Clinical relevance of alkaline phosphatase isoenzyme determinations by high performance liquid chromatography

A new method for the separation of alkaline phosphatase isoenzymes by means of high performance liquid chromatography (HPLC) is presented. One isoenzyme was identified in homogenate of small intestine, two were identified in bone, and two in liver, and fragment and biliary isoenzymes were identified in bile. Sera from 32 patients with different diseases of the skeletal system or the liver were analysed. High activities of the bone isoenzymes were detected in bone diseases, of the second liver isoenzyme in acute hepatitis and of the first liver and biliary isoenzymes in biliary obstruction. There are indications that the first liver isoenzyme is derived from the cell membrane and the second liver isoenzyme from the cytosol. The biliary isoenzyme is considered to be a highly sensitive and specific indicator for cholestasis.     

Accumulation of iron and iron compounds in liver tissue. A comparative study of the histological and chemical estimation of liver iron

Unsatisfactory results obtained by histological evaluation of liver tissue in iron loading diseases prompted us to study the distribution of the total liver iron, haem iron and ferritin iron in post mortem human liver tissue from two different sites of the same liver. The total liver iron content was measured by flameless atomic absorption spectroscopy in native liver homogenates and in acid digested liver tissue from 60 consecutive autopsies, and the results from the two methods were compared. From the standard deviation of the duplicate analyses, it was deduced that the liver iron is possibly inhomogeneously distributed. The CVduplo (22%) of total iron, measured in acid digested tissue was higher than the CVduplo (14%) of total iron in homogenates from liver tissue from which non-homogenized tissue e.g. vessel walls, fibrotic tissue, had been removed. The CVduplo of ferritin iron and haem iron in liver homogenate was 14% and 30% respectively. The ferritin iron increased with an increasing total iron content until saturation of ferritin iron appeared to be reached at 2.5 micrograms ferritin iron per mg liver protein. When the results of total non-heam liver iron measurements are expressed properly (amount of iron per amount of homogenized liver protein), the distribution of iron is found to be homogeneous in both normal and pathological liver tissues. It was concluded that the estimation of liver iron content by visual microscopic evaluation is unsatisfactory, and that more reliable results are obtained by atomic absorption spectrophotometry.     

Application of Fourier analysis to clinical study of patterns of tissue movement

An analysis is made of the kinetics of human liver parenchyma in response to mechanical impulses arising in the heart and aorta, and the results are applied to predicting the time course of the correlation between two time-separated A-scans derived from various regions of the liver. Such predictions are found to correspond well with data derived clinically, both from volunteers and from patients with liver metastases, using a commercial, real-time sector scanner. On the basis of Fourier spectral features of the clinically derived correlation patterns, a clear quantitative separation was demonstrated between the kinetic response of three classes of tissue: normal liver in volunteers, metastatic deposits in liver of cancer patients, and histologically normal liver regions in the same patients.     

Insulin and glucagon degradation in liver are not affected by hepatic cirrhosis

Hyperinsulinemia and impaired glucose tolerance are associated with liver cirrhosis. To investigate whether insulin-degrading activity in liver tissue plays a role in hyperinsulinemia, we assayed this activity in biopsy tissue from healthy and cirrhotic subjects. There was no difference in insulin degradation between these two groups. Also glucagon-degrading activity in liver tissue, which is catalyzed by the same enzyme as insulin-degrading activity, did not differ between the two groups studied. Therefore, insulin-degrading activity does not appear to be involved in the hyperinsulinemia that occurs in liver cirrhosis. The study provides indirect evidence that hyperinsulinemia and impaired glucose metabolism in liver cirrhosis are due to different mechanisms (receptorial and post-receptorial defects, and altered feedback inhibition of insulin secretion).     

