Background and Aim: Bacterial infections are a well described complication of cirrhosis and occur in 37% of hospitalized patients. Culture positive infections in addition to the presence of bacterial products and DNA lead to loss of liver function and decompensation in cirrhosis. The mechanisms and molecular pathways associated with Bacterial Translocation (BT) are unknown. The aims of this study were to determine: i. macrophage phenotype and molecular pathways associated with bacterial translocation ii. if intestinal macrophages in liver cirrhosis are capable of modulating intestinal permeability.iii. structural integrity of the epithelial barrier. Methods: Duodenal biopsies and serum samples were collected from 29 patients with decompensated cirrhosis, 15 patients with compensated and 19 controls. Duodenal macrophages were characterized by means of flow cytometry and IHC. Gene expression analysis was performed to determine molecular pathways involved in BT. Inflammatory cytokine determination was done in serum and culture supernatant by means of customized cytometric bead arrays. Results: Patients with decompensated cirrhosis demonstrated: increased frequency of CD33+/CD14+/TREM-1+ and iNOS+ macrophages in their duodenum, elevated mRNA levels of nitric oxide synthase 2 (NOS2), chemokine ligand 2 (CCL2), chemokine ligand 13 (CCL13) and interleukin 8 (IL8) and increased serum levels of interleukin 6 (IL6), IL8 and lipopolysaccharides (LPS). Additionally, patients with decompensated cirrhosis showed an increase in NO, IL6, IL8 and CCL2 levels in culture supernatant after short term duodenal biopsy culture. Although the epithelial barrier on EM seemed intact, significantly increased expression of the “pore” forming tight junction claudin 2 was observed. Conclusion: This study showed the presence of activated CD14+Trem- 1+iNOS+ intestinal macrophages and increased levels of NO, IL-6 and claudin-2 levels in the duodenum of patients with decompensated liver cirrhosis, suggesting that these factors enhance intestinal permeability to bacterial products. / Afrikaans: Inleiding: Bakteriele infeksie is ‘n beskryfde komplikasie van lewersirrose wat in 37% van gehospitaliseerde pasiente voorkom. Kultuur positiewe infeksies asook die teenwoordigheid van bakteriele produkte en DNA lei tot verlies van lewerfunksie en dekompensasie. Die molekulere meganismes wat verband hou met bakteriele translokasie is nog onbekend. Die doel van hierdie studie was om: i. Makrofaag fenotipe en molekulere meganismes geassosieerd met bakteriele translokasie te beskryf, ii. te bepaal of intestinale makrofage dermdeurlaatbaarheid beinvloed, asook iii. om die struktruele integriteit van die dermwand te bepaal. Methods: Serum en dunderm biopsies was verkry van 29 pasiente met gedekompenseerde lewer sirrose, 15 pasiente met gekompenseerde sirrose en 19 kontroles. Dunderm makrofage was gekarakteriseer met behulp van vloeisitometrie en immunohistochemie. Molekulere meganisms belangrik tydens bakteriele translokasie was bepaal met behulp van geneekspressie. Serum en selkultuur supernatant sitokien bepalings was met Bioplex assays gedoen. Resultate: Pasiente met gedekompenseerde sirrose demonstreer: ‘n verhoogde frekwensie van CD33+/CD14+/TREM-1+ en iNOS+ makrofage in hul dunderm, verhoogde mRNA vlakke van NOS2, CCL2, CCL13 en IL8 asook verhoogde serum vlakke van IL6, IL8, LPS. Addisioneel het pasiente met gedekompenseerde sirrose vehoogde supernatant vlakke van NO, IL6, IL8 and CCL2 na kort termyn dunderm biopsie kulture. Alhoewel elekronmikroskopie gewys het dat die dundermwand intak is, was daar statisties-beduidend verhoogde ekspressie van die “porie” vormende vasteaansluitings- proteien, claudin 2 sigbaar. Gevolgtrekking: Gesamentlik het die studie gewys dat geaktiveerde CD14+/Trem-1+/iNOS+ intestinale makrofage asook verhoogde vlakke van NO, IL-6 en claudin-2 teenwoordig is in die dunderm van pasiente met gedekompenseerde sirrose. Dit dui daarop dat diè faktore derm deurlaatbaarheid vir bakteriele produkte kan verhoog. / Dissertation (MSc)--University of Pretoria, 2011. / Immunology / MSc / Unrestricted

