Serum hyaluronic acid as a comprehensive marker to assess severity of liver disease in schistosomiasis.

Schistosomiasis mansoni is a non-cirrhotic fibrogenic disease model. The mild form shows normal liver function with slight or no liver fibrosis whereas in the periportal fibrosis form the manifestations of portal hypertension prevail over hepatocellular failure. We assessed serum hyaluronic acid as a marker of the course of the disease. We studied 24 patients presenting with pure chronic forms of schistosomiasis and seven with cirrhosis. In order to measure serum hyaluronic acid we developed a sandwich fluorescent ELISA-like assay. alpha2-Macroglobulin, prothrombin index, gamma-glutamyltransferase, platelets and ultrasound parameters were also assessed. The 20 micro g/l (ROC plot) hyaluronic acid level differentiated patients with the mild form (with no portal hypertension) from those with the severe form of schistosomiasis with 78% diagnostic efficacy. The 80 micro g/l cut-off value differentiated patients with the severe form of schistosomiasis from the cirrhotic group with similar diagnostic efficacy. alpha2-Macroglobulin provided no distinction between the groups studied. The hyaluronic acid serum concentration correlated positively with the splenic vein diameter (P=0.004) and marginally with alpha2-macroglobulin (P=0.059). Serum hyaluronic acid is a good marker for the initial phase of hepatic fibrosis and it was able to assess severity of liver disease in schistosomiasis.

Thrombocytemia as a predictor of portal hypertension in schistosomiasis.

Sufferers of schistosomiasis mansoni can evolve a clinical form of the disease associated with portal hypertension. To differentiate this form, routine clinical tests and biological indices were evaluated. In all, 54 HBsAg- and HCV-negative patients were studied, 42 with schistosomiasis and 12 normal volunteers. Using clinical criteria, ultrasonography, and endoscopy, the schistosomiasis patients were classified into two groups: mild chronic form (MS, N = 14) and chronic form associated with portal hypertension (PH, N = 28). The laboratory parameters of the MS group did not differ from the controls. The PH group differed from the others in prothrombin index, thrombocytemia, gamma-glutamyltransferase, serum alpha2-macroglobulin, and the calculated indices. ROC plot cutoff levels verified that isolated thrombocytemia was the most efficient marker for discrimination of the PH and MS forms. Thrombocytemia of 130 x 10(9) platelets/liter discriminated the groups with an 86% accuracy when all patients were analyzed and 96% when only schistosomiasis patients who did not consume alcohol were included.

Malignant melanoma with liver and spleen metastases: case report.

CONTEXT: The diagnosis of primary melanoma is easily confirmed after histological analysis of the lesion, whereas it is rarely diagnosed when the patient even has distant metastases. DESIGN: Case report CASE REPORT: Malignant melanoma is responsible for about 1% of all deaths caused by cancer in the USA and only 3% of all malignant skin diseases. Malignant melanoma is a rare disease, although it corresponds to 65% of all deaths caused by skin cancer. The liver and spleen are rarely the first sites of melanoma metastases. This paper reports on the clinical picture of a patient with fatal malignant melanoma and hepatic and spleen metastases. As this was an un-usual presentation, the melanoma diagnosis could only be made after pathological analysis of the skin and hepatic lesions.

Uso de concentrado de antitrombina III em cirróticos com distúrbios de coagulaçäo / Antithrombin III concentrate use in patients with cirrhosis with coagulation disorders