Immunopathologic Studies of Systemic Lupus Erythematosus (SLE). I. Tissue-bound Immunoglobulins in Relation to Serum Antinuclear Immunoglobulins in Systemic Lupus and in Chronic Liver Disease with LE Cell Factor

We studied the composition of tissue-bound immunoglobulins and of antinuclear factors by immunofluorescent techniques in five patients with systemic lupus and two with chronic liver disease associated with positive LE cell tests. Renal glomeruli in all seven demonstrated deposits of bound gammaG-globulin and complement, although the presence of gammaA- and gammaM-immunoglobulins was variable. Blood vessel walls contained primarily gammaG-globulin and complement in the systemic lupus patients, but such deposits were absent from vessels in the two with chronic liver disease.We observed antinuclear factors, demonstrated by immunofluorescence, in all three immunoglobulin classes. In six of the seven patients, evidence was obtained of a correspondence between the classes of bound immunoglobulins in glomeruli and vessels and the serum titers of antinuclear immunoglobulins. These observations are consistent with the concept that immunoglobulin deposits in tissues may be derived at least in part from antinuclear factors.Neither bound immunoglobulins nor complement was observed in liver parenchyma of the two patients with chronic liver disease or in two patients with systemic lupus and liver pathology. It thus seems doubtful that serum antibodies play a primary role in the pathogenesis of forms of chronic liver disease associated with positive LE cell tests.     

Equipment review: the molecular adsorbents recirculating system (MARS)

The molecular adsorbents recirculating system (MARS) is a form of artificial liver support that has the potential to remove substantial quantities of albumin-bound toxins that have been postulated to contribute to the pathogenesis of liver cell damage, haemodynamic instability and multi-organ failure in patients with acute liver failure (ALF) and acute-on-chronic liver failure (AoCLF). These toxins include fatty acids, bile acids, tryptophan, bilirubin, aromatic amino acids and nitric oxide. Data from controlled clinical trials are limited so far. One of two studies performed on small numbers of patients with AoCLF suggest a survival benefit, but no controlled data are available in the ALF setting. Our preliminary experience with MARS therapy, instituted late in the clinical course of five patients with severely impaired liver function, including three with AoCLF precipitated by sepsis and two with liver dysfunction due to sepsis in the absence of pre-existing chronic liver disease, indicates some clinical efficacy. However, the overall survival rate (1 of 5; 20%) remained poor. More data obtained from larger cohorts of patients enrolled in randomised controlled studies will be required in both the AoCLF and ALF settings to identify categories of liver failure patients who might benefit most from MARS treatment, to ascertain the most appropriate timing of intervention and to determine the overall impact on outcome, including cost-effectiveness.     

Multiple circular liver foci in chronic hepatic porphyria: two sonographic case reports

Appearance of liver foci in patients with chronic hepatic porphyria has been described in literature several times since 1988. We present two impressive examples of multiple coin-like lesions in the liver of patients with till than unknown porphyria. A 61-year-old women was hospitalized with suspected liver metastases: sonography showed multiple ring-like liver foci up to 2 cm. In a 52-year-old man sonography incidentally detected multiple liver foci, in this case homogeneous hyper-echogenic. In both patients a liver tumor was excluded by biopsy, the histologic examination of the specimens only showed uncharacteristic alterations. DISCUSSION: Sonographic findings in hepatic porphyria most times are only uncharacteristic alterated. But 10% of the patients show multiple hyper-echogenic hepatic foci: these lesions typically have a well marked rim, some times they even appear like a ring. In color doppler examination hepatic vessels are not affected by the lesions. The lesions themselves do not show an increased vascularisation. This allows to discriminate from other liver tumors, especially from liver metastases. Histologic findings are not pathognomonic, laboratory research is subsequently required. Strictly avoiding alcoholic drinks the presented discoveries are in principle reversible.     

Liver disease as presenting manifestation of Hodgkin's disease.

Six patients who were referred to the liver unit on account of jaundice are described. A different initial diagnosis has been made in each case, these being fulminant hepatic failure, severe hepatitis with renal failure, toxoplasma hepatitis, extrahepatic obstruction, sclerosing cholangitis, and liver abscess. After delays of four weeks to 12 months from the time of first symptoms all six patients were eventually found to have advanced Hodgkin's disease (stage 4). In four patients the diagnosis was made during life, but in two only at autopsy. In four lymphoma tissue was finally demonstrable in the liver, but in two liver biopsy showed only minor non-specific changes despite grossly abnormal liver function tests. Three of the six patients were treated with chemotherapy, and two of these recovered sufficiently to leave hospital. With the encouraging survival figures now being obtained in Hodgkin's disease, an awareness of the varied hepatic manifestations of the disease may allow treatment to be instituted at an earlier stage.     

