Spontaneous bacterial peritonitis in fulminant hepatic failure

Ascites may be associated with fulminant hepatic failure (FHF), but spontaneous bacterial peritonitis (SBP) is an extremely rare complication. We report on two patients with FHF who developed SBP. One patient died and the other recovered.     

Striking variability of hepatic copper levels in fulminant hepatic failure

Two cases of acute hepatic failure are reported in which the diagnosis of Wilson's disease was considered because of low serum ceruloplasmin, low serum copper levels and high 24 h urinary copper. Case 1 had Kayser-Fleischer rings, haemolysis and a high 24 h urinary copper, and so Wilson's disease was confidently diagnosed. Case 2 had high urinary copper excretion, but [64Cu] study indicated a 24:2 h ratio of 0.7 and made the diagnosis of Wilson's disease uncertain. Both patients underwent orthotopic hepatic transplantation, and multiple biopsies were taken from the resected specimen in order to estimate hepatic copper levels. In both cases, hepatic copper levels revealed considerable variation: 0.8-5.2 mumol/g dry wt (case 1) vs 0.02-12.65 mumol/g dry wt (case 2). In case 1, only two of 14 levels were within the diagnostic range for Wilson's disease (greater than 4 mumol/g dry wt), whereas hepatic copper levels in case 2 were in the Wilsonian disease range in three of 16 specimens. These results were in contrast to uniformly high hepatic copper levels in one patient with established cirrhosis secondary to Wilson's disease and two cases of primary biliary cirrhosis. This report indicates that hepatic copper levels vary greatly in acute liver failure, and that estimates from a single biopsy specimen may be misleading as to the cause of the underlying liver disease.     

凉血化瘀方对急性肝衰竭大鼠肝细胞凋亡的影响

目的：研究凉血化瘀方防治急性肝功能衰竭的作用机制。方法：将SD大鼠36只随机分为6组，除正常组外每组大鼠分别连续灌胃给药4天。末次给药后1小时，每组腹腔注射GaIN＋LPS，造成大鼠急性肝功能衰竭。6小时后采用流式细胞术检测大鼠肝细胞凋亡，同时采用原位末瑞标记（TUNEL）法半定量检测肝细胞凋亡情况。结果：流式细胞仪检测结果发现凉血化瘀方与阳性对照组细胞凋亡率比较模型组显著下降（P〈0．01，P〈0．05），并且模型组大量细胞阻滞在s期，G2期细胞减少，凉血化瘀方中剂量组与阳性药物对照组较模型组其细胞周期阻滞改善，凉血化瘀方组与模型组比较，差异有显著性意义（P〈0．01）。TUNEL半定量检测细胞凋亡与流式细胞仪结果基本一致，凉血化瘀方与模型组比较细胞凋亡率显著下降。结论：凉血化瘀方能够抑制急性肝损伤肝细胞凋亡，调节细胞周期阻滞，其机制可能为修复DNA复制损伤。     

Intrahepatic activation of caspases in human fulminant hepatic failure.

BACKGROUND/AIMS: Apoptosis has been implicated in the pathogenesis of fulminant hepatic failure (FHF) potentially involving caspases. Thus far, apoptosis in FHF has mainly been studied in animal models while human data are sparse. METHODS: Caspases-3, -8 and -9 activities and Fas expression were analyzed in correlation to TdT-mediated dUTP nick end labelling (TUNEL) positive apoptotic cells in livers of patients with FHF (n=26), chronic liver disease (CLD) (n=60) and normal controls (NC) (n=10). RESULTS: Numbers of TUNEL-positive cells were higher in FHF than in CLD and NC (P<0.001) correlating to the intrahepatic activities of caspase-3. The highest caspase-3 activities were found in fulminant hepatitis B, significantly surpassing those in FHF of any other etiology. In fulminant hepatitis B, caspase-9 activity was also higher than in controls, while caspase-8 activation was not higher than in NC. Unlike caspase-3, caspases -8 and -9 activities were not correlated to the numbers of TUNEL positive cells. Fas expression was also the highest in FHF but did not differ between hepatitis B virus-FHF and other FHF. CONCLUSIONS: Our data indicate differential activation of intrahepatic caspases in FHF depending on the underlying etiology. Massive activation of caspases in fulminant hepatitis B confirms a pivotal role of apoptotic pathways in the pathogenesis of human fulminant hepatitis B.     

