[show abstract][hide abstract] ABSTRACT: The current methods available for screening and detecting hepatocellular carcinoma (HCC) have insufficient sensitivity and specificity, and only a low percentage of diagnosis of small tumours is based on these assays. Because HCC is usually asymptomatic at potentially curative stages, identification of biomarkers for the early detection of HCC is essential to improve patient survival.
The aim of this study was to identify candidate markers for HCC development in the plasma from hepatitis C virus (HCV)-infected cirrhotic patients.
We compared protein expression profiles of plasma samples from HCV-infected cirrhotic patients with and without HCC, using two-dimensional fluorescence difference gel electrophoresis (2-D DIGE) coupled with MALDI-TOF/TOF mass spectrometry. The 2-D DIGE results were analysed statistically using Decyder™ software, and verified by western blot and enzyme-linked immunosorbent assay (ELISA).
In the plasma of HCV-infected HCC patients, we observed decreased expression of complement component 9, ficolin-3 (FCN3), serum amyloid P component (SAP), fibrinogen-gamma and immunoglobulin gamma-1 chain, and increased expression of vitronectin (VTN) and galectin-3 binding protein (G3BP) by DIGE analysis. ELISA confirmed DIGE results for VTN and G3BP but not for SAP or FCN3 in a larger patient population.
The proteins VTN and SAP are candidate biomarkers for HCC development in HCV-infected cirrhotic patients.
Liver international: official journal of the International Association for the Study of the Liver 07/2013; · 3.87 Impact Factor
[show abstract][hide abstract] ABSTRACT: Recurrence of hepatocellular carcinoma (HCC) is a major complication after liver transplantation (LT). The initial immunosuppression protocol may influence HCC recurrence, but the optimal regimen is still unknown.
219 HCC consecutive patients under Milan criteria who received a LT at 2 european centres between 2000-2010 were included. Median follow-up was 51 months (IQR 26-93). Demographic characteristics, HCC features, and immunosuppression protocol within the first month after LT were evaluated against HCC recurrence by using Cox regression.
In the explanted liver 110 patients (50%) had multinodular HCC, and largest nodule diameter was 3±2.1 cm. Macrovascular invasion was incidentally detected in 11 patients (5%), and microvascular invasion was present in 41 patients (18.7%). HCC recurrence rates were 13.3% at 3 years and 17.6% at 5 years. HCC recurrence was not influenced by the use/non use of steroids and antimetabolites (p=0.69 and p=0.70 respectively), and was similar with tacrolimus or cyclosporine (p=0.25). Higher exposure to calcineurin inhibitors within the first month after LT (mean tacrolimus trough concentrations >10ng/mL or cyclosporine trough concentrations >300ng/mL), but not thereafter, was associated with increased risk of HCC recurrence (27.7% vs 14.7% at 5 years; p=0.007). The independent predictors of HCC recurrence by multivariate analysis were: high exposure to calcineurin inhibitors defined as above (RR=2.82; p=0.005), diameter of the largest nodule (RR=1.31; p<0.001), microvascular invasion (RR=2.98; p=0.003) and macrovascular invasion (RR=4.57; p=0.003).
Immunosuppression protocols with early CNI minimization should be preferred in LT patients with HCC in order to minimize tumour recurrence.
Journal of Hepatology 07/2013; · 9.86 Impact Factor
[show abstract][hide abstract] ABSTRACT: Hepatitis C virus (HCV) is a major health problem that leads to chronic hepatitis, cirrhosis and hepatocellular carcinoma, being the most frequent indication for liver transplantation in several countries. Unfortunately, HCV re-infects the liver graft almost invariably following reperfusion, with an accelerated history of recurrence, leading to 10%-30% of patients progressing to cirrhosis within 5 years of transplantation. In this sense, some groups have even advocated for not re-transplanting this patients, as lower patient and graft outcomes have been reported. However, the management of HCV recurrence is being optimized and several strategies to reduce post-transplant recurrence could improve outcomes, decrease the rate of re-transplantation and optimize the use of available grafts. Three moments may be the focus of potential actions in order to decrease the impact of viral recurrence: the pre-transplant moment, the transplant environment and the post-transplant management. In the pre-transplant setting, it is not well established if reducing the pre transplant viral load affects the risk for HCV progression after transplant. Obviously, antiviral treatment can render the patient HCV RNA negative post transplant but the long-term benefit has not yet been fully established to justify the cost and clinical risk. In the transplant moment, factors as donor age, cold ischemia time, graft steatosis and ischemia/reperfusion injury may lead to a higher and more aggressive viral recurrence. After the transplant, discussion about immunosuppression and the moment to start the treatment (prophylactic, pre-emptive or once-confirmed) together with new antiviral drugs are of interest. This review aims to help clinicians have a global overview of post-transplant HCV recurrence and strategies to reduce its impact on our patients.