Turnover of radiolabelled plasminogen and prothrombin in cirrhosis of the liver

The turnover of purified radiolabelled plasminogen was studied in four patients with cirrhosis of the liver, and that of radiolabelled prothrombin in six patients with cirrhosis of the liver. The cirrhotic patients showed an increased fractional catabolic rate and a decreased synthetic rate, resulting in subnormal plasma levels of plasminogen and prothrombin. The plasma concentration of the two proteins correlated with the synthetic rate, but not with the fractional catabolic rate. Heparin infusion prolonged the shortened half-life of plasminogen in two cirrhotics from 1.25 to 2.10 days and from 1.45 to 1.90 days, and the half-life of prothrombin in three cirrhotics from 2.25 to 2.70 days, from 2.35 to 2.80 days and from 2.40 to 3.70 days. These results indicate that the abnormal turnover of labelled plasminogen and prothrombin in cirrhosis of the liver is due to two mechanisms; increased breakdown, reversible by heparin administration, and impaired synthesis. The decreased plasma levels are, however, mainly caused by decreased synthesis.     

Technetium 99m sulfur colloid spleen/liver ratio and other liver tests in the diagnosis of cirrhosis.

The results of seven laboratory tests of liver function, including spleen/liver activity ratios obtained by densitometric analysis of scans, are analyzed in 50 patients with proven Laennec's cirrhosis. In this series, the liver scan not only disclosed the liver gross anatomy and structural abnormality and established the best possible site for biopsy examination, but also, the increased splenic activity served as a useful diagnostic indication of Laennec's cirrhosis. Of 50 proven cases of Laennec's cirrhosis, 41 (82%) had abnormal spleen/liver ratios. An abnormal spleen/liver ratio in combination with abnormal results from any one or two other tests was relatively effective in the detection of cirrhosis. The accuracy is improved if the other laboratory tests are chosen from among tests for serum albumin, serum bilirubin, and SGOT. (Liver abnormalities other than cirrhosis can also present an abnormal spleen/liver ratio.) This simple determination extends the value of the liver scan commonly requested in search of metastases, primary lesions, or inflammatory processes, or in preparation for needle biopsy examination.     

Liver Disease as Presenting Manifestation of Hodgkin's Disease

Six patients who were referred to the liver unit on accountof jaundice are described. A different initial diagnosis hasbeen made in each case, these being fulminant hepatic failure,severe hepatitis with renal failure, toxoplasma hepatitis, extrahepaticobstruction, sclerosing cholangitis, and liver abscess. Afterdelays of four weeks to 12 months from the time of first symptomsall six patients were eventually found to have advanced Hodgkin'sdisease (stage 4). In four patients the diagnosis was made duringlife, but in two only at autopsy. In four lymphoma tissue wasfinally demonstrable in the liver, but in two liver biopsy showedonly minor non-specific changes despite grossly abnormal liverfunction tests. Three of the six patients were treated withchemotherapy, and two of these recovered sufficiently to leavehospital. With the encouraging survival figures now being obtainedin Hodgkin's disease, an awareness of the varied hepatic manifestationsof the disease may allow treatment to be instituted at an earlierstage.     

儿童乙型病毒性肝炎肝脏病理与肝功能、肝纤维化血清学指标的关系

【目的】探讨儿童慢性乙型病毒性肝炎的肝脏病理变化与肝功能、肝纤维化血清学指标、血清乙肝病毒的脱氧核糖核酸（HBV-DNA）载量的相关性。【方法】回顾性分析2010年7月至2015年6月本院肝病中心收治确诊的79例慢性乙型病毒性肝炎临床病理资料。收集患儿的术前3d的肝功能、肝纤维化血清学四项指标、HBV-DNA病毒栽量等检测指标。根据肝脏病理改变程度分为轻度和中重度炎症损伤两组及无肝纤维化和肝纤维化两组,分析与其血清谷丙转氨酶（ALT）、谷草转氨酶（AST）、总蛋白（Abl）、Ⅲ型胶原蛋白（PCⅢ）、层粘连蛋白（LN）、透明质酸酶（HA）、Ⅳ型胶原蛋白（Ⅳc）水平及HBV-DNA载量的关系。【结果】轻度肝脏炎症组57例,中重度肝脏炎症组22例,两组的ALT、AST、Abl及HBV-DNA载量的差异比较均无统计学意义（P〉0．05）。无肝脏纤维化组19例,肝脏纤维化组60例,两组的肝纤维四项指标发现Ⅲ型胶原蛋白、层粘连蛋白、透明质酸酶及Ⅳ型胶原蛋白差异比较具有统计学意义（P〈0．05）,但两组间的谷丙转氨酶、谷草转氨酶、白蛋白、HBV-DNA载量差异无明显统计学意义（P〉0．05）。【结论】肝功能及HBV-DNA载量不能预测儿童慢性乙型病毒性肝炎的肝脏病理炎症改变程度,肝纤维四项对评估患儿肝脏纤维化程度有一定临床意义。肝穿刺活检为评估患儿肝脏病理改变的金标准,对于指导儿童乙型病毒性肝炎的治疗具有重要作用。     

