A clinical-pathological analysis of drug-induced hepatic injury after liver transplantation

OBJECTIVE: The objective of this study was to investigate the histopathologic characteristics and clinical features of drug-induced hepatic injury after liver transplantation. METHODS: We retrospectively analyzed histopathologic characteristics and clinical features of 160 liver biopsy specimens obtained from 131 posttransplantation patients who were diagnosed as having drug-induced hepatic injury from June 2000 to August 2006 in our center. RESULTS: The histopathologic features of drug-induced hepatic injury after liver transplantation were characterized as centrilobular hepatocyte edema, fatty change, and variable intrahepatic cholestasis. Adverse drug reactions were diagnosed between days 5 and 1643 after transplantation, including 44.38% (71/160) at 5-30 days, 17.50% (28/160) at 31-90 days, and 38.12 (61/160) at 90-1643 days. The incidence of hepatic injury due to antifungal drugs, antibiotics, antiviral drugs, or other agents was 29.38% (47/160), 22.50% (36/160), 16.25% (26/160), and 31.87% (51/160), respectively. Abnormalities in routine liver function tests included ALT elevation>300 micro/L in 87 patients (54.38%), ALP elevation>300 micro/L in 37 patients (23.13%) or total bilirubin elevation>60 micromol/L in 36 patients (22.50%). Drug-induced toxic liver injury is characterized by a single notable increase in ALT, ALP, or TB, especially ALT. Common clinical manifestations were flu, rash, gastrointestinal symptoms, and eosinophilia. CONCLUSION: Drug-induced hepatic injury commonly appears within 30 days or after 90 days posttransplantation. Injury emerging within 30 days is always caused by antifungal, antiviral, or antibiotic drugs, whereas it displays more complicated reasons after 90 days. Drug-induced hepatic injury shows a complex and variable clinical manifestation. According to pathologic findings of liver biopsy, adequate drug history, and relationship between drug administration and onset of clinical manifestations, clinicians and pathologists can make a definitive diagnosis and access the extent of injury.     

Pirfenidone protects endotoxin-induced liver injury after hepatic ischemia in rats

BACKGROUND: Pirfenidone (PFD), an experimental antifibrotic agent, was investigated for its effects on endotoxin-induced liver injury after hepatic ischemia-reperfusion. METHODS: Male Sprague-Dawley rats were subjected to 30 minutes of partial hepatic ischemia, followed by reperfusion for 24 hours. Lipopolysaccharide (LPS) was injected at 30 minutes of reperfusion. PFD (300 mg/kg) or its vehicle (0.5% carboxymethylcellulose) was given orally following LPS administration. RESULTS: PFD prevented the increase in activities of serum alanine transaminase, aspartate transaminase, and lactate dehydrogenase after reperfusion. PFD inhibited the increase of cytokine-induced neutrophil chemoattractant in serum and liver tissue. The number of neutrophils infiltrating the liver was significantly lower in the PFD-treated group than the control group. CONCLUSION: These results indicate that PFD prevents endotoxin-induced liver injury after hepatic ischemia-reperfusion, in part through the decrease of neutrophil infiltration to the liver.     

c-Jun N-terminal kinase mediates hepatic injury after rat liver transplantation

BACKGROUND: Orthotopic liver transplantation (OLT) requires cold ischemic storage followed by warm reperfusion. Although c-Jun N-terminal kinase (JNK) is rapidly activated after OLT, the functional consequences of JNK activation are unknown. The aim of this study was to address the role of JNK after OLT using the selective JNK inhibitor CC-401. METHODS: Donors, recipients, or stored liver explants were treated with vehicle or JNK inhibitor before OLT by an arterialized two-cuff method with 40 hours of cold storage. Recipients were assessed for 30-day survival, and graft injury was assessed over time by hepatic histology, serum transaminases, caspase 3 activation, cytosolic cytochrome c, and lipid peroxidation. RESULTS: Survival after OLT increased after donor plus storage and storage only treatment with JNK inhibitor (P<0.05). Treatment of recipient only did not improve survival. Increased survival correlated with improved hepatic histology and serum aspartate aminotransferase levels. JNK inhibition significantly decreased nonparenchymal cell killing at 60 minutes after reperfusion (P<0.05) and pericentral necrosis at 8 hours after reperfusion (P<0.01). JNK inhibition decreased cytochrome c release, caspase 3 activation (P<0.05), and lipid peroxidation (P<0.05). JNK inhibition also transiently blocked phosphorylation of c-Jun at 60 minutes after reperfusion (P<0.05) without affecting other MAPK signaling, including p-38 and Erk activation. CONCLUSIONS: JNK inhibition decreases hepatic necrosis and apoptosis after OLT, suggesting that JNK activation promotes cell death by both pathways. Inhibition of JNK may be a new therapeutic strategy to prevent liver injury after transplantation.     