Introduktion: Levercirros är ett medicinskt tillstånd i slutskedet som är en följd av en leversjukdom och orsakas bland annat av missbruk av alkohol, kronisk hepatit B och C, och autoimmun hepatit. Enligt rapport från Världshälsoorganisationen lider cirka 10% av befolkningen i världen av kroniska leversjukdomar, och 20 miljoner människor drabbas av levercirros eller dess följd levercancer. Den registrerade mortaliteten av levercirros i Sverige är ca 600 personer per år. För många av dessa patienter innebär det ett stort lidande både fysiskt och psykiskt. Patienterna upplever inte alltid att deras lidande har kunnat lindras, och därför är det angeläget att kunskaper om och förståelse för denna patientgrupp utifrån deras egna upplevelser förbättras och fördjupas.   Syfte: Att beskriva patienters upplevelser av att leva med levercirros och deras självskattning av sin livskvalitet.   Metod: Litteraturöversikt med en systematisk ansats baserad på sex kvalitativa och nio kvantitativa originalartiklar publicerade på engelska under åren mellan 2003 och 2020.    Resultat: Resultatet innefattar tre huvudteman: fysiskt lidande, psykologiskt lidande, och försämrad hälsorelaterad livskvalité. Individer med levercirros upplever rent generellt ett lidande, dock på olika plan samt grader. Ett fysiskt lidande förekommer men även ett psykiskt, och ofta leder det till en försämrad livskvalité.   Slutsats: Forskning har visat att patienter med levercirros möjligen inte kan uttrycka sina åsikter på samma sätt som andra patienter på grund av stigmatisering och skam. Denna litteraturstudie kommer att hjälpa såväl närstående som vårdpersonal att förstå denna patientgrupp, och minska deras lidande på ett adekvat sätt. / Introduction: Liver cirrhosis is a medical condition in the final stages that is a consequence of a liver disease and is caused by, among other things, alcohol abuse, chronic hepatitis B and C, and autoimmune hepatitis. According to a report from the World Health Organization, about 10% of the world's population suffers from chronic liver disease, and 20 million people suffer from liver cirrhosis or its consequent liver cancer. The registered mortality from liver cirrhosis in Sweden is about 600 people per year. For many of these patients, it means great suffering both physically and mentally. Patients do not always feel that their suffering has been alleviated, and therefore it is important that knowledge of and understanding of this patient group based on their own experiences is improved and deepened.   Aim: To describe patients' experiences of living with liver cirrhosis and their self-esteem of their quality of life.   Method: Literature review with a systematic approach based on six qualitative and nine quantitative original articles published in English during the years between 2003 and 2020.   Results: The results include three main themes: physical suffering, psychological suffering, and deteriorating health-related quality of life. Individuals with liver cirrhosis generally experience suffering, however, on different levels and degrees. A physical suffering occurs but also a mental one, and often it leads to a deteriorating quality of life.   Conclusion: Research has shown that patients with liver cirrhosis may not be able to express their views in the same way as other patients due to stigma and shame. This literature review will help both relatives and caregivers understand this patient group, and reduce their suffering adequately.

