Severity of hepatic encephalopathy before liver transplantation is associated with quality of life after transplantation.

BACKGROUND--Cirrhosis is associated with a chronic low-grade hepatic encephalopathy and disturbances in quality of life. This study investigated the extent to which severity of hepatic encephalopathy before orthotopic liver transplantation correlated with quality of life. METHODS--A battery of neuropsychological tests was administered to nonalcoholic patients to quantify severity of hepatic encephalopathy. The Sickness Impact Profile was administered before and after surgery to document quality of life across multiple health and psychosocial dimensions. RESULTS--There was substantial improvement from the pretransplant to the posttransplant periods across almost all dimensions of quality of life. Neuropsychological test scores explained up to 20% of the variance in magnitude of change from pre (before) to post (after) surgery. CONCLUSION--Severity of hepatic encephalopathy (particularly with respect to static ataxia and fine motor control) is associated with posttransplantation improvement in quality of life.     

Activation of endothelial L-arginine pathway in resistance arteries. Effect of age and hypertension

In conduit arteries, nitric oxide is formed from L-arginine in the endothelium and released after stimulation with acetylcholine. The contribution of the L-arginine pathway and the effects of age and hypertension on endothelium-dependent vascular regulation were studied, using a video dimension analyzer, in pressurized and perfused mesenteric resistance arteries of 8- and 16-20-week-old Wistar-Kyoto and spontaneously hypertensive rats. Norepinephrine and phenylephrine caused contractions, which were similarly augmented after removal of the endothelium. NG-Monomethyl-L-arginine, an inhibitor of nitric oxide formation, augmented the contraction, but less than endothelial removal. Acetylcholine caused endothelium-dependent relaxations that were much more pronounced with intraluminal than with extraluminal application. NG-Monomethyl-L-arginine, methylene blue, and hemoglobin only partially inhibited the response. With aging, the endothelium-dependent inhibition of the response to norepinephrine decreased in Wistar-Kyoto rats; in spontaneously hypertensive rats this inhibition was smaller as compared with age-matched Wistar-Kyoto rats. In Wistar-Kyoto rats, the difference between intraluminal and extraluminal activation became more pronounced in adult rats. In the adult but not the young spontaneously hypertensive rats, the response to intraluminal but not extraluminal acetylcholine was reduced as compared with Wistar-Kyoto rats. Thus, in mesenteric resistance arteries of the rat, nitric oxide is released from L-arginine under basal conditions and after stimulation with acetylcholine but only in part accounts for endothelium-dependent responses. With aging and hypertension, the inhibitory effects of the endothelium against norepinephrine-induced contractions decrease. In hypertension, the intraluminal but not extraluminal activation of the release of endothelium-derived relaxing factors is impaired.     

Cardiac death after autologous stem cell transplantation (ASCT) for treatment of systemic sclerosis (SSc): no evidence for cyclophosphamide-induced cardiomyopathy

In patients with systemic sclerosis (SSc) treatment-related mortality after autologous stem cell transplantation (ASCT) appears to be increased as compared to patients with hematological malignancies. In our phase I/II study on ASCT in autoimmune diseases a patient with SSc died on day 2 after ASCT. Here we report the results of the autopsy which revealed advanced pulmonary and cardiac fibrosis as the most probable cause of death. In spite of detailed technical examination before enrollment, the cardiopulmonary function tests did not reflect the advanced stage of the disease. We conclude that in selected patients with SSc, biopsies should be performed to reduce mortality after ASCT.     

Role of serum complement,immunoglobulins, and cell-mediated immune system in the pathogenesis of spontaneous bacterial peritonitis (SBP)