大黄对暴发性肝衰竭大鼠肝损伤及肝再生的影响

[目的]探讨大黄对暴发性肝衰竭(FHF)大鼠肝损伤及肝再生的影响.[方法]Wistar大鼠随机分4组:正常对照(对照)组、模型(FHF)组、大黄组、促肝细胞生长素(PHGF)组.FHF、大黄组和PHGF组动物模型采用皮下注射(sc)硫代乙酰胺(TAA)600 mg/kg体重,2次,每次间隔24 h,复制FHF动物模型.大黄组和PHGF组动物除予TAA外,于实验前3天至实验结束分别sc大黄注射液1 ml/100 g和PHGF 1 ml/100g,对照组和FHF组同时sc 0.85%氯化钠液1 ml/100g.FHF组、大黄组和PHGF组,于第2次注射TAA后24 h,随机各取8只,腹主动脉取血测肝功能.迅速取肝组织,用10%甲醛液固定,石蜡切片,检测肝细胞有丝分裂指数(MI)和增殖细胞核抗原(PCNA).[结果]大黄具有降低FHF大鼠丙氨酸氨基转移酶、天冬氨酸转氨酶及总胆红素,并能显著提高MI和PCNA(P＜0.05,＜0.01).[结论]大黄具有改善FHF大鼠肝功能和促进肝细胞增殖及再生的作用.     

Serum and urinary zinc in fulminant hepatic failure

Patients with chronic hepatic encephalopathy have been shown to have low serum zinc levels. Moreover, in a controlled study, significant improvement was seen in these patients on oral zinc supplementation. Information on zinc status in fulminant hepatic failure is insufficient. Serum and urinary zinc abnormalities were studied in 22 patients with fulminant hepatic failure (FHF) and they were compared with age- and sex-matched controls. The mean serum zinc values were significantly less in patients with FHF (72.7 +/- 3.7 micrograms/100 mL versus 107.9 +/- 6.2 micrograms/mL) while the urinary zinc values were significantly higher compared with controls (603.5 +/- 9.3 micrograms/24 h versus 334.4 +/- 10 micrograms/24 h). The serum zinc levels significantly and progressively decreased, while urinary zinc significantly increased after admission in patients with FHF. The serum zinc values in the group that survived were significantly higher than those in the group of patients who died. Correspondingly, urinary zinc was lower in survivors than in the group that expired. This study indicates that serum and urinary zinc levels could be used as a prognostic indicator in FHF. A therapeutic trial with zinc supplementation is justified in this group of patients.     

Evidence against a role for endotoxin in the hepatic encephalopathy of rats with thioacetamide-induced fulminant hepatic failure

BACKGROUND AND AIMS: Endotoxin has been proposed to participate in the development of hepatic encephalopathy. However, there is no published data concerning the effects of endotoxin neutralization on the degree of hepatic encephalopathy. The present study investigated the effect of chronic intraperitoneal injection of polymyxin B, a neutralizing antagonist of endotoxin, on hepatic encephalopathy in rats with thioacetamide (TAA)-induced fulminant hepatic failure. METHODS: Male Sprague-Dawley rats weighing 300-350 g were used. Fulminant hepatic failure was induced by intraperitoneal injection of TAA (350 mg/kg/day) for 3 days. Two series of rats were designed to compare the effects of low dose (0.1 mg) or high dose (0.2 mg) intraperitoneal polymyxin B administration versus normal saline (NS) on hepatic encephalopathy. The injection was twice daily started from 2 days prior to TAA administration and lasted for 5 days. Severity of encephalopathy was assessed by the counts of motor activity in an Opto-Varimex animal activity meter. Plasma levels of endotoxin and tumor necrosis factor-alpha (an index of liver injury) were measured by Limulus assay and the ELISA method, respectively. RESULTS: Neutralization of endotoxin by either low dose or high dose polymyxin B administration did not significantly alleviate the degree of hepatic encephalopathy, as represented by the counts of motor activities (P > 0.05). Plasma levels of endotoxin and tumor necrosis factor-alpha were comparable between rats treated with polymyxin B or NS (P > 0.05). CONCLUSION: Our findings do not support the notion that endotoxin plays a major role in the pathogenesis of hepatic encephalopathy in rats with TAA-induced fulminant hepatic failure.     