BACKGROUND: After proteolysis, the majority of released amino acids from dietary protein are transported to the liver for gluconeogenesis or to peripheral tissues where they are used for protein synthesis and eventually catabolized, producing ammonia as a byproduct. High ammonia levels in the brain are a major contributor to the decreased neural function that occurs in several pathological conditions such as hepatic encephalopathy when liver urea cycle function is compromised. Therefore, it is important to gain a deeper understanding of human ammonia metabolism. The objective of this study was to predict changes in blood ammonia levels resulting from alterations in dietary protein intake, from liver disease, or from partial loss of urea cycle function. METHODS: A simple mathematical model was created using MATLAB SimBiology and data from published studies. Simulations were performed and results analyzed to determine steady state changes in ammonia levels resulting from varying dietary protein intake and varying liver enzyme activity levels to simulate liver disease. As a toxicity reference, viability was measured in SH-SY5Y neuroblastoma cells following differentiation and ammonium chloride treatment. RESULTS: Results from control simulations yielded steady state blood ammonia levels within normal physiological limits. Increasing dietary protein intake by 72% resulted in a 59% increase in blood ammonia levels. Simulations of liver cirrhosis increased blood ammonia levels by 41 to 130% depending upon the level of dietary protein intake. Simulations of heterozygous individuals carrying a loss of function allele of the urea cycle carbamoyl phosphate synthetase I (CPS1) gene resulted in more than a tripling of blood ammonia levels (from roughly 18 to 60 μM depending on dietary protein intake). The viability of differentiated SH-SY5Y cells was decreased by 14% by the addition of a slightly higher amount of ammonium chloride (90 μM). CONCLUSIONS: Data from the model suggest decreasing protein consumption may be one simple strategy to decrease blood ammonia levels and minimize the risk of developing hepatic encephalopathy for many liver disease patients. In addition, the model suggests subjects who are known carriers of disease-causing CPS1 alleles may benefit from monitoring blood ammonia levels and limiting the level of protein intake if ammonia levels are high.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第17974号 / 医博第3838号 / 新制||医||1001(附属図書館) / 80818 / 京都大学大学院医学研究科医学専攻 / (主査)教授 羽賀 博典, 教授 坂井 義治, 教授 千葉 勉 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18457号 / 医博第3912号 / 新制||医||1004(附属図書館) / 31335 / 京都大学大学院医学研究科医学専攻 / (主査)教授 坂井 義治, 教授 羽賀 博典, 教授 武藤 学 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

INTRODUCTION: Cirrhosis is a significant cause of mortality and morbidity worldwide. Recent studies suggested that cirrhosis is associated with an increased risk of venous thromboembolism (VTE), which disproves the old belief that chronic liver disease coagulopathy is considered protective against VTE. We conducted a retrospective study which is to our knowledge the first of its kind to assess clinical characteristics and outcomes of decompensated cirrhosis (DC) patients admitted with acute pulmonary embolism (APE). METHODOLOGY: We used the National Inpatient Sample database for the years 2016-2019. All adults admitted to the hospitals with a primary diagnosis of APE were included. Patients less than 18 years old, missing race, gender, or age were excluded. Patients were divided into two groups, either having DC or not. A multivariate logistic regression model was built by using only variables associated with the outcome of interest on univariable regression analysis at P < 0.05. RESULTS: 142 million discharges were included in the NIS database between the years 2016 and 2019, of which 1,294,039 met the study inclusion criteria, 6,200 patients (0.5%) had DC. For adult patients admitted to the hospitals with APE, odds of inpatient all-cause mortality were higher in the DC group than in patients without DC; OR of 1.996 (95% CI, 1.691-2.356, P-value < 0.000). Also, vasopressor use, mechanical ventilation, and cardiac arrest were more likely to occur in the DC group, OR of 1.506 (95% CI, 1.254-1.809, P-value < 0.000), OR of 1.479 (95% CI, 1.026-2.132, P-value 0.036), OR of 1.362 (95% CI, 1.050-1.767, P-value 0.020), respectively. In addition, DC patients tend to have higher total hospital charges and longer hospital length of stay, coefficient of 14521 (95% CI, 6752-22289, P-value < 0.000), and a coefficient of 1.399 (95% CI, 0.848-1.950, P-value < 0.000), respectively. CONCLUSION: This study demonstrates that DC is a powerful predictor of worse hospital outcomes in patients admitted with APE. An imbalance between clotting factors and natural anticoagulants produced by the liver is believed to be the primary etiology of thrombosis in patients with DC. The burden of APE can be much more catastrophic in cirrhotic than in non-cirrhotic patients; therefore, those patients require closer monitoring and more aggressive treatment.

