Introdução: A síndrome hepatopulmonar (SHP) é definida pela tríade clínica composta de doença hepática, dilatações vasculares intrapulmonares (DVIP) e alterações de gases arteriais, caracterizados por diferença alvéolo-arterial de oxigênio (PA-aO2)≥ 15mmHg (≥20 mmHg,se idade > 64 anos) ou PaO2<80mmHg. Essa síndrome é considerada uma complicação freqüente da cirrose, independente de sua etiologia. Objetivos: Caracterizar a prevalência da doença e o perfil dos portadores de SHP candidatos a transplante hepático na Santa Casa de Porto Alegre; avaliar a presença de fatores de risco como idade, sexo, etiologia da cirrose, gravidade da doença hepática, bem como analisar as variações gasométricas e da função pulmonar em pacientes portadores da síndrome. Métodos: Foram avaliados pacientes listados para transplante hepático no Complexo Hospitalar Santa Casa de Porto Alegre, que apresentaram ecocardiograma e gasometria arterial para avaliar a presença SHP de acordo com as diretrizes vigentes. Foi realizada a pesquisa no prontuário e os analisados exames laboratoriais, ecocardiograma e testes de função pulmonar. Foi realizada a análise univariada através do programa do software R (R Development Core Team, 2012), com cálculo do odds ratio e utilizado o Teste Exato de Fisher para testar a significância estatística das características clínicas, demográficas e das etiologias mais comuns.Foi determinado o intervalo de confiança de 95%. Para análise estatística das variáveis quantitativas, foi empregado o teste t de Student para comparação entre os grupos com presença e ausência da SHP. Resultados: Estudaram-se 133 pacientes e a prevalência da SHP em nossa série foi de 36,84%, utilizando como ponto de corte de gradiente alvéolo-arterial (PA-aO2)≥ 15mmHg (≥20 mm Hg, se idade > 64 anos), conforme determinado pela Diretriz de Doenças Vasculares Hepatopulmonares (PHD) publicado em 2004.. A presença de idade superior a 50 anos, bem como a cirrose causada exclusivamente por vírus C ficaram definidas como fatores de risco estatisticamente significativos. A cirrose causada exclusivamente por vírus C, etiologia mais prevalente, envolvendo 68,66% dos pacientes. Dos pacientes com MELD maior que 15, a SHP esteve presente em 44,9%. Dentro da amostra estudada, 100 pacientes possuíam espirometria com medida da difusão de monóxido de carbono (DLCO), 22,37% dos pacientes apresentaram DLCO menor que 60% do previsto. Desses apenas 41,18% tinham diagnóstico de SHP. A mediana de DLCO, nos pacientes com ou sem SHP, mostrou-se semelhante entre os grupos, de modo que esse parâmetro de função pulmonar, apesar de ser o único alterado, em alguns pacientes, não se apresentou como critério fidedigno de avaliação. A PaCO2 e PaO2 100% não apresentaram diferença entre os grupos com ou sem SHP. No entanto, a PaO2 mostrou-se diferente, estatisticamente, reforçando o conceito de critério diagnóstico e forte indicador da presença de shunt. Conclusões: Principais conclusões do estudo: a prevalência em nossa amostra foi consideravelmente maior que a maioria das publicações, onde a ocorrência da doença ficou em torno de 13 a 18%, possivelmente, devido à adequação do ponto de corte do gradiente alvéolo-arterial, conforme determinado pela Diretriz de Doenças Vasculares Hepatopulmonares (PHD) publicado em 2004. A redução da DLCO (<60% do previsto) pode ser vista em um terço dos pacientes com cirrose hepática, com ou sem SHP, possivelmente relacionados à ascite ou à anemia. No entanto, conforme já descrito em estudos anteriores, a mediana de DLCO em pacientes com critérios diagnósticos para SHP foi menor, podendo sugerir que esse marcador funcional possa ser o único útil na avaliação complementar, mesmo sabendo que a DLCO é um parâmetro que não se altera após o transplante hepático. A PaO2 é dado imprescindível a ser avaliado nos pacientes cirróticos, já que é definido como critério diagnóstico de SHP, além de retornar aos níveis normais após transplante hepático. A análise bioquímica para cálculo do MELD ganhou destaque desde que passou a ser o principal critério de inclusão em lista de transplante. Na série estudada, a maioria dos pacientes apresentou MELD menor que 15, o que define doença menos avançada. Este fato esclarece que os pacientes incluídos na amostra, em sua maioria, foram listados antes de 2006, quando o critério era cronológico e não gravidade. Normalmente, a evolução da hepatopatia até cirrose hepática é mais frequente em pacientes portadores de hepatite por vírus C. Dessa maneira, a relação encontrada, nesse estudo, com a presença de cirrose por vírus C e SHP foi, possivelmente, casual e devido à alta prevalência de hepatopatia por vírus C seguida de cirrose. / Introduction: The hepatopulmonary syndrome (HPS) is defined by the clinical triad consists of liver disease, pulmonary vascular dilatation (IPVD) and changes in arterial blood gases, characterized by alveolar-arterial oxygen gradient (PA-aO2) ≥ 15mmHg (≥ 20 mm Hg, if age> 64 years) or PaO2 <80mmHg. This syndrome is considered a frequent complication of cirrhosis, regardless of etiology. Objectives: To describe the prevalence of the disease and the profile of patients with SHP liver transplant candidates at the hospital Santa Casa de Porto Alegre; evaluate the presence of risk factors such as age, sex, etiology of cirrhosis, severity of liver disease, well as to analyze the variations of gas exchange and pulmonary function in patients with the syndrome. Methods: We evaluated patients listed for liver transplantation in a Hospital Santa Casa de Porto Alegre, who had echocardiography and arterial blood gas analysis to assess the presence SHP according to current guidelines. A survey was conducted in the medical records and analyzed laboratory tests, echocardiography and pulmonary function tests. Univariate analysis was performed using the software program R (R Development Core Team, 2012), with calculation of odds ratios and used the Fisher Exact Test to test the statistical significance of demographic, clinical and the most common etiologies. It was determined the confidence interval of 95%. For statistical analysis of quantitative variables, we used the Student t test for comparison between groups with and without HPS. Results: We studied 133 patients and the prevalence of HPS in our series was 36.84%, using a cutoff of alveolar-arterial gradient (PA-aO2) ≥ 15mmHg (≥ 20 mm Hg, if age> 64 years), as determined by Guideline Hepatopulmonares Vascular Diseases (PHD) published in 2004. The presence of older than 50 years, as well as cirrhosis caused by hepatitis C virus were exclusively defined as statistically significant risk factors. Cirrhosis caused solely by virus C, more prevalent etiology involving 68.66% of patients. Of the patients with MELD scores greater than 15, the SHP was present in 44.9%. Within the study sample, 100 patients had spirometry with measurement of diffusion of carbon monoxide (DLCO), 22.37% of patients had DLCO less than 60% predicted. These only 41.18% had a diagnosis of HPS. The median DLCO in patients, with or without SHP, was similar between the groups, so that this parameter of lung function, despite being the only altered, in some patients, it is not presented as an evaluation criterion reliable assessment. The PaCO2 and PaO2 100% showed no difference between groups with or without SHP. However, PaO2 proved statistically different, reinforcing the concept of diagnostic criteria and a strong indicator of the presence of shunts. Conclusions: Main conclusions of the study: the prevalence in our sample was considerably higher than most publications, where the occurrence of the disease was around 13 to 18%, possibly, due to the cutoff adequacy of alveolar-arterial gradient as determined by the Guideline Hepatopulmonares Vascular Diseases (PHD) published in 2004. The decrease in DLCO (<60% predicted) can be seen in one third of patients with liver cirrhosis, with or without HPS, possibly related to ascites or anemia. However, as already described in previous studies, the median DLCO in patients with diagnostic criteria for HPS was lower, may suggest that this functional marker may be the only useful in further evaluation, even though the DLCO is a parameter that does not change after liver transplantation. The PaO2 is essential given to be evaluated in cirrhotic patients, since it is defined as diagnostic criteria of HPS, and return to normal levels after liver transplantation. Biochemical analysis for calculating the MELD gained prominence since it became the main criterion for inclusion on the transplant list. In the series studied, most patients had MELD less than 15, which defines less advanced disease. This fact explains that the patients included in the sample, most were listed before 2006, when the criterion was chronological and not gravity. Typically, the development of liver cirrhosis is even more frequent in patients with viral hepatitis C. Thus, the relationship found in this study with the presence of cirrhosis and HPS C virus was possibly due to casual and high prevalence of C virus liver cirrhosis followed.