Spontaneous bacterial peritonitis (SBP) is a common complication of advanced liver disease, which has a reported prevalence of between 4 and 27%. Frequent bacteremias due to inadequate host defense mechanisms, particularly the reticuloendothelial system (RES), with seeding of an ascitic fluid that lacks a normal opsonic activity, is believed to be the principal cause of SBP. Little data exist as to the role of serum levels of complement and immunoglobulins as well as the cell-mediated immune system in the pathogenesis of SBP. The aim of this study was to determine the serum levels of the third and fourth components of complement (C3, C4), total hemolytic complement activity (CH₁₀₀), and properdin factor B (PFB) and immunoglobulins G, A, and M and various T-cell parameters in individuals admitted to hospital with ascites and advanced liver disease and to determine whether one or more of these factors could be used to predict the development of SBP in patients with advanced liver disease. Fourteen consecutive patients (nine male and five female; age 47.5±3.1 years, mean±Sem) with end-stage liver disease and ascites, who were evaluated for possible liver transplant at the University of Pittsburgh and who developed SBP, comprised the study group. The diagnosis of SBP was determined by positive ascitic fluid culture (three patients) and/or ascitic fluid neutrophil count of>250 cells/mm³ (all patients). The control group consisted of 14 patients, matched for type of liver disease, age, and sex, who did not develop SBP. Each patient studied underwent a prospective elective abdominal paracentesis, and the recovered fluid was assayed for total protein, total white blood cell count, total neutrophil count, and culture. The immunological status of each individual was accomplished by determining the serum levels of C3, C4, PFB, CH₁₀₀, and immunoglobulins G, A, and M. Finally the percentage of lymphocytes and their distribution in the various T-cell subsets was determined also. No difference in the immunological status between these two groups was evident. However, the ascitic fluid protein level, although not significantly different between the two groups studied, was less than 2 g/dl more often in the group developing SBP than in the control group that did not subsequently develop SBP. The estimated risk for developing SBP in individuals with ascitic fluid protein level of <2 g/dl was increased eightfold (95% CI: 50.05, 1.28) compared to those with ascitic fluid total protein levels above this cutoff level. Based on these data, it is concluded that serum immunoglobulin and complement levels and the cell-mediated immune system activity are similar in patients with advanced liver disease who develop and do not develop SBP. Thus, these parameters cannot be used as predictors for the development of SBP. In contrast, the ascitic fluid protein level was found to be a simple readily measurable parameter capable of identifying patients at high risk for the development of SBP.This work was supported by grants from NIAAA (06601) and from NIDDK (32556 and 39789).     

Growth of the Reh cell line in diffusion chambers. Evidence for differentiation along the T- and B-cell pathway.

Cells of the Reh line, originally derived from an ALL of the 'Non-T, Non-B' type were cultured in diffusion chambers implanted intraperitoneally into perirradiated CBA mice. At different intervals over a period of 20 d changes in surface characteristics were examined by labelling the cells with AcALLG, ATCG as well as with polyvalent AIg. The evaluation was performed by using direct immunofluorescence. In addition, the ability to form rosetts with SRBC, AET-treated sheep erythrocytes, mouse red blood cells and EoxAC was tested. On day 0 of the diffusion chamber culture the cells only carried cALLA, and no rosette formation was observed. In the course of the diffusion chamber culture the cells unequivocally developed T-cell antigen, and in 1 of 2 experiments they further acquired a receptor for forming AET- and E-rosettes. Conversely, in the other experiment a receptor for mouse red blood cells was detected in a considerable portion of the cells. Our data show that the rather undifferentiated Reh line cells in vitro are able to develop features of mature T-cells and attributes of early B-cells during the diffusion chamber culture. In vitro they apparently retain a bivalent potentiality of lymphatic maturation. The diffusion chamber system proves to be a suitable tool for promoting differentiation in these cells.     

Prethymic phenotype and genotype of pre-T (CD7+/ER-)-cell leukemia and its clinical significance within adult acute lymphoblastic leukemia

Pretreatment blast cells from 739 adults with acute lymphoblastic leukemia (ALL) were immunophenotyped as part of a prospective treatment protocol study. Among 192 patients (26%) with T lineage ALL, 47 (6%; 24% of T lineage ALL) had lymphoblasts without sheep erythrocyte rosette formation, but with pan-T antigen CD7 on the membrane and intracellular CD3 proteins mostly in perinuclear accumulation. The T-cell surface antigens CD5 and/or CD2 and focal acid phosphatase were additional markers of this subgroup traditionally called pre-T ALL, whereas thymocyte antigen CD1 as well as CD4 and CD8 antigens were not expressed. Hematopoietic progenitor cell markers, namely terminal deoxynucleotidyl transferase (TdT), and in part common ALL antigen (CD10), HLA-DR antigens, and/or My-10 (CD34), a unique antigen of marrow cells absent in thymus cells, further characterized this immature T-ALL form of putative prothymocytic phenotype (CD7+/intracellular CD3+/TdT+/My-10+/-/HLA-DR+/-/CD10+/-). The prethymic T cell character was supported by germ-line T-cell receptor beta genes found in 21 of 36 patients analyzed. In five cases only T gamma-chain genes were rearranged. Fifteen patients, however, had rearrangements of both T beta and T gamma genes. Immunoglobulin heavy chain genes were rearranged only in two cases. Pre-T ALL differed significantly from E-rosette+ T-ALL in some presenting clinical features, namely mediastinal mass, lymphoadenopathy, and platelet count, and independently of clinical factors in prognosis (P = .02, median remission duration: 15.7 v 33.5 months, and P = .02, median survival time: 24.6 v 50.7 months). We conclude that ALL classification based solely on T- or B-cell lineage affiliation is not sufficient but needs further subdivision according to relevant maturation stages as exemplified here within the T-cell axis. The putative prethymic T cell progenitor phenotype described might help elucidate the sequence of genetic events that commit normal hematopoietic cells to the T-cell lineage.