A deficiência de antitrombina III (ATIII) é observada na hepatopatia grave e pode ser decorrente da reduçäo de síntese ou de consumo aumentado, o que poderia ser compensado com o uso de concentrado de ATIII. OBJETIVO. Avaliar a eficiência da administraçäo de uma dose fixa de concentrado de ATIII, em pacientes com hepatopatia descompensada com distúrbio de hemostasia. CASUISTICA E MÉTODO. Foram avaliados seis pacientes, com idade média de 44 anos, variando de 14 a 63 anos, portadores de cirrose (quatro de etiologia alcoólica, um viral e um doença de Wilson), com alteraçäo de pelo menos dois dos parâmetros da hemostasia (TP> 1,40, TTPA> 1,25, fibrinogênio < 1,5g/L, plaquetas < 80.000/mm3). A média do nível de albumina foi de 2,6g/dL (1,9 a 3,8g/dL). O concentrado de ATIII (Kybernin) foi administrado na dose de 50U/kg, em dias alternados. Foi colhido sangue antes da primeira infusäo, 4 horas após e, depois, diariamente, antes da infusäo do dia, para medida da ATIII plasmática (amidolítico). Nenhum paciente recebeu hemoderivados. RESULTADOS. As médias da dosagem de ATIII foram: inicial = 35,8 por cento, 4 horas = 56,2 por cento*, 2 dias = 48,7 por cento*, 4 dias = 45,7 por cento* e 8 dias = 42,3 por cento*. Após a infusäo houve elevaçäo significante dos níveis de ATIII (* = p < 0,02, teste de Friedman), que se manteve até o 4§ dia. Näo houve alteraçäo dos demais parâmetros de coagulaçäo. CONCLUSÕES. O uso de concentrado de ATIII na dose utilizada é suficiente para elevar os níveis desse inibidor na hepatopatia; entretanto, com essa dose näo se obteve normalizaçäo de seus níveis. Esses dados sugerem que doses mais elevadas devem ser usadas em pacientes com hepatopatias graves, que apresentam näo apenas reduçäo de síntese, mas aumento de consumo dos fatores da coagulaçäo e de seus inibidores.

[Antithrombin III concentrate use in patients with cirrhosis with coagulation disorders]. / Uso de concentrado de antitrombina III em cirróticos com distúrbios de coagulação.

BACKGROUND: Patients with severe hepatic failure present acquired deficiency of antithrombin III (ATIII) owing to reduced synthesis associated with intravascular activation of blood coagulation, which may be corrected by ATIII infusion. OBJECTIVE: The aim of this uncontrolled trial was to verify the effect of a standard dose of ATIII concentrate (Kybernin), that is, 50 U/kg of body weight per day, every 2 days, on ATIII levels in patients with severe hepatic failure and hemostatic imbalance. PATIENTS AND METHODS: Six cirrhotic patients were studied: mean age of 44 years (14 to 63 years), who presented at least 2 abnormal coagulation tests (PT > 1.40, APTT > 1.25, Fibrinogen < 1.5 g/dL, Platelet count < 80,000/mm3). Mean serum albumin was 2.6 g/dL (1.9 to 3.8 g/dL). Blood was drawn before infusion, 4 h after the first infusion, and just before the next infusion. ATIII levels were measured by amidolytic method. RESULTS: Mean ATIII levels were: initial = 35.8%, 4th h = 56.2%*, 2nd d = 48.7%*, 4th d = 45.7%*, and 8th d = 42.3%. ATIII levels increased significantly after infusion of this standard dose in all patients, although they have not been fully corrected (Friedman test, * p < 0.02), which has been sustained till the 4th day. There was no improvement on the clinical outcome. CONCLUSIONS: These findings suggest that doses of ATIII concentrate higher than 50 U/kg/infusion must be administered to patients with severe hepatic failure, to guarantee normal levels of the inhibitor, in order to verify its influence on the hemostatic mechanism.

Depuraçäo hepática da calicreína plasmática na cirrose experimental / Plasma kallikrein clearance by the liver in experimental cirrhosis

OBJETIVO. Estudar a depuraçao de glicoproteína, e calicreína plasmática, pelo fígado de ratos com cirrose descompensada. MATERIAL E MÉTODO. Produçao de cirrose pela administraçao de tetracloreto de carbono, 520 mg/kg de peso corporal, uma vez por semana, intragastricamente, durante 16 a 19 semanas. Após o período de tratamento cada fígado foi isolado, exsanguinado e perfundido a 37 graus Celsius com calicreína plasmática de rato (CPR) 10nM. A velocidade de depuraçao da CPR na cirrose foi comparada com a de grupos-controle. RESULTADOS. 58 por cento dos animais morreram durante o tratamento. Os sobreviventes desenvolveram prostraçao, ascite, icterícia e sangramentos; ao final do período de tratamento as aminotransferases séricas eram normais e a albumina sérica diminuída. A histologia hepática (hematoxilina-eosina e coloraçao para reticulina) mostrou cirrose no grupo tratado. A velocidade de depuraçao hepática da CPR no grupo cirrótico (5,4 + 0,9pmol/g fígado/10 min) foi significativamente menor (p < 0,05) do que no grupo controle (13,5 + 2,7pmol/g fígado/10min). CONCLUSAO. O desenvolvimento de cirrose descompensada acompanha-se de diminuiçao da capacidade hepática de depurar glicoproteína, que é internalizada por endocitose mediada por receptor.