Detrimental effects of nitric oxide inhibition on hepatic encephalopathy in rats with thioacetamide-induced fulminant hepatic failure: role of nitric oxide synthase isoforms

BACKGROUND: Hepatic encephalopathy is a complex neuropsychiatric syndrome. A previous study showed that chronic nitric oxide (NO) inhibition aggravated the severity of encephalopathy in thioacetamide (TAA)-treated rats. The present study investigated the relative contribution of NO synthase (NOS) isoforms on the severity of hepatic encephalopathy in TAA-treated rats. METHOD: Fulminant hepatic failure was induced in male Sprague-Dawley rats by intraperitoneal injection of TAA (350 mg/kg/day) for 3 days. Rats were divided into three groups to receive N(omega)-nitro-L-arginine methyl ester (L-NAME, a non-selective NOS inhibitor, 25 mg/kg/day in tap water), L-canavanine (an inducible NOS inhibitor, 100 mg/kg/day via intraperitoneal injection) or normal saline (N/S) from 2 days prior to TAA administration and lasting for 5 days. Severity of encephalopathy was assessed by the counts of motor activity. Plasma levels of tumor necrosis factor-alpha (TNF- alpha) were determined by enzyme-linked immunosorbent assay (ELISA), and total bilirubin, alanine aminotransferase (ALT) and creatinine were determined by colorimetric assay. RESULTS: Compared with L-canavanine or N/S-treated rats (0% and 4%, respectively), the mortality rate was significantly higher in rats receiving L-NAME administration (29%, P < 0.005). Inhibition of NO created detrimental effects on the counts of motor activities (P < 0.05). Rats treated with L-NAME had significantly higher plasma levels of total bilirubin, ALT, creatinine and TNF- alpha as compared with rats treated with L-canavanine or N/S (P < 0.01). CONCLUSION: Chronic L-NAME administration, but not L-canavanine, had detrimental effects on the severity of hepatic damage and motor activities in TAA-treated rats. These results suggest that constitutive NOS activities play a major protective role in rats with fulminant hepatic failure.     

MyD88 is involved in the signalling pathway for Taxol-induced apoptosis and TNF-alpha expression in human myelomonocytic cells

Taxol is an effective anti-tumour drug against a variety of tumour cells. Taxol directly induces apoptosis in addition to a G2/M cell cycle arrest. However, it remains poorly understood how Taxol induces apoptosis in tumour cells. Taxol induces the secretion of inflammatory cytokines in murine macrophages in a toll-like receptor-4 (TLR-4)-dependent manner in addition to its anti-tumour effects, but the effect of Taxol on human macrophages is controversial. In this study, we demonstrated that low doses (less than 1000 nmol/l) of Taxol induced the expression of tumour necrosis factor (TNF)-alpha in human myelomonocytic cells and that the induction of TNF-alpha mRNA was inhibited by dominant-negative myeloid differentiation protein (dnMyD88). Furthermore, we demonstrated that the same doses of Taxol induced apoptosis of the same myelomonocytic cells and that the Taxol-induced apoptosis was also inhibited by dnMyD88. In accordance with the previous reports, Taxol induced the expression of TNF-alpha and apoptosis in a TLR4-independent manner. These results suggest that TNF-alpha expression and apoptosis, both induced by Taxol in human myelomonocytic cells, share the signal transduction molecule MyD88.     

Effect of extracorporeal bioartificial liver support system on fulminant hepatic failure rabbits

AIM To evaluate the possibility of using cultured human hepatocytes as a bridge between bioartificial liver and liver transplantation. METHODS In this experiment, the efficacy of extracorporeal bioartificial liver support system (EBLSS) consisting of spheriodal human liver cells and cultured hepatocytes supernatant was assessed in vivo using galactosamine induced rabbit model of fulminant hepatic failure. RiESULTS There was no difference of survival between the two groups of rabbits, but in the supported rabbits serum alanine aminotransferase, total bilirubin and creatinine were significantly lower and hepatocyte necrosis was markedly milder than those in control animals. In addition, a good viability of human liver cells was noted after the experiment. CONCLUSION EBLSS plays a biologic role in maintaining and compensating the function of the liver.     