Effect of artificial cells on hepatic function after ischemia-reperfusion injury in liver

BACKGROUND: The liver suffers from ischemia/reperfusion injury during transplantation. Reactive oxygen species generated by xanthine oxidase during reperfusion of the ischemic liver may be partially responsible for the hepatic injury. Oxygen free radicals are removed by antioxidant enzymes such as superoxide dismutase (SOD), catalase, and glutathione peroxidase. Using glutaraldehyde and lysine we constructed crosslinked hemoglobin, containing SOD and catalase, and assessed its ability to protect against ischemia/reperfusion injury during transplantation. METHODS: In contrast to the sham-operated control groups, blood was exchanged using crosslinked hemoglobin (polyHb) a PolyHb-SOD-catalase (PSC) group. After ischemia/reperfusion injury, several parameters of hepatic damage and oxygen free radicals were measured as well as microscopic examination. RESULTS: Alanine aminotransferase, aspartate aminotransferase, superoxide production, hydrogen peroxide, and malondialdehyde levels were higher among the PolyHb group than sham-operated controls. The PolyHb group revealed a few apoptotic bodies, some acute inflammatory infiltrates in the sinusoids, nuclear fragmentations, cell shrinkage, and chromatin clumping with formation of apoptotic bodies in the apoptotic cells under microscopic examination. Alanine aminotransferase, aspartate aminotransferase, superoxide production, and hydrogen peroxide levels were lower in the PSC than the PolyHb group. Hepatic structures were well preserved in the PSC group. CONCLUSIONS: Reactive oxygen species contribute to hepatic dysfunction with morphologic changes. PSC is effective to reduce hepatic damage by lowering oxygen free radical-mediated injury after ischemia/reperfusion in the liver.     

Recurrent hepatic lymphangiomatosis after orthotopic liver transplantation.

Hepatic lymphangiomatosis is a rare disease characterized by an abnormal lymphatic proliferation involving the liver alone, liver and spleen, or multiple organs. Hepatic lymphangiomatosis becomes symptomatic secondary to compression or replacement of the normal parenchyma, which can lead to liver failure. Resection and orthotopic liver transplantation (OLT) can be used as treatment for this disease. We herein describe a 42-year-old female who had undergone successful OLT for hepatic lymphangiomatosis with recurrent disease detected 19 yr later in the transplanted liver. This is, to our knowledge, the first described case of recurrent hepatic lymphangiomatosis after OLT. In conclusion, we discuss the clinical, radiologic, pathologic, and immunohistochemical findings and review other reported cases of hepatic lymphangiomatosis that have undergone OLT.     

Glutamine does not protect against hepatic warm ischemia/reperfusion injury in rats

