enzyme activities, bilirubin, cholesterol, bile acids and symptoms in patients with primary sclerosing cholangitis. A 30-mo, open-label, pilot trial was designed to cover four periods: (a) 3 mo of pretreatment observation (period 1), (b) 6 mo on ursodiol (period 2), (c) 3 mo withdrawal of treatment (period 3) and (d) 18 mo of extended retreatment (period 4). Diagnosis was confirmed by cholangiography and liver biopsy specimens. We enrolled 12 patients with persistently elevated pretreatment alkaline phosphatase and gamma-glutamyltransferase levels (at least twice the upper limit of normal), and observed them for a median of 37 mo. Significant reductions in serum total cholesterol levels and in serum enzyme activities indicating cholestasis and hepatocellular injury occurred during ursodiol treatment in both treatment periods 2 and 4 and relapsed with treatment interruption in period 3. Elevated serum bilirubin and symptoms of disabling fatigue, pruritus and diarrhea were improved by ursodiol. Improvements have continued after 2 yr of treatment in 10 patients (1 patient had a transplantation after he relapsed on withdrawal of ursodiol therapy; another died of postoperative complications of colon resection for carcinoma). No other cases of clinical deterioration were observed in the retreatment period. The longer term reductions of alkaline phosphatase, transaminases, bilirubin and cholesterol after 2 yr of treatment were even greater than the initial reductions after 6 mo of treatment. These results justify initiation of larger, controlled clinical trials, with serial morphological evaluations of the liver and biliary tree.