[Plasma kallikrein clearance by the liver in experimental cirrhosis]. / Depuração hepática da calicreína plasmática na cirrose experimental.

AIM: To study the hepatic clearance of a glycoprotein (rat plasma kallikrein) by the liver of rats with experimental decompensated cirrhosis. MATERIAL AND METHODS: Cirrhosis was induced by intragastrically administration of carbon tetrachloride 520 mg/kg/week, during 16-19 weeks. After this period, each liver was isolated, exsanguinated and perfused at 37 degrees C with 10nM rat plasma kallikrein (RPK). RESULTS: 58% of the animals died during the treatment and the remaining developed prostration, ascites, jaundice and bleeding; at the end of the treatment period serum aminotransferases were not altered and serum albumin decreased. The liver histology showed cirrhosis. RPK clearance rate of the cirrhosis group (5.4 +/- 0.9 pmol/g liver/10 min) was significantly lower (p < 0.05) than that of the control group (13.5 +/- 2.7 pmol/g liver/10 min). CONCLUSION: The development of cirrhosis is associated with a decreased hepatic clearance of a glycoprotein which endocytosis is mediated by a receptor.

Plasma kallikrein clearance by the liver of chronic carbon tetrachloride-treated rats.

We have previously reported that the endocytosis of rat plasma kallikrein (RPK) by hepatocytes is a calcium-independent and beta-galactoside-dependent mechanism. We now report the clearance of RPK by the liver of four groups of rats: normal, inflamed (48 h ex-turpentine) and two groups chronically treated with CCl4 (52 mg/kg per week, intragastrically, for 9-12 weeks). Each liver was isolated, exsanguinated and perfused at 37 degrees C with 30 mL of BSA-Krebs-Henseleit-bicarbonate medium containing 10 nmol/L RPK. Although all rats received the same mild CCl4 treatment, the liver histology showed that they evolved either to severe hepatitis (serum alanine aminotransferase [ALT] 4852 +/- 885 U/L, parenchymatous necrosis in the perivenous region) or to compensated cirrhosis (serum ALT 209 +/- 42 U/L, vigorous fibrous encircling regeneration nodules); neither jaundice nor ascites was noted. The results show that serum albumin was not altered among the groups and that: the acute-phase response by itself (inflamed group) increased RPK clearance rate (3.01 +/- 0.59 mL/min) as compared with the normal group (1.85 +/- 0.14 mL/min); the CCl4 treatment, although induced an acute-phase response, decreased (P < 0.01) RPK clearance rates (0.80 +/- 0.11 mL/min hepatitis group and 0.98 +/- 0.10 mL/min cirrhosis group). These findings suggest that the hepatic clearance rate of plasma kallikrein is an early indicator of liver injury.

Plasma-kallikrein clearance by the liver of acetaminophen-intoxicated rats.