World journal of hepatology. 05/2013; 5(5):237-250.
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: The optimal allocation of organs in liver transplantation is a problem that can be resolved using machine-learning techniques. Classical methods of allocation included the assignment of an organ to the first patient on the waiting list without taking into account the characteristics of the donor and/or recipient. In this study, characteristics of the donor, recipient and transplant organ were used to determine graft survival. We utilised a dataset of liver transplants collected by eleven Spanish hospitals that provides data on the survival of patients three months after their operations. METHODS AND MATERIAL: To address the problem of organ allocation, the memetic Pareto evolutionary non-dominated sorting genetic algorithm 2 (MPENSGA2 algorithm), a multi-objective evolutionary algorithm, was used to train radial basis function neural networks, where accuracy was the measure used to evaluate model performance, along with the minimum sensitivity measurement. The neural network models obtained from the Pareto fronts were used to develop a rule-based system. This system will help medical experts allocate organs. RESULTS: The models obtained with the MPENSGA2 algorithm generally yielded competitive results for all performance metrics considered in this work, namely the correct classification rate (C), minimum sensitivity (MS), area under the receiver operating characteristic curve (AUC), root mean squared error (RMSE) and Cohen's kappa (Kappa). In general, the multi-objective evolutionary algorithm demonstrated a better performance than the mono-objective algorithm, especially with regard to the MS extreme of the Pareto front, which yielded the best values of MS (48.98) and AUC (0.5659). The rule-based system efficiently complements the current allocation system (model for end-stage liver disease, MELD) based on the principles of efficiency and equity. This complementary effect occurred in 55% of the cases used in the simulation. The proposed rule-based system minimises the prediction probability error produced by two sets of models (one of them formed by models guided by one of the objectives (entropy) and the other composed of models guided by the other objective (MS)), such that it maximises the probability of success in liver transplants, with success based on graft survival three months post-transplant. CONCLUSION: The proposed rule-based system is objective, because it does not involve medical experts (the expert's decision may be biased by several factors, such as his/her state of mind or familiarity with the patient). This system is a useful tool that aids medical experts in the allocation of organs; however, the final allocation decision must be made by an expert.
Artificial intelligence in medicine 03/2013; · 1.65 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND AND AIMS: Tremelimumab is a monoclonal antibody that blocks cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4), an inhibitory co-receptor that interferes with T cell activation and proliferation. The purpose of this pilot clinical trial was to test the antitumor and antiviral effect of Tremelimumab in patients with hepatocellular carcinoma (HCC) and chronic hepatitis C virus (HCV) infection; and to study the safety of its administration to cirrhotic patients. METHODS: Tremelimumab at a dose of 15 mg/kg IV every 90 days was administered until tumor progression or severe toxicity. Twenty patients were evaluable for toxicity and viral response and 17 were evaluable for tumor response. Most patients were in the advanced stage and 43% had an altered liver function (Child-Pugh class B). RESULTS: A good safety profile was recorded and no patient needed steroids because of severe immune-mediated adverse events. Some patients had a transient albeit intense elevation of transaminases after the first dose but not following subsequent cycles. Partial response rate was 17.6% and disease control rate was 76.4%. Time to progression was 6.48 months (95%CI 3.95 to 9.14). A significant drop in viral load was observed while new emerging variants of the hypervariable region 1 of HCV replaced the predominant variants present before therapy, particularly in those patients with a more prominent drop in viral load. This antiviral effect was associated with an enhanced specific anti-HCV immune response. CONCLUSIONS: Tremelimumab safety profile and antitumor and antiviral activity in patients with advanced HCC developed on HCV-induced liver cirrhosis support further investigation.
Journal of Hepatology 03/2013; · 9.86 Impact Factor
[show abstract][hide abstract] ABSTRACT: Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamase-producing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.