The administration of glutamine before experimental ischemia/reperfusion (I/R) has been shown to protect intestinal, pulmonary, and myocardial tissue by inducing heat shock proteins (HSP). However, it is not known whether glutamine is protective for all organs. We therefore tested whether pretreatment with glutamine reduces injury following hepatic I/R in rats. Male lean Zucker rats were pretreated with either glutamine (0.75 g/kg intraperitoneally, n=6) or saline (n=6), 24 and 6 hours before ischemia. Seventy percent of the liver was exposed to 75 minutes of warm ischemia followed by 24 hours reperfusion. Liver enzymes, histology, neutrophil accumulation, survival, and heat shock protein (HSP) 70 induction were examined. Glutamine administration did not reduce liver injury. In both groups, 5 of 6 animals survived 24 hours of reperfusion. There was no difference in serum transaminase levels with AST 15113 ± 4336 U/L (glutamine) vs. 17695 ± 8531 U/L (control, P>0.05), and ALT 7763 6 2524 (glutamine) U/L vs. 5884 ± 2063 U/L (control, P>0.05). The degree of neutrophil accumulation and necrosis was not different between groups at 24 hours of reperfusion. Pretreatment did not result in HSP70 upregulation in any of the groups. Pretreatment with glutamine did not reduce hepatic ischemia/ reperfusion injury. The lack of protection was associated with an absence of HSP70 upregulation prior to ischemia. Presented at the 2005 American Hepato-Pancreato-Biliary Association Congress, Hollywood, Florida, April 14–17, 2005.     

Hepatocyte-derived microRNAs as serum biomarkers of hepatic injury and rejection after liver transplantation

Recent animal and human studies have highlighted the potential of hepatocyte-derived microRNAs (HDmiRs) in serum as early, stable, sensitive, and specific biomarkers of liver injury. Their usefulness in human liver transplantation, however, has not been addressed. The aim of this study was to investigate serum HDmiRs as markers of hepatic injury and rejection in liver transplantation. Serum samples from healthy controls and liver transplant recipients (n = 107) and peritransplant liver allograft biopsy samples (n = 45) were analyzed via the real-time polymerase chain reaction quantification of HDmiRs (miR-122, miR-148a, and miR-194). The expression of miR-122 and miR-148a in liver tissue was significantly reduced with prolonged graft warm ischemia times. Conversely, the serum levels of these HDmiRs were elevated in patients with liver injury and positively correlated with aminotransferase levels. HDmiRs appear to be very sensitive because patients with normal aminotransferase values (<50 IU/L) had 6- to 17-fold higher HDmiR levels in comparison with healthy controls (P < 0.005). During an episode of acute rejection, serum HDmiRs were elevated up to 20-fold, and their levels appeared to rise earlier than aminotransferase levels. HDmiRs in serum were stable during repeated freezing and thawing. In conclusion, this study shows that liver injury is associated with the release of HDmiRs into the circulation. HDmiRs are promising candidates as early, stable, and sensitive biomarkers of rejection and hepatic injury after liver transplantation.     

Impact of hepatic rearterialization on reperfusion injury and outcome after mouse liver transplantation

BACKGROUND: Nonarterialized mouse liver transplantation is a well-established model for immunologic studies on rejection and tolerance mechanisms. However, the importance of graft arterialization has-in contrast to rat liver transplantation-not been thoroughly examined in the mouse model. The aim of the current study was to investigate the impact of arterial reconstruction on long-term graft survival, histologic alterations, ischemic liver damage, and early immunologic activation pathways. METHODS AND RESULTS: All recipients of arterialized (n=6) and nonarterialized (n=8) syngeneic liver grafts survived indefinitely. There were no differences in their histologic architecture, including no evidence of bile duct proliferation, periductal fibrosis, or alterations in serum transaminases, in long-term survivors from either group. Twenty-four hours after syngeneic liver transplantation, aspartate aminotransferase and alanine aminotransferase levels were increased to an equivalent extent in both groups, in agreement with early reperfusion injury and solitary traumatic injuries as assessed histologically (n=3 per group). Visualized by immunohistochemistry, intercellular adhesion molecule-1 expression was increased on sinusoidal and hepatic vein endothelium at both 1 and 100 days after transplantation, in both arterialized and nonarterialized grafts. Messenger RNA for interleukin-1, interferon-gamma, and tumor necrosis factor-alpha were measured by real-time polymerase chain reaction 24 hr after transplantation. No significant changes in the expression of cytokine mRNA levels were observed. CONCLUSIONS: Arterialization of mouse liver grafts does not appear to have a major impact on survival rate or the degree of immunologic activation. Therefore, the value of arterial reconstruction in mouse liver transplantation for experimental investigations is negligible.     