Two-dimensional diffraction scanning of normal and cancerous human hepatic tissue in vitro

A technique and associated equipment are described which investigate the acoustic signals backscattered from small tissue volumes and interrogated over a solid angle of transmitter/receiver positions. This two-dimensional diffraction technique produces acoustic scatter maps termed, by us “interferograms”, which are analysed to determine their usefulness in discriminating between normal, freshly excised liver tissue and cancerous tissue within the intact organ. The “interferograms” are collected at three different narrow-band frequencies and have been used in investigating 26 normal liver and 13 liver tumour samples. The preliminary results indicate that this novel technique has a 97% success in discriminating normal liver from tumour, compared to an 87% success achieved by two observers when scoring conventional sector B-scan images of the same tissue regions.     

Two new methods for separating and quantifying bone and liver alkaline phosphatase isoenzymes in plasma

We describe two new methods for the separation and quantification of the bone and liver isoenzymes of alkaline phosphatase (EC 3.1.3.1) in plasma. In the first, we use wheat-germ lectin to precipitate the bone isoenzyme. About 80% of this, but minimal liver isoenzyme, is precipitated. The activity of the bone isoenzyme is calculated from measuring the alkaline phosphatase activity in the precipitate, that of liver alkaline phosphatase by subtracting the activity of the bone isoenzyme from total alkaline phosphatase activity. The liver fraction will also contain biliary, intestinal, and placental alkaline phosphatase if these are present in the original plasma, but correction for such activity is readily made. In the second method, samples are separated on cellulose acetate membranes that, before electrophoresis, have been soaked in buffer containing wheat-germ lectin. The bone isoenzyme is retarded and clearly separated from the liver fraction, allowing these isoenzymes to be quantified by densitometry. Both methods are rapid, reproducible, and suitable for use in the diagnostic laboratory.     

Long-term treatment of Wilson's disease with triethylene tetramine dihydrochloride (trientine)

Long-term treatment with triethylene tetramine dihydrochloride,(trientine, TETA) was evaluated in 19 patients with Wilson'sdisease (WD). Two were given the drug as first choice and 17after treatment with penicillamine. The change was made becauseof side-effects, lack of improvement or worsening of neurologicalsymptoms. All penicillamine-induced side-effects reverted. Thirteenpatients still receive trientine, and the mean total observationtime on this treatment is 8.5 years/patient. Seven of the 13are free from symptoms related to WD, five have mild to moderateneurological symptoms, mainly dysarthria. One patient with neurologicalsymptoms who received trientine from the start of treatmentdeteriorated rapidly and is now severely dystonic. The symptomsinitially worsened and later improved in one patient. All otherpatients improved during trientine treatment. Three patientsdied: two from a multifocal cancer including the liver and onenon-complier from a ruptured spleen. Two patients underwentliver transplantation for progressive liver failure: one non-complierand one with liver cirrhosis whose liver function deteriorateddespite treatment; both are now free from symptoms. Unexpectedly,two patients developed a serious colitis, one with duodenitisas well, that improved after withdrawal of the drug. No otherunfavourable effects of trientine were recorded.     

Liver steatosis classification using high-frequency ultrasound

High-frequency B-mode images of 19 fresh human liver samples were obtained to evaluate their usefulness in determining the steatosis grade. The images were acquired by a mechanically controlled single-crystal probe at 25 MHz. Image features derived from gray-level concurrence and nonseparable wavelet transform were extracted to classify steatosis grade using a classifier known as the support vector machine. A subsequent histologic examination of each liver sample graded the steatosis from 0 to 3. The four grades were then combined into two, three and four classes. The classification results were correlated with histology. The best classification accuracies of the two, three and four classes were 90.5%, 85.8% and 82.6%, respectively, which were markedly better than those at 7 MHz. These results indicate that liver steatosis can be more accurately characterized using high-frequency B-mode ultrasound. Limitations and their potential solutions of applying high-frequency ultrasound to liver imaging are also discussed.     