[show abstract][hide abstract] ABSTRACT: Acute on chronic liver failure (ACLF) is a frequent cause of death in cirrhosis. Albumin dialysis with the molecular adsorbent recirculating system (MARS®) decreases retained substances and improves hemodynamics and hepatic encephalopathy (HE). However, its survival impact is unknown. 189 patients with ACLF were randomized either to MARS® (n=95) or to standard therapy (SMT) (n=94). Ten patients (5 per group) were excluded due to protocol violations. In addition, 23 patients (MARS®: 19; SMT: 4) were excluded from per-protocol (PP) analysis (PP population n=156). Up to ten 6-8 hours MARS® sessions were scheduled. Main endpoint was 28-day ITT and PP survival. There were no significant differences at inclusion, although the proportion of patients with MELD score over 20 points and with SBP as precipitating event was almost significantly greater in the MARS® group. 28-day survival was similar in the two groups in ITT and PP population (60. 7% vs.58.9 %; 60 % vs. 59.2 % respectively). After adjusting by confounders, a significant beneficial effect of MARS® on survival was not observed (OR: 0.87 CI 95 % 0.44-1.72). MELD score and HE at admission and the increase in serum bilirubin at day 4 were independent predictors of death. At day 4, a greater decrease in serum creatinine (p= 0.02) and bilirubin (p=0.001) and a more frequent improvement in HE (from grade II-IV to grade 0-I; 62.5 % vs. 38.2 %; p=0.07) was observed in MARS® group. Severe adverse events were similar. Conclusion: At scheduled doses, a beneficial effect on survival of MARS® therapy in patients with ACLF could not be demonstrated. However MARS® has an acceptable safety profile, has significant dialysis effect and non-significantly improves severe HE. (HEPATOLOGY 2012.).
[show abstract][hide abstract] ABSTRACT: This paper reports on a decision support system for assigning a liver from a donor to a recipient on a waiting-list that maximises the probability of belonging to the survival graft class after a year of transplant and/or minimises the probability of belonging to the non-survival graft class in a two objective framework. This is done with two models of neural networks for classification obtained from the Pareto front built by a multi-objective evolutionary algorithm – called MPENSGA2. This type of neural network is a new model of the generalised radial basis functions for obtaining optimal values in C (Correctly Classified Rate) and MS (Minimum Sensitivity) in the classifier, and is compared to other competitive classifiers. The decision support system has been proposed using, as simply as possible, those models which lead to making the correct decision about receptor choice based on efficient and impartial criteria.
European Journal of Operational Research 10/2012; 222(2):317–327. · 2.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Orthotopic liver transplantation (OLT) is currently the elective treatment for advanced liver cirrhosis and acute liver failure. Ischemia/reperfusion damage may jeopardize graft function during the postoperative period. Cardiotrophin-1 (CT-1) has demonstrated cytoprotective properties in different experimental models of liver injury. There is no evidence to demonstrate its potential use in the prevention of the ischemia/reperfusion injury that occurs during OLT. The present study is the first report to show that the administration of CT-1 to donors would benefit the outcome of OLT. MATERIALS AND METHODS: We tested the cytoprotective effect of CT-1 administered to the donor prior to OLT in an experimental pig model. Hemodynamic changes, hepatic histology, cell death parameters, activation of cell signaling pathways, oxidative and nitrosative stress, and animal survival were analyzed. RESULTS: Our data showed that CT-1 administration to donors increased animal survival, improved cardiac and respiratory functions, and reduced hepatocellular injury as well as oxidative and nitrosative stress. These beneficial effects, related to the activation of AKT, ERK, and STAT3, reduced caspase-3 activity and diminished IL-1β and TNF-α expression together with IL-6 upregulation in liver tissue. CONCLUSIONS: The administration of CT-1 to donors reduced ischemia/reperfusion injury and improved survival in an experimental pig model of OLT.
Journal of Surgical Research 08/2012; · 2.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: Abstract Aims: The study evaluated the role of increased intracellular nitric oxide (NO) concentration using NO donors or stably NO synthase-3 (NOS-3) overexpression during CD95-dependent cell death in hepatoma cells. The expression of cell death receptors and caspase activation, RhoA kinase activity, NOS-3 expression/activity, oxidative/nitrosative stress, and p53 expression were analyzed. The antitumoral activity of NO was also evaluated in the subcutaneous implantation of NOS-3-overexpressing hepatoma cells, as well NO donor injection into wild-type hepatoma-derived tumors implanted in xenograft mouse models. Results: NO donor increased CD95 expression and activation of caspase-8 and 3 in HepG2, Huh7, and Hep3B cells. NOS-3 overexpression increased oxidative/nitrosative stress, p53 and CD95 expression, cellular Fas-associated death domain (FADD)-like IL-1beta converting enzyme (FLICE) inhibitory protein long (cFLIP(L)) and its short isoform (cFLIP(S)) shift, and cell death in HepG2 (4TO-NOS) cells. The inhibition of RhoA kinase and p53 knockdown using RNA interference reduced cell death in 4TO-NOS cells. The supplementation with hydrogen peroxide (H(2)O(2)) increased NOS-3 activity and cell death in 4TO-NOS cells. NOS-3 overexpression or NO donor injection into hepatoma-derived tumors reduced the size and increased p53 and cell death receptor expression in nude mice. Innovation and Conclusions: The increase of intracellular NO concentration promoted oxidative and nitrosative stress, Rho kinase activity, p53 and CD95 expression, and cell death in cultured hepatoma cells. NOS-3-overexpressed HepG2 cells or intratumoral NO donor administration reduced tumor cell growth and increased the expression of p53 and cell death receptors in tumors developed in a xenograft mouse model. Antioxid. Redox Signal. 00, 000-000.