The liver synthesizes prokallikrein and is the main organ to clear the active enzyme (plasma-kallikrein) from circulation. This clearance, a receptor-mediated endocytosis, is calcium-independent and not affected by the blockade of Kupffer cells. The effects of endothelial cells blockade and of acetaminophen intoxication on the clearance of 10 nM rat plasma-kallikrein (RPK) by the isolated, exsanguinated and perfused rat liver are now reported. Endothelial cells blockade obtained by the addition of large excess (30 uM) of formaldehyde-treated serum albumin to the perfusion fluid does not affect the hepatic clearance of RPK (the half-lives of hepatic uptake were 15.5 +/- 1.0 min in the absence versus 16.5 +/- 1.4 min in the presence of the treated protein, p > 0.05). Some livers were perfused 24 hours after acetaminophen intoxication: 6.6 mmol/kg given i.p. after a 42-hour period of fast. Hepatocyte injury suggested by elevated aminotransferase activity (ALT 10 times control value, AST 30 times control value), acute phase inflammatory response (serum alpha 2-macroglobulin increase) and reduced synthetic function (serum albumin decrease), was confirmed histologically and only zone 3 hepatocytes were necrotic. A 66-hour period of fast does not affect by itself the hepatic clearance of RPK (16.9 +/- 1.3 min of half-life of hepatic uptake) when compared with the control group (15.5 +/- 1.0 min, p > 0.05). On the other hand the RPK clearance by the livers of rats previously intoxicated with acetaminophen was markedly deficient (the half-life of hepatic uptake was 39.2 +/- 3.2 min). These findings suggest that RPK is internalized by hepatocytes, preferentially by those of the perivenular zone of the hepatic acinus.

Chronic administration of ethanol does not alter plasma kallikrein hepatic clearance.

1. The clearance of plasma kallikrein by the isolated and perfused liver of rats chronically intoxicated with ethanol was studied. Alcohol was added to the diet as 36% of total calories, and the animals were kept on this diet for 5-7 weeks. 2. The hepatic clearance of plasma kallikrein by these rats (uptake half-life, 15 +/- 2 min; N = 3) was similar to that observed in the control groups (normal diet, uptake half-life, 14 +/- 2 min; N = 5, or normal diet with sucrose added as 36% of total calories, uptake half-life, 16 +/- 3 min; N = 4). 3. These results provided indirect evidence that the endocytosis mechanism of plasma kallikrein by the liver differs from that described for glycoproteins which use the galactosyl receptor, since liver endocytosis via this latter system is reduced by chronic alcohol intoxication.

Chronic administration of ethamol does not alter plasma kallikrein hepatic clearance

1. The clearance of plasma kallikrein bu the isolated and perfused liver of rats chronically intoxicated with ethanol was studied. Alcohol was added to the diet as 36% of total calories, and the animals were kept on this diet for 5-7 weeks. 2. The hepatic clearance of plasma kallikrein by these rats (uptake half-life, 15 ñ 2 min; N = 3) was similar to that observed in the control groups (normal diet, iptake half-life, 14 ñ 2 min; N = 5, or normal diet with sucrose added as 36% of total calories, uptake half-life, 16 ñ 3 min; N = 4). 3. These results provided indirect evidence that the endocystosis mechanism of plasma kallikrein by the liver differs from that descrived for glycoproteins which use the galactosyl receptor, since liver endocystosis via this latter system is reduced by chronic alcohol intoxication

Plasma kallikrein clearance by the liver of normal and injured rats.

We report the clearance of rat plasma kallikrein (RPK) by the perfused livers of normal rats and from others at 2 and 4 days after subcutaneous injection of turpentine oil. RPK removal from the perfusate follows a logarithmic curve (y = a+b lnx) and from this equation its half-life of removal can be calculated. RPK clearance rate followed the potential equation y = axb. Both the half-life of RPK removal and RPK clearance rates were similar in the 3 groups of perfused livers. We conclude that, at the initial concentration of RPK used (approximately 3 nM), its liver clearance is not affected during the acute-phase response to inflammation.

Protein C deficiency in the compensated form of hepatosplenic schistosomiasis.

Plasma levels of protein C (enzyme immunoassay), albumin (electrophoresis), and transthyretin (radial immunodiffusion) were measured in 15 patients with the compensated hepatosplenic form of schistosomiasis and in 10 healthy volunteers. Plasma levels of protein C were below normal in 47% of the schistosomiasis patients; this deficiency could be explained by diminished hepatic synthesis since it occurred in conjunction with low plasma levels of albumin and/or transthyretin. In 33% of the schistosomiasis patients, plasma levels of protein C were below 0.5 U/ml, a value which has been associated with thrombotic disease. Protein C deficiency may explain the unexpectedly low incidence of hemorrhagic episodes, as well as the occurrence of portal vein thrombosis that is not infrequent in these patients.