PGE1 abolishes the mitochondrial-independent cell death pathway induced by D-galactosamine in primary culture of rat hepatocytes

Background and Aim:  PGE₁ reduces in vivo and in vitro D-galactosamine (D-GalN)-induced cell death in hepatocytes. The present study was undertaken to elucidate the intracellular pathway by which D-GalN induces cell death in cultured hepatocytes. In addition, we evaluated if PGE₁ was able to modulate different parameters related to D-GalN-induced apoptosis in cultured rat hepatocytes.
Methods:  Hepatocytes were isolated from male Wistar rats (225–275 g) by the classical collagenase procedure. PGE₁ (1 µM) was administered 2 h before D-GalN (5 mM) in primary culture of rat hepatocytes. Apoptosis was determined by DNA fragmentation and caspase-3, -6, -8 and -9 activation in hepatocytes. Caspase activation was evaluated by the detection of the related cleaved product and its associated activity. Cell necrosis was determined by the measurement of lactate dehydrogenase (LDH) activity in culture medium. To elucidate the role of mitochondria, we measured neutral (nSMase) and acid (aSMase) sphingomyelinase, as well as the expression of cytochrome c in mitochondria and cytoplasm fractions from D-GalN treated hepatocytes.
Results:  D-GalN induced caspase-3 activation and DNA fragmentation in hepatocytes. This apoptotic response was not associated with the activation of caspase-6, -8 or -9. The use of specific inhibitors confirmed that only caspase-3 was involved in D-GalN-induced apoptosis. D-GalN did not modify nSMase and aSMase activities, nor mitochondrial cytochrome c release in hepatocytes.
Conclusions:  D-GalN induced apoptosis through caspase-3 activation but without modification of the activity of caspase-6, -8, -9, SMases or cytochrome c release. PGE₁ appears to prevent D-GalN-induced apoptosis by a mitochondria-independent mechanism.     

Hepatic stimulator substance activity in animal model of fulminant hepatic failure and encephalopathy

Hepatic stimulator substance (HSS) is a known liver-specific but species-nonspecific growth factor. In the present study we examined the activity of the endogenously produced HSS in an established experimental model of fulminant hepatic failure (FHF) and encephalopathy, induced by repeated injections of thioacetamide (TAA). FHF was induced by three consecutive intraperitoneal injections of TAA (400 mg/kg body weight) in rats, at time intervals of 24 hr. The animals were killed at 0, 6, 12, or 18 hr following the last injection of TAA. The rate of tritiated thymidine incorporation into hepatic DNA, the enzymatic activity of liver thymidine kinase (EC 2.7.1.21), and the assessment of mitotic index in hepatocytes were used to estimate liver regeneration. HSS extract obtained from the livers of TAA-treated rats, sacrificed at the above-mentioned time points was tested for its activity. Increased HSS activity was noted in all TAA-treated animals, presenting a peak at 12 hr following the third TAA dose, suggesting active participation of this growth factor in hepatocyte replication in this animal model of FHF and encephalopathy. It may also be suggested that up-regulation of HSS activity could be used in future as a therapeutic approach in FHF.     

前列腺素E1对老年肺心病患者氧代动力学的影响

目的评估前列腺素Ｅ１（ＰＧＥ１）对老年肺心病患者的氧代动力学、血流动力学和血液流变学的作用。方法对１２例老年肺心病患者静脉滴注ＰＧＥ１（４０μｇ·ｋｇ－１／ｍｉｎ），静滴前、后测定氧输送、氧消耗、氧摄取率、血液动力学参数及血液流变学。结果ＰＧＥ１可增加老年肺心病患者心脏指数、氧输送、氧消耗和氧摄取率；降低肺及体循环的血管阻力指数；改善血粘度。结论ＰＧＥ１通过降低肺血管阻力、改善肺内血流分布和增加心输出量，从而改善了氧供给和血液流变性，抑制了由于乏氧性缺氧而代偿性增加血红蛋白的负面效应——氧摄取缺陷。     