[show abstract][hide abstract] ABSTRACT: Information regarding liver retransplantation in HIV-infected patients is scant. Data from 14 HIV-infected patients retransplanted between 2002 and 2011 in Spain (6% retransplantation rate) were analyzed and compared with those from 157 matched HIV-negative retransplanted patients. In HIV-infected patients, early (≤30 days) retransplantation was more frequently indicated (57% vs. 29%; p = 0.057), and retransplantation for HCV recurrence was less frequently indicated (7% vs. 37%; p = 0.036). Survival probability after retransplantation in HIV-positive patients was lower than in HIV-negative patients, 42% versus 64% at 3 years, although not significantly (p = 0.160). Among HIV-infected patients, those with undetectable HCV RNA at retransplantation and those with late (>30 days) retransplantation showed better 3-year survival probability (80% and 67%, respectively), similar to that in their respective HIV-negative counterparts (72% and 70%). In HIV-infected and HIV-negative patients, 3-year survival probability in those with positive HCV RNA at retransplantation was 22% versus 65% (p = 0.008); in those with early retransplantation, 3-year survival probability was 25% versus 56% (p = 0.282). HIV infection was controlled with antiretroviral therapy after retransplantation. In conclusion, HIV-infected patients taken as a whole have unsatisfactory survival after liver retransplantation, although patients with undetectable HCV RNA at retransplantation or undergoing late retransplantation show a more favorable outcome.
American Journal of Transplantation 06/2012; 12(9):2465-76. · 6.19 Impact Factor
[show abstract][hide abstract] ABSTRACT: Increased blood pressure (BP) is common after liver transplantation. However, there is scarce information on its control.
In this prospective, cross-sectional, multicenter study, we determined BP according to the recommended international standards in 921 liver transplant patients during one routine outpatient visit to assess their grade of control of BP. At the time of the study, 490 patients had been previously diagnosed with arterial hypertension and were receiving antihypertensive treatment, and 431 were not previously diagnosed as hypertensive.
In the hypertensive group, arterial hypertension was uncontrolled (BP >140/90 mm Hg [>130/80 in diabetics]) in 158 (32%) patients and controlled in 332 (68%) patients. In a multivariate analysis, only diabetes was identified as a significant predictor of uncontrolled hypertension. Among patients not previously diagnosed as hypertensive, BP was increased in 106 (25%) and normal in 325 (75%). On multivariate analysis, the only variable independently associated with increased BP in this group was metabolic syndrome.
BP is not adequately controlled in a noticeable percentage of liver transplant patients, especially in subjects with diabetes or metabolic syndrome.
[show abstract][hide abstract] ABSTRACT: Donor-recipient matching constitutes a complex scenario difficult to model. The risk of subjectivity and the likelihood of falling into error must not be underestimated. Computational tools for the decision-making process in liver transplantation can be useful, despite the inherent complexity involved. Therefore, a multi-objective evolutionary algorithm and various techniques to select individuals from the Pareto front are used in this paper to obtain artificial neural network models to aid decision making. Moreover, a combination of two pre-processing methods has been applied to the dataset to offset the existing imbalance. One of them is a resampling method and the other is a outlier deletion method. The best model obtained with these procedures (with AUC = 0.66) give medical experts a probability of graft survival at three months after the operation. This probability can help medical experts to achieve the best possible decision without forgetting the principles of fairness, efficiency and equity.