Background: Hepatocellular Carcinoma (HCC) is the third most common cause of cancer related death worldwide and is often diagnosed by measuring serum Alpha-fetoprotein (AFP); a stand-alone biomarker with limited diagnostic proficiency. To compensate for this, AFP is commonly used in conjunction with high performance imaging and radiological methods. However, as the burden of HCC is predominantly in the developing world where such technologies are not readily available, it is imperative that efforts are made to pursue the discovery of novel, high performance, easy to measure and robust biomarkers. With the aim of improving on the diagnostic ability of AFP, our project focuses on the study of plasma proteins as identified by Mass Spectrometry (MS) in order to investigate differences seen in the respective proteomes of controls and subjects with liver cirrhosis (LC) and HCC. Methods: Matrix Assisted Laser Desorption Ionization Time-of-Flight MS (MALDI-TOF MS) was first attempted on weak cation exchange (WCX) fractionated plasma in a pilot selection of forty subjects. On the main case-control group, quantitative MS analysis using liquid chromatography electro spray ionization quadrupole time-of-flight (LC-ESI Q-TOF) was conducted on 339 subjects using a pooled expression profiling approach. Enzyme-linked immunosorbent assays (ELISA) and 1 and 2Dimentional electrophoresis methods were performed to validate and detail candidate protein levels and modification patters in individual and pooled subjects. The human plasma used for the MS based protein discovery experiments was collected as part of a five year Liver Cancer Case-control Study (Gambia, West Africa). A smaller set of samples from subjects who formed a spectrum of non-liver disease controls, LC and HCC were obtained from the Jos University Teaching Hospital (JUTH) in Nigeria and ELISA and gel electrophoresis assays conducted on them to confirm the trends and differences seen in the Gambian subject set. Results: Bioinformatic evaluation of MALDI-TOF data highlighted peak masses 2444m/z, 2583m/z and 2559m/z to have high diagnostic abilities based on area under curve (AUC) statistics of >0.75. Of these polypeptide fragments, one was identified as the plasma glycoprotein, alpha chain fibrinogen. Results from the large-scale label free discovery experiments indicated twenty-six proteins to be differentially expressed between the three subject groups. These prospective markers include proteins previously linked to HCC as well as novel candidates, namely glutathione peroxidase 3, serum amyloid p, carboxypeptidase N and complement factors I and H which have not been implicated in the context of HCC diagnostics. Direct measurement of Hemopexin (HPX), alpha-1-antitrypsin (α1AT), apolipoprotein A1 (Apo A1) and complement component 3 (CC3) levels confirmed their change in abundance in LC and HCC versus control patients. Further biochemical characterization of glycosylated HPX isolated from glycoprotein enriched plasma sample pools showed evidence of isoelectric point shifts, indicating differential glycosylation patterns in high mannose structures of HPX which may be disease stage linked. The direct measurements of HPX, α1AT, Apo A1 & CC3 conducted on the independent Nigerian subject group also confirmed much of the trends reported from the Gambia Liver Cancer Study (GLCS) plasma. Conclusions: The independently validated, significant changes in the quantitative expression of ApoA1, α1AT, CC3 and HPX could be exploited for development into high-performance affordable assays, usable in the diagnosis and monitoring of HCC and LC patients. The unique signatures observed for most of these proteins, from liver disease free controls to LC and HCC suggest their involvement in independent pathways. As such, combining some or all of these four markers within a diagnostic panel could offer a much-needed boost in robustness and accuracy for AFP. The differences in the processing and molecular weight separation of these proteins also offers a novel inroad into biomarker identification. These suggested disease specific signatures could with further study offer highly specific biomarkers able to discern the key stages that predispose individuals to hepatocarcinogenesis. Impact: This is the first MS based discovery and extensive validation study on West African subjects whose primary cause of HCC are the Hepatitis B Virus (HBV) and fungal toxins.