Visual and auditory evoked responses in acute severe hepatitis

Evoked responses have not been studied in patients with acute severe hepatitis (ASH) with or without hepatic encephalopathy. This prospective study was undertaken to find out diagnostic as well as prognostic value of visual evoked responses (VER), and brain stem auditory evoked responses (BAER) in patients with ASH with or without encephalopathy. Visual evoked responses and BAER were studied in 20 patients (14 males and six females) with ASH. The patients were diagnosed as having severe hepatitis if acute hepatitis was associated with raised serum bilirubin and serum transaminases, and if they had a prothrombin time index of < 50%. After a detailed neuropsychiatric examination of each patient, the study sample was divided into two groups of 10 patients: ASH without encephalopathy (ASH-WOE), and ASH with encephalopathy (fulminant hepatic failure, FHF). The median P100 latencies of FHF patients were significantly increased compared with controls and patients in the ASH-WOE group. Abnormal P100 latencies, exceeding 95th percentile values of the controls, were present in one patient in the ASH-WOE group and six patients in the FHF group. The median interpeak latencies I-III, III-V and I-V were significantly prolonged in the FHF group. Interpeak latencies III-V were also increased significantly in patients in the ASH-WOE group. While abnormal BAER were seen frequently in both groups, VER abnormalities were largely confined to patients in the FHF group. In the FHF group, six out of 10 patients survived and exhibited clinical improvement in the status of hepatic encephalopathy. Evoked responses were repeated after 2–3 weeks of recovery in these patients and VER abnormalities showed a tendency to normalize, thereby suggesting a prognostic implication. The incidence of abnormal VER in hepatic encephalopathy complicating ASH far exceeded that of abnormal BAER. Markedly prolonged P100 latencies in FHF patients indicate poor prognosis.     

前列地尔治疗慢性心功能不全患者血浆脑钠肽的疗效研究

目的动态观察前列地尔（PGE1）治疗慢性心功能不全患者（CHF,简称心衰）血浆脑钠肽（BNP）的影响。方法慢性心衰患者72例,随机分为对照组（36例）和治疗组（36例）。对照组给予常规药物治疗。治疗组在CHF常规治疗的基础上加用（PGE1）20μg/d,共14 d,观察治疗前和治疗后7、14d各组患者血浆脑钠肽（BNP）水平。结果与治疗前相比,治疗后两组血浆BNP水平均明显改善（P〈0.05）,对比每一时间位点治疗组改善更为明显。结论前列地尔可有效辅助治疗慢性心衰,改善心功能。     

清肝活血方对酒精性肝纤维化大鼠肝星状细胞增殖与凋亡的影响

目的:观察酒精性肝纤维化大鼠肝星状细胞(HSC)的增殖与凋亡以及清肝活血方的调节作用。方法:雄性Wistar大鼠60只,随机分为空白对照组、模型对照组以及清肝活血方高、中、低剂量组,采用复合因素制备酒精性肝纤维化动物模型。观察清肝活血方对酒精性肝纤维化大鼠肝功能、病理、α-平滑肌动蛋白(α-SMA)以及HSC增殖与凋亡的影响。结果:清肝活血方各剂量组能显著降低酒精性肝纤维化大鼠血清ALT、AST水平(P<0.05);清肝活血方高剂量组能显著降低血清γ-GT水平(P<0.05);各药物组均能在不同程度上减轻肝脏炎症和纤维化,减少肝组织α-SMA的表达(P<0.05),抑制HSC增殖并提高HSC的凋亡率。结论:清肝活血方能有效改善酒精性肝纤维化大鼠肝功能,减轻纤维化程度。其作用机制可能是通过抑制HSC的增殖并促进活化HSC凋亡实现的。     

丙酮酸乙酯对D-氨基半乳糖诱导的急性肝损伤大鼠的保护作用

目的观察丙酮酸乙酯（EP）对D-氨基半乳糖盐酸盐诱导的急性肝损伤模型大鼠的保护作用,并探讨其作用机制。方法制备D-氨基半乳糖盐酸盐诱导的急性肝损伤大鼠模型48只,并随机分成正常组、模型组、小剂量EP提前干预组、大剂量EP提前干预组、小剂量EP治疗组和大剂量EP治疗组。在造模后24h时取血,采用ELISA法检测TNF-α、IFN-γ、IL-10和IL—18水平;采用RT—PCR法检测肝组织HMGB1mRNA水平变化。结果与正常组比较,模型组大鼠血清TNF-α、IFN-γ,IL-10和IL-18水平均无明显变化（P〉0．05）,而肝组织HMGB1mRNA水平明显升高（P〈0．01）;与模型组比较,EP提前干预组和EP治疗组动物血清TNF-α、IFN-γ,IL-10和IL-18水平均无明显变化,而EP提前干预则显著降低了肝组织HMGB1 mRNA水平（P〈0．01）,其中大剂量组最为显著（P〈0．01）;病理学检查显示,EP提前干预组大鼠肝组织学得到明显改善,尤其是在大剂量组,而且比EP治疗组更加显著。结论EP能有效保护D-氨基半乳糖盐酸盐诱导的大鼠急性肝损伤,保护效果与药物的干预剂量成正相关,并且提前干预的效果更明显。     