Base teórica: As doenças hepáticas representam um grande problema de saúde pública, sendo responsáveis por um considerável número de atendimentos e internações hospitalares, com crescente índice de mortalidade. A melatonina (MLT), uma potente molécula antioxidante, tem-se mostrado benéfica em diversas situações patológicas, incluindo as hepáticas. Objetivo: O objetivo foi avaliar os efeitos da MLT na cirrose hepática induzida por CCl4 em ratos machos Wistar. Métodos: Utilizaram-se 20 ratos machos Wistar, (230-250g), divididos em 4 grupos: I: Controle (CO), II: CO+MLT, III: CCl4 e IV: CCl4+MLT. O CCl4 foi administrado i.p.: 10 aplicações de 5 em 5 dias, 10 aplicações de 4 em 4 dias, e 7 aplicações de 3 em 3 dias. A MLT (20mg/Kg i.p.) iniciada na 10ª semana, perdurando até o final do experimento na 16ª semana. Resultados: Como resultados apresentados nos dois artigos, observamos que a MLT no grupo CCl4+MLT, em relação ao grupo CCl4, diminuiu os níveis séricos das enzimas AST, ALT e FA. Na avaliação do estresse oxidativo, diminuiu a LPO avaliada por TBARS e F2-isoprostanos; aumentou a atividade da enzima antioxidante (SOD) e diminuiu a expressão da NQO1; aumentou a expressão do fator de transcrição Nrf2 e diminuiu a expressão de seu inibidor o Keap1. Na avaliação do estresse do RE, diminuiu a expressão de proteínas preditoras de estresse do RE, GRP78 e ATF6. Na avaliação das proteínas e fatores de choque térmico, diminuiu a expressão da HSP70 e do HSF1. No processo inflamatório, diminuiu a presença de infiltrado inflamatório e a expressão das proteínas NF-KB/p65 e da iNOS. No processo fibrogênico, diminuiu os septos e a presença de nódulos de fibrose, além de diminuir a expressão das proteínas TGF-β1 e da α-SMA. No processo de angiogênese, diminuiu a expressão do VEGF. Conclusão: Com este estudo, demonstramos que a MLT, uma indolamina sintetizada a partir do aminoácido triptofano, protegeu o parênquima hepático da progressão da fibrose induzida em ratos pelo CCl4. / Background: Conclusion Liver diseases represent a major problem in public health, accounting for a significant number of hospitalizations and care, with increasing mortality rates. Melatonin (MLT) is a powerful antioxidant molecule, that has demonstrated to be beneficial in various pathological situations, including liver diseases. Objective: The aim was to evaluate the effects of MLT in liver cirrhosis induced by CCl4 in male Wistar rats. Methods: We used 20 male Wistar rats (230- 250g) divided into 4 groups: I : control (CO), II: CO + MLT, III: CCl4 and IV: CCl4 + MLT. The CCl4 was administered ip: 10 applications in 5 to 5 days , 10 applications in 4 to 4 days and 7 applications in 3 to 3 days. The MLT (20 mg / kg ip) started at the 10th week and lasted until the end of the experiment, at 16 weeks. Results: As results presented in the two articles, we found that the MLT in the CCl4+MLT group when compared to CCl4 group, decreased serum levels of AST, ALT and FA enzymes. In the evaluation of oxidative stress, decreased LPO measured by TBARS and F2- isoprostanes; increased the activity of the antioxidant enzyme (SOD) and decreased the expression of NQO1; increased expression of the transcription factor Nrf2 and decreased the expression of its inhibitor Keap1. In the assessment of ER stress, decreased the expression of proteins predictors of ER stress, GRP78 and ATF6. In the evaluation of proteins and heat shock factors, decreased expression of HSP70 and HSF1. In the inflammatory process, decreased inflammatory infiltration and the expression of proteins NF-KB/p65 and iNOS. In the fibrogenic process, decreased the sept and the presence of nodules of fibrosis, in addition to decreasing the expression of TGF-β1 protein and α-SMA. In the process of angiogenesis, decreased expression of VEGF. Conclusion: In this study, we demonstrated that MLT, an indoleamine synthesized from tryptophan, protected the liver parenchyma from fibrosis progression induced by CCl4 in rats.