Matrine attenuates endotoxin-induced acute liver injury after hepatic ischemia/reperfusion in rats

Purpose  

Hepatic ischemia/reperfusion (HIR) injury is an unavoidable consequence of major liver surgery, during which endotoxemia often takes place. This study aimed to investigate whether matrine has a protective effect against HIR-induced liver injury aggravated by endotoxin.     

Glutamine enhances selectivity of chemotherapy through changes in glutathione metabolism.

OBJECTIVE: Chemotherapy doses are limited by toxicity to normal tissues. Intravenous glutamine protects liver cells from oxidant injury by increasing intracellular glutathione (GSH) content. The authors hypothesized that supplemental oral glutamine (GLN) would increase the therapeutic index of methotrexate (MTX) by improving host tolerance through changes in glutathione metabolism. The authors examined the effects of oral glutamine on tumor and host glutathione metabolism and response to methotrexate. METHODS: Thirty-six 300-g Fischer 344 rats were implanted with fibrosarcomas. On day 21 after implantation, rats were randomized to receive isonitrogenous isocaloric diets containing 1 g/kg/day glutamine or glycine (GLY) by gavage. On day 23 after 2 days of prefeeding, rats were randomized to one of the following four groups receiving an intraperitoneal injection of methotrexate (20 mg/kg) or saline (CON): GLN+MTX, GLY+MTX, GLN-CON, or GLY-CON. On day 24, rats were killed and studied for arterial glutamine concentration, tumor volume, kidney and gut glutaminase activity, and glutathione content (tumor, gut, heart, liver, muscle, kidney, and lung). RESULTS: Provision of the glutamine-enriched diets to rats receiving MTX decreased tumor glutathione (2.38 +/- 0.17 in GLN+MTX vs. 2.92 +/- 0.20 in GLY+MTX, p < 0.05), whereas increasing or maintaining host glutathione stores (in gut, 2.60 +/- 0.28 in GLN+MTX vs. 1.93 +/- 0.18; in GLY+MTX, p < 0.05). Depressed glutathione levels in tumor cells increases susceptibility to chemotherapy. Significantly decreased glutathione content in tumor cells in the GLN+MTX group correlated with enhanced tumor volume loss (-0.8 +/- 1.0 mL in GLN+MTX vs. +9.5 +/- 2.0 mL in GLY+MTX, p < 0.05). CONCLUSION: These data suggest that oral glutamine supplementation will enhance the selectivity of antitumor drugs by protecting normal tissues from and possibly sensitizing tumor cells to chemotherapy treatment-related injury.     

Bactericidal/permeability-increasing protein preserves leukocyte functions after major liver resection

OBJECTIVE: To analyze postoperative leukocyte functions in patients undergoing hemihepatectomy, and to assess the effect of treatment with the endotoxin-neutralizing agent bactericidal/permeability-increasing protein (rBPI21). SUMMARY BACKGROUND DATA: Extensive liver resection is associated with a high incidence of infectious complications. Because elimination of pathogenic microorganisms occurs mainly by leukocytes, this increased rate of infections is most likely due to an impaired function of these cells. Endotoxin, translocated from the gut into the systemic circulation as a result of increased gut permeability and reduced hepatic clearance function after major liver resection, may play an important role in the impairment of posthepatectomy leukocyte function. METHODS: To investigate whether hemihepatectomy results in impaired leukocyte functions and to determine the role of endotoxin in this process, leukocyte oxidative burst and leukocyte antigen expression were studied in three groups of patients: patients undergoing a hemihepatectomy and receiving rBPI21 treatment, patients undergoing hemihepatectomy and receiving placebo, and as an extra control group patients undergoing other major abdominal surgeries. Blood samples were collected before surgery, 2 hours after surgery, and at days 1, 2, 5, and 7. Phorbol myristate acetate-stimulated oxidative burst was measured using dihydrorhodamine, and leukocyte surface expression of the antigens CD11b, CD16, and CD14 was investigated by indirect immunofluorescence. Both oxidative burst and membrane surface expression were quantified by flow cytometry. An indication of the antiendotoxin effect of rBPI21 treatment was provided by assessment of plasma lipopolysaccharide binding protein (LBP) levels by enzyme-linked immunosorbent assay. RESULTS: The oxidative burst in the hemihepatectomized patients receiving placebo and the controls increased 2 hours after surgery, whereas it decreased in the rBPI21-treated patients, resulting in significant differences between the groups. On day 1, neutrophil CD11b expression and monocyte CD14 expression in the rBPI21-treated patients and controls were significantly lower than in the placebo group. At 2 hours, CD16 expression in the placebo-treated patients was significantly higher than in the rBPI21-treated patients and controls. On day 5 and day 7, plasma LBP levels were significantly higher in the placebo-treated patients compared with the rBPI21-treated patients. CONCLUSIONS: The results of this study show that patients undergoing major liver resection have an increased activation of leukocytes compared with those undergoing other major abdominal surgery. This enhanced activation may contribute to the increased risk of infection in these patients. Administration of the endotoxin-neutralizing agent rBPI21 to hemihepatectomy patients was shown to reduce plasma LBP levels, to preserve leukocyte functions partially, and to reduce leukocyte activation to the level of other, nonhepatic abdominal surgery.     