INTRODUÇÃO: As hérnias de parede abdominal têm elevada incidência em pacientes cirróticos. Ascite e desnutrição contribuem para que essas hérnias adquiram grandes proporções, causando sintomas álgicos, decréscimo da qualidade de vida e maior risco de complicações locais que exijam tratamento cirúrgico de urgência. Contudo, o tratamento conservador é o mais empregado pela elevada morbimortalidade associada a procedimentos cirúrgicos nesses pacientes. OBJETIVO: O objetivo deste estudo é analisar os resultados do tratamento cirúrgico de hérnias de parede abdominal em pacientes cirróticos. MÉTODOS: Estudo prospectivo, baseado no seguimento de pacientes cirróticos com hérnia de parede abdominal no Ambulatório de Transplante Hepático do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, durante o período de 01/01/2009 à 01/11/2014. Foram analisadas as características demográficas, da hepatopatia, do tipo de hérnia, ocorrência de complicações e mortalidade dos pacientes que foram submetidos à cirurgia eletiva ou mantidos em acompanhamento clínico. Desse último grupo, os pacientes que apresentaram complicações com indicação de cirurgia, foram submetidos à cirurgia de urgência. Os pacientes submetidos à cirurgia eletiva foram selecionados de forma randômica. RESULTADOS: Foram avaliados 246 pacientes nesse período do estudo. A cirurgia eletiva foi realizada em 57 pacientes. Desses, 186 permaneceram em acompanhamento clínico. A incidência de complicações exigindo tratamento cirúrgico de urgência foi de 22,7% (43 pacientes). A sobrevida a longo prazo foi maior entre os pacientes submetidos à cirurgia eletiva em relação aos pacientes em acompanhamento clínico (p=0,012). A cirurgia de urgência apresentou maior incidência de complicações pós-operatórias e maior mortalidade em comparação à cirurgia eletiva (p=0,005). CONCLUSÕES: O paciente cirrótico, com hérnia de parede abdominal, apresenta elevada mortalidade em sua evolução, independente da realização da correção cirúrgica da hérnia. A cirurgia eletiva proporcionou maior sobrevida em comparação aos pacientes mantidos em acompanhamento clínico. A cirurgia de urgência foi um fator de risco para maior morbidade e mortalidade / INTRODUCTION: Cirrhotic patients have higher incidence of abdominal wall hernias. Ascistes and sarcopenia are risk factors to development of huge hernias, leading to pain, poor quality of life and need of urgent surgery due local complications. However, hernia surgery is usually delayed among cirrhotic patients due higher morbidity and mortality. OBJECTIVE: This study aimed to analyze the surgical treatment of abdominal wall hernias in cirrhotic patients. METHODS: A prospective, analytical study, based on follow-up of cirrhotic patients with abdominal wall hernia that were followed in Liver Transplant Clinic at the Hospital das Clinicas, Faculty of Medicine, University of São Paulo, during the period from January 2009 to November 2014. We analyzed demographics, characteristics of liver disease, type of hernia, complications and mortality of patients who underwent elective hernia surgery or were kept in exclusive clinical follow up. The exclusive clinical group underwent urgent hernia surgery when indicated. Elective surgery was performed in unselected patients. RESULTS: We enrolled 246 patients during the study period. Elective surgery was performed in 57 patients. 186 patients had clinical follow up, incidence of urgent surgery was 22,7% (43 patients). Elective surgery provided better long term survival then clinical follow up (p=0.012). Urgent surgery had higher morbidity and it was an independent risk factor for mortality (p=0.005). CONCLUSIONS: cirrhotic patients with abdominal wall hernia have higher mortality, regardless of performing the surgical correction. Hernia elective repair provided better survival than patients in conservative treatment. Urgent surgery imposes higher morbidity and mortality than elective surgery