Increased serum and hepatic tissue levels of interleukin-18 in patients with fulminant hepatic failure

BACKGROUND: Fulminant hepatic failure is a serious clinical condition associated with a high mortality rate. Interleukin (IL)-18 is a pro-inflammatory cytokine that is associated with several inflammatory diseases. The purpose of the present paper was therefore to investigate whether IL-18 is elevated in patients with fulminant hepatic failure. METHODS: Serum levels of IL-18 were measured in patients with fulminant hepatic failure before and after liver transplantation. Native liver tissue samples were collected and the tissue levels of IL-18 were determined. Liver tissues were stained immunohistochemically with antihuman IL-18 antibody. The serum levels of IL-1beta, IL-6, IL-8, IL-12, interferon-gamma, and tumor necrosis factor-alpha were also determined in patients with fulminant hepatic failure before and after liver transplantation. RESULTS: Elevated levels of IL-18 in serum and hepatic tissue were observed in patients with fulminant hepatic failure. Native liver tissue samples were immunohistochemically positive for IL-18. Interleukin-18 levels were markedly reduced after liver replacement. No other inflammatory cytokines were substantially elevated in patients with fulminant hepatic failure. CONCLUSION: The serum levels of IL-18 levels are elevated much more than those of other cytokines in patients with fulminant hepatic failure.     

Matrix metalloproteinase inhibitor reduces apoptosis induction of bone marrow cells in MDS-RA

BACKGROUND AND OBJECTIVES: We examined the involvement of apoptosis with myelodysplastic syndrome (MDS) accompanied by peripheral cytopenias despite normo-hypercellular bone marrow. MATERIALS AND METHODS: Bone marrow smears from 31 patients with MDS-refractory anemia (RA) and five normal controls were stained using the in situ end labeling (ISEL) method. Next, the inhibitory effects of a caspase-3 inhibitor, matrix metalloproteinase inhibitor (MMPI), anti-tumor necrosis factor (TNF)-alpha or anti-Fas antibody upon the apoptosis induction in overnight cultures of bone marrow cells from the patients were examined. Further, TNF-alpha, transforming growth factor (TGF)-beta and soluble Fas ligand (sFasL) concentrations in culture supernatants of the cells were assessed by enzyme-linked immunosorbent assay (ELISA). RESULTS: The incidence of ISEL-positive cells among MDS patients was significantly higher than in normal controls (50.8 +/- 14.0% vs. 11.3 +/- 2.4%; P < 0.0001). A caspase-3 inhibitor reduced significantly the ISEL-positive rates (32.6 +/- 15.2% vs. 50.2 +/- 16.5%; P < 0.0001). Anti-TNF-alpha or anti-Fas antibody reduced the ISEL-positive rates significantly (28.2 +/- 6.0%, 29.2 +/- 5.8%, vs. 44.2 +/- 3.4%, P < 0.001, P = 0.001, respectively). KB-R7785 also significantly decreased the ISEL-positive rates (18.0 +/- 9.3% vs. 43.6 +/- 14.0%; P < 0.0001). The concentration of TNF-alpha was significantly reduced by KB-R7785 (P < 0.05), whereas that of TGF-beta was not. Concentration of sFasL was under detectable level in the present assay system. The derivatives of KB-R7785 that can be administrated orally showed inhibitory effect on apoptosis induction as well. CONCLUSIONS: These findings suggest that MMPIs inhibits the apoptosis induction of MDS bone marrow cells via the inhibition of TNF-alpha and probably sFasL secretion, and that MMPIs can be used to control the abnormal induction of apoptosis in MDS.