Acute liver disease after cutaneous thermal injury.

To better define the acute liver disease complicating thermal injury, 81 burn patients were evaluated for hepatic damage. Clinical and laboratory evidence of hepatocellular injury was present as early as 24 hours after burn in 47 patients (58%). Patients with liver disease had a larger mean burn size (p less than 0.01) and greater mortality than patients with normal liver studies. The magnitude of initial enzyme derangements did not distinguish the survivors, but jaundice was associated with a poor prognosis. Seventeen of the 19 jaundiced patients (90%) died. The early occurrence of hepatocellular injury suggested that acute hemodynamic alterations were important etiologically. Intrahepatic cholestasis and jaundice developed later in septic or hypoxic patients and was accentuated by hemolysis and blood transfusions. In these patients, liver histology showed a nonspecific hepatitis. An increased risk of septic complications could not be attributed to the presence of liver disease. Late emergence of conjugated hyperbilirubinemia suggested an underlying septic process.     

Oxygen free radicals and glutathione in hepatic ischemia/reperfusion injury

Oxygen free radicals have been implicated as mediators of ischemia/reperfusion injury in a variety of organs. We investigated the role of oxidative injury and endogenous hepatic glutathione (GSH) in liver cell injury associated with complete hepatic ischemia and reperfusion. Forty-five minutes of complete hepatic ischemia followed by reperfusion caused an increase in serum GPT and a fall in hepatic GSH but no increase in hepatic lipid peroxidation products. Chemical depletion of hepatic GSH with diethyl maleate did not cause hepatocellular injury but augmented hepatic ischemia/reperfusion-induced SGPT release and promoted lipid peroxidation. Pretreatment with the selective, membrane-permeable oxygen radical scavenger dimethyl sulfoxide protected against the ischemia/reperfusion-induced drop in hepatic GSH but did not reduce SGPT release in normal rats. In rats sensitized to oxidative injury by depletion of endogenous GSH with diethyl maleate the oxygen radical scavenger protected against ischemia/reperfusion-induced lipid peroxidation and reduced the release of SGPT. These findings suggest that the rich hepatic supply with endogenous GSH has a crucial role in the protection against oxygen radical injury following short periods of total hepatic ischemia. Oxygen radical injury only occurs after depletion of these endogenous GSH stores.     

Haemobilia after penetrating and blunt liver injury: treatment with selective hepatic artery embolisation

Although traumatic haemobilia is uncommon and occurs in less than 3% of liver injuries, the magnitude of the bleeding may result in life-threatening complications. This study evaluated the efficacy of selective hepatic artery embolisation (HAE) in the control of bleeding in patients with traumatic haemobilia. The demographic, clinical and angiographic data on all patients with traumatic haemobilia were obtained from a prospectively documented database of patients undergoing visceral angiography for liver haemorrhage between 1967 and 2002. During the 36-year period under review, 30 patients were found to have haemobilia on selective hepatic angiography. Ten of these 30 patients had haemobilia due to accidental non-iatrogenic trauma and form the basis of this study. In 8 of the 10 patients haemobilia resulted from penetrating liver injuries and two patients had blunt trauma. The mean delay between the initial injury and the diagnosis of haemobilia was 23.5 (range 1-120) days. The mean blood loss before angiography was 8 (range 3-19) units. Six patients were treated successfully with selective hepatic arterial embolisation, three required surgery and one resolved without any intervention. There were no deaths and no complications resulting in long term sequelae. Traumatic haemobilia is an uncommon but life-threatening complication of liver injury. Selective arterial embolisation is the initial treatment of choice with a substantial rate of success and a low incidence of serious complications.     