[show abstract][hide abstract] ABSTRACT: Wnt/β-catenin pathway controls biochemical processes related to cell differentiation. In committed cells the alteration of this pathway has been associated with tumors as hepatocellular carcinoma or hepatoblastoma. The present study evaluated the role of Wnt/β-catenin activation during human mesenchymal stem cells differentiation into hepatocytes. The differentiation to hepatocytes was achieved by the addition of two different conditioned media. In one of them, β-catenin nuclear translocation, up-regulation of genes related to the Wnt/β-catenin pathway, such as Lrp5 and Fzd3, as well as the oncogenes c-myc and p53 were observed. While in the other protocol there was a Wnt/β-catenin inactivation. Hepatocytes with nuclear translocation of β-catenin also had abnormal cellular proliferation, and expressed membrane proteins involved in hepatocellular carcinoma, metastatic behavior and cancer stem cells. Further, these cells had also increased auto-renewal capability as shown in spheroids formation assay. Comparison of both differentiation protocols by 2D-DIGE proteomic analysis revealed differential expression of 11 proteins with altered expression in hepatocellular carcinoma. Cathepsin B and D, adenine phosphoribosyltransferase, triosephosphate isomerase, inorganic pyrophosphatase, peptidyl-prolyl cis-trans isomerase A or lactate dehydrogenase β-chain were up-regulated only with the protocol associated with Wnt signaling activation while other proteins involved in tumor suppression, such as transgelin or tropomyosin β-chain were down-regulated in this protocol. In conclusion, our results suggest that activation of the Wnt/β-catenin pathway during human mesenchymal stem cells differentiation into hepatocytes is associated with a tumoral phenotype.
PLoS ONE 01/2012; 7(4):e34656. · 3.73 Impact Factor
[show abstract][hide abstract] ABSTRACT: Rifampicin has been used for the treatment of patients with jaundice and pruritus. This study evaluated the effect of rifampicin on the expression of different detoxification systems and bile acid transporters during in-vivo and in-vitro experimental models of cholestasis.
Rifampicin was administered to glycochenodeoxycholic acid (GCDCA)-treated human hepatocytes and bile duct-obstructed rats. Different parameters related to cell death, and the expression of phase I and II drug metabolizing enzymes (DME) and bile acid transporters were determined.
The induction of hepatocellular injury induced by cholestasis was associated with a reduction in cytochrome P4503A4 (CYP3A4), CYP7A1, and UDP-glucuronosyltransferase 2B4 (UGT2B4) expression, as well as an increase in import (Na(+)-taurocholate co-transporting polypeptide, NTCP) system expression. The beneficial properties of rifampicin were associated with an increase in DME and export bile acid systems (multidrug resistance-associated protein 4, MRP4, and bile acid export pump to bile duct, BSEP) expression, as well as a reduction in NTCP expression.
The beneficial effect of rifampicin in cholestasis is associated with an increase in DME expression involved in toxic, bile acid and cholesterol metabolism, as well as a reduction in the bile acid importing system in hepatocytes.
Journal of hepato-biliary-pancreatic sciences. 04/2011; 18(5):740-50.
[show abstract][hide abstract] ABSTRACT: The involvement of bone marrow hematopoietic stem cells (BMHSC) mobilization during liver regeneration from hepatectomized patients is under debate. The main aim of this study was to investigate the role of BMHSC mobilization after hepatic resection in 33 patients with liver disease.
Mobilization of CD34(+) BMHSC after 72 h of surgery was found in peripheral blood of some, but not all, of the hepatectomized patients. These CD34(+) cells co-expressed other stem cells markers. The patients without BMHSC mobilization showed high levels of circulating and liver tissue BMHSC (CD34(+) cells) previous to surgery. Therefore, two types of patients: "mobilizers" and "non-mobilizers" were distinguished based on the values of CD34(+) cells before and after surgery. Changes in cytokines involved in the hepatic regeneration (HGF and TGF-β), and in BMHSC mobilization process (SCF, SDF-1, IL-12, or MMP-2), were detected in both groups. In addition, a higher activation previous to surgery of the SDF-1/CXCR4 axis in liver tissue was observed in non mobilizers patients compared to mobilizer patients.
BMHSC mobilization seems to be associated with variations in the levels of cytokines and proteolytic enzymes involved in hepatic regeneration and bone marrow matrix degradation. Hepatectomy may be an insufficient stimulus for BMSHC mobilization. The pre-hepatectomy higher levels CD34(+) cells in peripheral blood and liver, associated to the activation of hepatic SDF-1/CXCR4 axis, suggest a BMHSC mobilization process previous to surgery in non mobilizer patients.
Journal of Gastrointestinal Surgery 04/2011; 15(8):1459-67. · 2.36 Impact Factor