O uso de tetracloreto de carbono (CCl4) em ratos é um modelo experimental de dano ao tecido hepático, desencadeando fibrose e, a longo prazo, cirrose. A cirrose hepática é uma doença crônica progressiva que representa um estado de disfunção hepática irreversível ou lentamente reversível, caracterizado pela formação de nódulos fibróticos. Este estudo possui como objetivo avaliar as alterações hepáticas e pulmonares causadas pelo modelo de cirrose hepática através da utilização de CCl4 intraperitoneal. Foram utilizados 18 ratos Wistar machos divididos em 3 grupos: grupo controle (CO) e outros 2 grupos divididos pelo tempo de indução da cirrose por CCl4. G1 (11 semanas), G2 (16 semanas). Verificamos a elevação significativa no nível das transaminases hepáticas, na lipoperoxidação do tecido hepático e pulmonar (TBARS) e nas enzimas antioxidantes SOD e CAT, além de um aumento da expressão de TNF-M e IL-1N no pulmão dos animais cirróticos. Observamos alteração nas trocas gasosas de ambos os grupos cirróticos. Podemos concluir que nosso modelo reproduziu a cirrose hepática, além de causar alterações no sistema pulmonar, provocando alteração nas trocas gasosas e alterando o tamanho dos vasos pulmonares. / The use of carbon tetrachloride (CCl4) in rats is an experimental model of hepatic tissue damage, which leads to fibrosis, and at the long term, cirrhosis. Cirrhosis is a chronic progressive disease that represents a state of irreversible or slowly reversible hepatic disfunction, characterized by fibrotic nodules formation. The aim of this study is to evaluate the changes caused by cirrhosis in lung and liver, through the experimental model of intraperitoneal CCl4 administration. We used 18 male Wistar rats divided into three groups: control (CO) and two groups divided by the time of cirrhosis induction by CCl4. G1 (11semanas), G2 (16semanas). We found significant increase of transaminase levels and lipid peroxidation (TBARS) in liver and lung tissue. Also, increased antioxidant enzymes SOD and CAT, as well as the expression of TNF-M and IL-1N in the lung of cirrhotic animals. We observed changes in gas exchange in both cirrhotic groups. We can conclude that our model reproduces the liver cirrhosis, that causes alterations in the pulmonary system that leads to changes in gas exchange and size of pulmonary vessels.