肝病患者的肝组织单细胞悬液与外周血中淋巴细胞亚群的分析比较

目的探讨肝脏组织单细胞悬液的制备方法,了解慢性肝病患者的肝组织和外周血的淋巴细胞亚群差异。方法分别选择慢性乙型肝炎(CHB)14例、自身免疫性肝炎(AIH)4例和原发性肝细胞癌(HCC)3例,在超声引导下经皮作肝脏穿刺活检,用单细胞制备仪或物理研磨方法将肝组织制备成单细胞悬液,肝组织中淋巴细胞经4种特异性荧光抗体标记,在流式细胞仪(FCM)上作四色荧光分析,并与外周血测定结果比较。结果单细胞制备仪和物理研磨方法制备的肝组织单细胞悬液,细胞成活率分别为92.4%和91.5%;检测肝组织单细胞悬液中淋巴细胞亚群,正常对照组和慢性肝病各组间差异均有显著性(P<0.05),AIH组和CHB组间差异有显著性(P<0.05)。而外周血中淋巴细胞亚群检测,HCC组和CHB组间差异有显著性(P<0.05)。肝组织和外周血相应项目比较差异均有显著性(P<0.05)。结论用2种方法制备单细胞悬液能满足FCM检测的特殊需要;肝脏组织中淋巴细胞与外周血的淋巴细胞亚群比例差异有显著性。     

Absence of argininosuccinate lyase protein in the liver of two patients with argininosuccinic aciduria

The enzyme defects in two cases of argininosuccinic aciduria were examined at the molecular level by enzymatic and immunological methods. No argininosuccinate lyase activity was detected in the liver or erythrocytes of either patient nor in the kidney or brain of one of the patients even in the presence of high concentrations of the substrate. The titration curve of antiserum to human argininosuccinate lyase with the liver extract from a control subject was not affected by the addition of the liver extracts from one of the patients. Double immunodiffusion analysis revealed a single precipitin line between the purified antiserum and the liver extract from a control, but no precipitin lines between the antisera and the liver extracts from the two patients. These results indicate a complete or almost complete defect of an immunologically cross-reactive material in the liver of the patients.     

控制性呼吸和人工胸水协助高强度聚焦超声治疗肝肿瘤

目的 探讨在HIFU治疗过程中应用控制性呼吸和人工胸水的临床安全性，以及对HIFu治疗的意义。方法 12例肝肿瘤患者在NIFu治疗过程中采用气管或双支气管插管法控制呼吸，根据HIFu治疗需要，通过暂时阻断呼吸，以消除肝脏运动对HIFu治疗的影响；其中对5例病灶位于肝膈顶部的患者，同时在右侧胸膜腔内注入生理盐水，推开治疗入路的肺组织，显露并治疗肝膈顶部肿瘤。结果 控制性呼吸暂停后，肝脏随呼吸的运动明显减小或消失，使mIFu治疗能在肝脏静止状态下进行，注入人工胸水后，HIFu治疗入路的肺组织被推开，肝膈顶部清楚显露；HIFu治疗肝膈顶肿瘤顺利完成，所有治疗均无相关并发症发生。结论 此两项措施是安全的，有助于提高NIFu治疗的效率和安全，并拓宽HIFU治疗的适应范围。     

经典式肝移植与背驮式肝移植手术的回顾性分析

目的通过比较经典式肝移植和背驮式肝移植术中、术后各项指标,探讨不同术式肝移植后肝功能的情况及生存情况。方法回顾分析郑州人民医院自2010年3月至2012年8月收治的92例肝移植患者的病例资料,根据肝移植术式将患者分为经典式组(52例)和背驮式组(40例),观察两组术中、术后情况,观察指标包括手术时间、术中失血量、谷草转氨酶、谷丙转氨酶、总胆红素、直接胆红素、肌酐、血氨等,分析两组患者在肝移植术后的肝功能情况及生活质量。结果两组患者术中失血量不同,差异有统计学意义(P<0.05),两组患者术后1周血氨、总胆红素不同,差异有统计学意义(P<0.05),其余指标差异无统计学意义。结论经典式肝移植与背驮式肝移植手术相比较,后者术中失血量较大,但是两者术后生存质量无较大差别,具体有待进一步研究。