Introdução: A cirrose hepática é uma patologia crônica grave e irreversível. Ela causa debilidades variadas que afetam de forma significativa a qualidade de vida (QV), além de provocar constante vulnerabilidade emocional. O transplante é a única terapêutica capaz de reverter o estado de saúde do paciente em estágio terminal e de promover o retorno a uma vida potencialmente saudável. As taxas de sobrevida são satisfatórias e os benefícios deste tipo de cirurgia sobre a QV são demonstradas em alguns estudos. No entanto, não é raro encontrar ressalvas quanto aos ganhos em saúde mental após o transplante de fígado. Mensurar os efeitos desse tratamento sobre a vida do paciente tem sido um importante indicador para decisões e intervenções no campo da medicina, mas também para outras especialidades, entre elas, a psicologia da saúde. Objetivo: Avaliar a QV de pacientes em lista de espera e após seis meses de realizado o transplante hepático, identificar os fatores de maior influência sobre a QV e analisar a percepção do impacto do adoecimento e do transplante na vida dos doentes. Método: Participaram da pesquisa 42 pacientes que estavam em acompanhamento ambulatorial pelo Serviço de Transplante de Órgãos Abdominais do HC-FMUSP. O estudo teve um desenho prospectivo longitudinal, exploratório e descritivo, com abordagem metodológica mista (quantitativa e qualitativa). Foram aplicados dois questionários de QV (SF-36 e LDQOL), uma escala sobre autopercepção de saúde (EQ VAS) e uma entrevista em profundidade. Os dados quantitativos foram avaliados de acordo com as normas propostas por cada instrumento e submetidos à análise estatística (teste de Mann-Whitney). Para a realização da análise multivariada, foi aplicada a técnica de análise fatorial. A amostra da análise qualitativa foi composta por 10 pacientes e definida por critério de saturação. As entrevistas foram gravadas, transcritas, decompostas em categorias e submetidas à análise temática, conforme o método de análise de conteúdo proposto por Bardin. Resultados: A amostra total foi composta por 27 (64,3%) homens e 15 (35,7%) mulheres, com idade entre 21 e 70 anos. O perfil clínico dos pacientes abrangeu diferentes categorias diagnósticas, sendo a hepatite pelo vírus C a mais frequente (36,73%). Complicações graves associadas à hepatopatia apareceram em 90,47% dos casos. Os resultados obtidos por meio dos instrumentos SF-36 e LDQOL e da escala EQ VAS registraram expressiva melhora da QV após o transplante hepático, na maior parte dos domínios avaliados. Apenas os domínios \'limitações por aspectos emocionais\' (p= 0,083), do SF-36, e \'interação social\' (p= 0,087), do LDQOL, não atingiram significância estatística. A análise fatorial permitiu identificar as dimensões que mais interferiram sobre a percepção da QV, e a entrevista em profundidade possibilitou discutir, de forma mais ampla, as limitações impostas pela condição crônica da doença hepática, bem como as transformações trazidas pelo transplante. Conclusão: A melhora da qualidade de vida após o transplante foi confirmada por todos os instrumentos utilizados. Entretanto, verificou-se ressalvas quanto a melhora da qualidade da saúde psíquica do paciente transplantado, não ocorrida na mesma proporção que a expressiva reconquista do bem-estar físico / Background: Liver cirrhosis is a serious and irreversible chronic disease. It causes varied weaknesses that significantly affect quality of life (QOL), as well as causing constant emotional vulnerability. Transplantation is the only therapy capable of reversing the patient\'s state of health in the terminal stage and of promoting a return to a potentially healthy life. Survival rates are satisfactory and the benefits of this type of surgery on QOL are demonstrated in some studies. However, it is not uncommon to find caveats regarding gains in mental health after liver transplantation. Measuring the effects of this treatment on the patient\'s life has been an important indicator for decisions and interventions in the field of medicine, but also for other specialties, among them, health psychology. Aims: To assess the QOL of patients on the waiting list and after six months of liver transplantation, to identify the factors that have a greater influence on QoL and to analyze the perception of the impact of illness and transplantation on patients\' lives. Method: A total of 42 patients who underwent ambulatory follow-up by the