Não consta resumo na publicação. / Abstract not available.

Large efforts have been made to target integrin αVβ3 of endothelial cells. We have successfully developed a new class of protein (Ref to as ProAgio) by rational protein design using a stable host protein, domain 1 of cell adhesion protein CD2. ProAgio is designed to target integrin αVβ3 at a novel site and induces angiogenic endothelial cell apoptosis by recruiting and activating caspase 8 to the cytoplasmic domain of the targeted integrins. Tests with tumor xenograft models show that ProAgio strongly inhibits tumor growth. Histology analyses indicate that tumor vessels are reduced, while the established vasculatures are not affected. Toxicity analyses demonstrate that ProAgio is not toxic to mouse. Our study develops an effective anti-angiogenesis agent and provides a new platform for development of therapeutics by targeting integrins. We have successfully developed an anti-angiogenesis protein targeting integrin αVβ3 at a novel site by rational protein design. The developed agent is not toxic to non-cancerous blood vessels and other tissue/organs, providing an excellent candidate for future potential clinical development. Our developed protein is one of the very few examples that do not act through targeting VEGF/VEGFR or any other RTK pathways. The βA groove is present in almost all other β integrins. This approach may be applicable to develop agents targeting the similar βA groove of other integrin pairs, which can address wide array of pathological conditions such as AMD, Rheumatoid Arthritis, Osteoporosis etc.

京都大学 / 0048 / 新制・論文博士 / 博士(医学) / 乙第13371号 / 論医博第2208号 / 新制||医||1047(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 川口 義弥, 教授 妹尾 浩, 教授 浅野 雅秀 / 学位規則第4条第2項該当 / Doctor of Medical Science / Kyoto University / DFAM

JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley and Sons Australia, Ltd. Background and Aim: The United Kingdom-primary biliary cholangitis (UK-PBC) and global primary biliary cholangitis group (GLOBE) prognostic models have been recently developed to predict long-term outcomes in primary biliary cholangitis (PBC). However, these predictive scores have not yet been well evaluated in the U.S. population. Methods: We retrospectively reviewed newly diagnosed PBC patients at the Cleveland Clinic between November 1998 and February 2017. Adverse events were defined as liver transplantation, liver-related mortality, and all-cause mortality. Transplant-free survival (TFS) was estimated using the Kaplan–Meier method. Predictive performances of all prognostic models were evaluated using the C-statistic. Results: We identified 352 patients who used ursodeoxycholic acid therapy. Of them, 311 (88.4%) only had PBC, while 41 (11.6%) were diagnosed with PBC-autoimmune hepatitis overlap. A total of 22 (6%), 47 (13%), and 55 (16%) patients had adverse events within 5, 10, and 15 years after diagnosis, respectively. In patients with PBC only, the C-statistic in predicting 15-year adverse events was 0.75 per GLOBE compared to 0.74 per UK-PBC (P = 0.94), 0.73 per Rotterdam (P = 0.44), 0.66 per Barcelona (P = 0.004), 0.65 per Paris 1 (P = 0.005), 0.62 per Paris 2 (P < 0.0001), 0.60 per Toronto (P < 0.0001), and 0.60 per Mayo (P < 0.0001) scores. Median follow-up was 9.2 years. Ten-year TFS for patients who had optimal versus suboptimal treatment response was 92 versus 74% per Paris 1 (P < 0.0001), 95 versus 79% per Paris 2 (P = 0.0002), 93 versus 65% per Barcelona (P < 0.0001), and 96 versus 68% per Rotterdam (P < 0.0001) risk scores, respectively. Conclusion: In our cohort of PBC patients, the UK-PBC and GLOBE scores were both accurate and reasonably valid prognostic models in the U.S. population.