Prolonged hepatic ischaemia due to liver injury: a case report.

A case is reported in which a young male who underwent right hepatectomy necessitated by gunshot wound to the liver, survived 2 h 20 min of normothermic hepatic ischaemia. This case extends the documented duration of hepatic ischaemia compatible with survival and documents the histopathology of the post-ischaemic liver.     

Isolated right hepatic vein obstruction after piggyback liver transplantation.

The "piggyback" technique for liver transplantation has gained worldwide acceptance. Still, complications such as outflow obstruction have been observed, usually attributable to technical errors such as small-caliber anastomosis of the suprahepatic vena cava, twisting, or kinking. Iatrogenic Budd-Chiari syndrome after piggyback liver transplantation has been reported as a consequence of obstruction involving the entire anastomosis (usually the 3 hepatic veins). Here we describe technical issues, clinical presentation, diagnosis, and treatment of 3 cases in which outflow obstruction affected only the right hepatic vein. In conclusion, all 3 patients developed recurrent ascites requiring angioplasty and/or stent placement across the right hepatic vein to alleviate the symptoms.     

Diffuse biliary tract injury after orthotopic liver transplantation.

An unusual type of diffuse biliary tract injury after liver transplantation that is characterized by multiple intrahepatic biliary strictures, ductal dilatations, fluid collections, or intrahepatic abscesses has been identified. Over a 5-year period, a total of 10 patients (2%) developed diffuse intrahepatic biliary injury with established vascular patency and no obvious source for their biliary tract pathology. All patients received livers preserved in University of Wisconsin solution with a mean preservation time of 16 hours. This biliary tract injury was associated with the presence of severe preservation injury and Roux limb biliary reconstruction. Of the 10 patients, 5 were treated nonoperatively with multiple stricture dilations and stent placements, 3 underwent retransplantation, 1 was treated operatively with hepaticojejunostomy, and 1 died of sepsis. This study suggests that this complication appears to be related to preservation injury and that the etiology may be ischemic in origin.     

Risk factors for liver abscess formation in patients with blunt hepatic injury after non-operative management

Purpose

To identify risk factors for liver abscess formation in patients with blunt hepatic injury who underwent non-operative management (NOM).

Methods

From January 2004 to October 2008, retrospective data were collected from a single level I trauma center. Clinical data, hospital course, and outcome were all extracted from patient medical records for further analysis.

Results

A total of 358 patients were enrolled for analysis. There were 13 patients with liver abscess after blunt hepatic injury. Patients with abscess had a significant increase in glutamic oxaloacetic transaminase (GOT, p = 0.006) and glutamic pyruvic transaminase (GPT, p < 0.0001), and a decrease in arterial blood pH (p = 0.023) compared to patients without abscess in the univariate analyses. In addition, high-grade hepatic injury and transarterial embolization (TAE, p < 0.001) were also risk factors for liver abscess formation. Five factors (GOT, GPT, pH level in the arterial blood sample, TAE, and high-grade hepatic injury) were included in the multivariate analysis. TAE, high-grade hepatic injury, and GPT level were statistically significant. The odds ratios of TAE and high-grade hepatic injury were 15.41 and 16.08, respectively. A receiver operating characteristic (ROC) analysis was used for GPT, and it suggested cutoff values of 372.5 U/L. A prediction model based on the ROC analysis had 100 % sensitivity and 86.7 % specificity to predict liver abscess formation in patients with two of the three independent risk factors.

Conclusions

TAE, high-grade hepatic injury, and a high GPT level are independent risk factors for liver abscess formation.