Abdominal Organ Transplantation Service of HC-FMUSP participated in the study. The study has a prospective longitudinal, exploratory and descriptive design, with a mixed methodological approach (quantitative and qualitative). Two QOL questionnaires (SF-36 e LDQOL) were applied, one scale of self-perceived health (EQ VAS) and one in-depth interview. The quantitative data were evaluated according to the norms proposed by each instrument and submitted to statistical analysis (Mann-Whitney test). For the multivariate analysis the factorial analysis technique was applied. The sample of the qualitative analysis was composed by 10 patients and defined by saturation criterion. The interviews were recorded, transcribed, broken down into categories and submitted to thematic analysis, according to the method of content analysis proposed by Bardin. Results: The total sample consisted of 27 (64.3%) men and 15 (35.7%) women, aged between 21 and 70 years. The clinical profile of patients covered different diagnostic categories, being hepatitis C virus the most frequent (36.73%). Severe complications associated with hepatopathy appeared in 90.47% of the cases. The results obtained using the SF-36 and LDQOL instruments and the EQ VAS scale showed a significant improvement in QOL after liver transplantation in most of the evaluated domains. Only the domains \'limitations by emotional aspects\' (p = 0.083), SF-36, and \'social interaction\' (p = 0.087), LDQOL, did not reach statistical significance. Factor analysis allowed us to identify the dimensions that most interfered with the perception of QoL, and the in-depth interview made it possible to discuss, in a broader way, the limitations imposed by the chronic condition of the liver disease, as well as the transformations brought about by the transplant. Conclusions: The improvement in the quality of life after transplantation was confirmed by all the instruments used. However, there were reservations regarding the improvement in the quality of the psychic health of the transplanted patient, not occurring in the same proportion as the expressive reconquest of physical well-being

O carcinoma hepatocelular (CHC) é a principal causa de morte em pacientes com cirrose hepática. O prognóstico para o CHC é muito pobre; trata-se de um tumor agressivo que progride rapidamente e, portanto, o diagnóstico precoce é o único meio de aumentar a sobrevida dos pacientes. O presente estudo sugere a tioacetamida (TAA) como modelo experimental de carcinogênese no microambiente cirrótico e busca identificar os mecanismos iniciais do desenvolvimento tumoral durante a cirrose. Neste trabalho, ratos Wistar machos foram injetados com TAA i.p. 3 vezes/semana por 14, 21 e 35 semanas. Foram examinados os efeitos sobre a função hepática, morfologia, desenvolvimento e características de lesões pré-neoplásicas (LPNs), bem como expressão tecidual e gênica dos marcadores tumorais mais comuns no CHC. O tratamento com TAA promoveu alterações que compreenderam a deposição de tecido cicatricial com desenvolvimento de cirrose hepática, inflamação, aumento da proliferação celular e da apoptose, desenvolvimento de LPNs e modificações na expressão dos marcadores tumorais. As alterações celulares e estruturais do tecido hepático resultaram em redução do ganho de peso dos animais e aumento do peso e do volume do fígado, proporcional ao tempo de tratamento. O índice de atividade histológica foi maior no fígado cirrótico e alcançou maior valor após 35 semanas de tratamento. Marcadores sanguíneos de lesão hepática aumentaram nos animais tratados ao passo que os marcadores de função mostraram melhora com o passar do tempo. Os níveis de alfa-fetoproteína foram maiores após 14 semanas de tratamento. A administração de TAA por 21 semanas resultou em maior número de LPNs, com predomínio de lesões persistentes sobre remodelantes em número e tamanho. A proliferação celular foi exacerbada nos fígados cirróticos sendo mais elevada em 14 semanas e apresentando redução significativa após 35 semanas. O número de corpúsculos apoptóticos foi maior no tecido cirrótico e a apoptose foi mais pronunciada em 21 semanas. O painel imuno-histoquímico composto por