Goals: The purpose of our study was to evaluate trends of hospitalization, acute kidney injury (AKI) and mortality in cirrhotic patients with spontaneous bacterial peritonitis (SBP). Background: SBP is a frequent bacterial infection in cirrhotic patients leading to increased morbidity and mortality. Materials and Methods: A total of 4,840,643 patients hospitalized with cirrhosis from 2005 to 2014 were identified using the Nationwide Inpatient Sample database, of which 115,359 (2.4%) had SBP. We examined annual trends and used multivariable mixed-effects logistic regression analyses to obtain adjusted odds ratios by accounting for hospital level and patient level variables. Results: We identified a striking increase in hospitalizations for SBP in cirrhotic patients (0.45% to 3.12%) and AKI in SBP patients (25.6% to 46.7%) from 2005 to 2014. Inpatient mortality decreased over the study period in patients with SBP (19.1% to 16.1%) and in patients with SBP plus AKI (40.9% to 27.6%). Patients with SBP had a higher inpatient mortality rate than those without SBP [15.5% vs. 6%, adjusted odd ratio (aOR): 2.02, P<0.001]. AKI was 2-fold more prevalent in cirrhotics with SBP than those without SBP (42.8% vs. 17.2%, aOR: 1.91, P<0.001) and concomitant AKI was associated with a 6-fold mortality increase (aOR: 5.84, P<0.001). Cirrhotic patients with SBP had higher hospitalization costs and longer length of stays than patients without SBP. Conclusions: Despite a higher hospitalization rate and prevalence of concomitant AKI, mortality in patients with SBP decreased during the study period. SBP is associated with high likelihood of development of AKI, which in turn, increases mortality.

Liver fat-storing cells (FSC) play an important role in collagen deposition. During the induction of liver cirrhosis, FSC lose their fat droplets, acquire an actin-rich cytoskeleton and transform into myofibroblasts. Myofibroblasts have been associated with increased collagen production in cirrhotic livers. Cultured FSC resemble myofibroblasts. However, it is not known whether regulation of collagen gene expression is similar in FSC obtained from normal or cirrhotic livers. In this communication, we describe the characterization of two fat-storing cell lines, one from normal (NFSC) and one from CCl4-cirrhotic liver (CFSC), obtained after spontaneous immortalization in culture. We studied the effect of serum and various growth factors on cell proliferation. We determined the production of collagen and fibronectin and we analyzed the presence of mRNA transcripts of collagens type I, III, and IV, fibronectin laminin, transforming growth factor-β and interleukin-6. We found that CFSC have a greater serum-dependency than NFSC. NFSC grow with a mixture of insulin and epidermal growth factor, whereas CFSC proliferate only with platelet-derived growth factor. Although we did not find significant differences in the expression of mRNAs for collagen type I, fibronectin and transforming growth factor-β, collagen and fibronectin synthesis was increased 2- and 1.5-fold respectively. NFSC contained 1.6- and 2.0-fold more type III collagen and laminin mRNAs, respectively, than CFSC. Neither cell line expressed type IV collagen mRNA. NFSC but not CFSC produced interleukin-6. These results suggest that, except for the lack of transcripts of collagen type IV, both cell lines resemble primary cultures of FSC. However, significant differences in cell proliferation and interleukin-6 production between the two cell lines were found. We suggest that these cell lines could be useful tools to study possible differences in regulation of matrix production by FSC.

Abstract not available. / by Wong Lai-hung, Grace. / Source: Dissertation Abstracts International, Volume: 72-04, Section: B, page: . / Thesis (Ph.D.)--Chinese University of Hong Kong, 2010. / Includes bibliographical references (leaves 218-252). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. Ann Arbor, MI : ProQuest Information and Learning Company, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web.