GPC3, HSP70 e GS demonstrou maior positividade para a combinação HSP70+GS, uma vez que a expressão de GPC3 foi baixa em todos os grupos. A análise dos marcadores moleculares GPC3, survivina e LYVE1 concordou com os resultados das LPNs. A expressão gênica de survivina foi maior em 14 semanas, quando foi observada também maior proliferação, e diminuiu ao longo do tratamento. A expressão de LYVE1 diminuiu nos grupos de 14 e 21 semanas, porém, foi significativamente elevada em 35 semanas. A partir desses resultados, concluímos que o modelo da TAA foi adequado para a indução de cirrose e para o desencadeamento da hepatocarcinogênese. As fases de iniciação e promoção foram identificadas em todos os períodos avaliados, entretanto, a TAA mostrou-se uma importante ferramenta para a fase de promoção aumentando a proliferação celular e o tamanho das LPNs. O tratamento por 21 semanas foi o mais eficaz em aliar a iniciação e promoção da hepatocarcinogênese, como mostrado pelo número e pelo tamanho das lesões. Contudo, nenhum grupo desenvolveu CHC indicando que a TAA, provavelmente, necessita ser associada com outras substâncias tendo em vista seu principal efeito como agente promotor. / Hepatocellular carcinoma (HCC) is the main cause of death in patients with liver cirrhosis. The prognosis for HCC is very poor; it is an aggressive tumor that progresses rapidly and therefore early diagnosis is the only way to increase the survival of these patients. This study suggests the thioacetamide (TAA) as experimental model of carcinogenesis in cirrhotic microenvironment and seeks to identify the initial mechanisms of tumor development during cirrhosis. In this study, male Wistar rats were injected ip with TAA 3 times / week for 14, 21 to 35 weeks. We examined the effects on liver function, morphology, characteristics and development of preneoplastic lesions (PNLs), as well as tissue gene expression and the most common tumor markers in HCC. Treatment with TAA made changes that comprised the deposition of scar tissue in the liver cirrhosis, inflammation, increased cell proliferation and apoptosis, PNLs development and changes in the expression of tumor markers. The cellular and structural changes of the liver tissue resulted in reduced weight gain of the animals and an increase in liver weight and volume proportional to the treatment time. The histological activity index was higher in cirrhotic liver and achieved greater value after 35 weeks of treatment. Blood markers of liver damage in the treated animals increased while the function markers showed improvement over time. The alpha-fetoprotein levels were higher after 14 weeks of treatment. The administration of TAA for 21 weeks resulted in a greater number of PNLs, with a predominance of persistent lesions over remodeling lesions in number and size. Cell proliferation was exacerbated in cirrhotic livers and was higher in 14 weeks with a significant reduction after 35 weeks. The number of apoptotic corpuscles was higher in cirrhotic tissue and apoptosis was more pronounced in 21 weeks. Immunohistochemical panel of GPC3, HSP70 and GS showed higher rates of HSP70 + GS combination, since GPC3 expression was low in all groups. The analysis of molecular markers GPC3, surviving, and LYVE1 agreeded with the results obtained in the PNLs. Survivin gene expression was higher in 14 weeks, when it was observed also increased proliferation and decreased during treatment. The expression of LYVE1 decreased in groups of 14 and 21 weeks, however, was significantly higher in 35 weeks. From the results obtained, we conclude that the TAA model was suitable for induction of cirrhosis and the onset of hepatocarcinogenesis. The stages of initiation and promotion were identified in all periods, however, the TAA proved to be an important tool for the promotion phase increasing cell proliferation and size of PNLs. Treatment for 21 weeks was more effective in combining the initiation and promotion of hepatocarcinogenesis, as shown by the number and size of the lesions. However, no group has developed HCC indicating that the TAA probably needs to be associated with other substances because its primary effect is like promoting agent.