INTRODUCTION: Groote Schuur Hospital (GSH) is a large academic hospital Cape Town. It serves a population of about 2 million, comprising three population groups, black people of African origin, coloured, who are people of Asian or mixed origin, and white - of European descent. The hospital serves as a secondary referral centre for the surrounding regions, as a tertiary referral centre for the Western Cape province and much of the Eastern Cape province, and as a quaternary super-specialist centre for certain services, including liver and cardiac transplantation, for much of South Africa. A significant number of patients with cirrhosis present for the first time at Groote Schuur Hospital with decompensation and a diagnosis of cirrhosis is made on the basis of association of signs of liver failure, portal hypertension, radiological features consistent with cirrhosis with or without a proven cause of cirrhosis (personal observation). A study in Italy and another study done in Birmingham showed that a proportion of 63% and 65% respectively of patients have decompensated cirrhosis when first seen and in the English study the figure was unchanged in 18 years (Saunders et al 1981, D'Amico et al 1986). Most patients with cirrhosis remain compensated for many years and have a relatively long-life expectancy. Clinical decompensation, which is evidenced by the development of one or more complications, has a poor prognosis. The high rate of repeated consultations in patients with cirrhosis confirmed the high morbidity associated with this condition (Dufour et al 1993). In the United States between 1973 and 1983, cirrhosis mortality declined by one third to 10.2/100 000 deaths and the decline continued through to 1987 when the death rate reduced to 9.2/100 000 deaths. Furthermore, an increase in morbidity was observed with this decreasing mortality rate (Noble et al 1993). AIM OF THE STUDY: Accordingly, this study was intended to delineate the demographic and clinical profile of patients with cirrhosis admitted to our hospital, to assess the relative importance of the various underlying causes of cirrhosis, to assess the frequency of complications of cirrhosis and describe their presentation and management, to assess the outcome of treatment and to estimate its cost.

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Background and Aims: Several single nucleotide polymorphisms (SNPs), including rs4444903 in the epidermal growth factor (EGF) gene, rs12979860 near the interleukin-28B (IL28B) gene, and rs738409 in the patatin-like phospholipase domain-containing protein 3 (PNPLA3) gene, have been linked to treatment response, steatosis, fibrosis, and development of hepatocellular carcinoma (HCC) in chronic hepatitis C (HCV). No study has comprehensively examined the effects of these SNPs on the natural history of HCV-related cirrhosis. Methods: We performed a retrospective cohort study of 169 subjects with chronic HCV and biopsy-proven cirrhosis who had long term followup for clinical events. Formalin-fixed, paraffin-embedded liver biopsy specimens were genotyped for EGF, IL28B, and PNPLA3 using a TaqMan assay with commercial probes and primers. Cox proportional hazards modeling was used to determine the hazard ratio for clinical decompensation, defined as the development of ascites, encephalopathy, variceal hemorrhage, HCC, or cirrhosis-related death. Results: During a median followup of 6.6 years, 66 patients (39%) experienced clinical decompensation. On univariate analysis, EGF non-A/A, PNPLA3 non-C/C, and IL28B non-C/C genotypes were each associated with increased risk of decompensation. In multivariable Cox regression modeling, EGF non-A/A genotype was independently associated with an increased rate of clinical decompensation (HR = 3.00, p = 0.005). Conclusions: HCV cirrhotics with the EGF A/G and G/G genotypes at rs4444903, a functional polymorphism associated with higher intrahepatic EGF levels, have an increased risk of clinical decompensation. Further study of the predictive value of EGF genotyping in patients with earlier stages and other etiologies of liver disease is warranted.

Hepatocellular carcinoma (HCQ is one of the commonest cancers worldwide. There is, however, a marked geographical variation in incidence and it has been suggested that the pathogenesis may vary in different parts of the world. A retrospective analysis of 110 HCC patients was initially undertaken which confirmed that only 29% of British patients had markers of hepatitis B infection, suggesting a possible role for other environmental agents in the pathogenesis, and that 80% of patients had underlying cirrhosis. The nature of the strong relationship between HCC and cirrhosis has not been established but it has been postulated that increased hepatocyte turnover in the cirrhotic liver may predispose to DNA damage by environmental mutagens. Cell proliferation is required to express the strongly promutagenic DNA base lesion 0'-methylguanine, produced by alkylating agents, as a mutation. &- methylguanine is repaired by the DNA repair enzyme 06-methylguanine-DNA methyltTansferase (06-MT). A microassay was developed which could reliably measure 06-MT levels in liver biopsy samples. Using this approach 06-MT levels were found to be significantly lower in cirrhotic liver when compared to non-cirrhotic and normal liver tissue. No correlation was found between lymphocyte and liver levels from individual patients with liver disease indicating that the deficiency in DNA repair is disease-a nd tissue-specific. Three polyclonal antibodies were subsequently raised to 06-MT peptides and characterised by immunoblotting in an attempt to establish the tissue distribution of the enzyme in liver. Although none of the antisera were able to detect &-MT in tissue sections they were used to analyse structural differences in the enzyme between cirrhotic and non-cirrhotic liver using SDS-PAGE followed by immunoblotting and fluorography. A band of M, 24,000r,e presentingn ative enzyme, was visualised by fluorography in all liver extracts. Densitometry of these bands correlated with the enzyme activity determined by the direct enzyme assay, validating the assay findings. Other small molecular weight bands were seen in all liver extracts and comparison with immunoblots suggested that these bands represent C-terminal truncated enzyme. The spectrum of smaller molecular weight enzyme forms was similar in cirrhotic and non-cirrhotic liver. It was, thus, concluded that although 06-MT levels were lower in'cirrhosis this was not accounted for by structural differences in the enzyme. DNA mutations (G to A) produced by the failure to repair 06-methylguanine are known to activate oncogenes and turnour suppressor genes such as p53. However only 5/55 (9%) of HCC expressed mutant p53. Other factors potentially involved in hepatocarcinogenesis include the growth factor TGF-a and a growth factor receptor encoded by the c-erb B-2 proto-oncogene. Expression of TGF-a and the C-erbB -2 oncoprotein were seen in 8/28 (28%) and 2/26 (8%) of HCC respectively, findings which differ from those observed in HCC from the Far East. Deficient DNA repair by &-MT provides one possible reason why cirrhosis is an important risk factor for the development of HCC. However, failure to repair 06-mothylguanine does not result in mutations within the p53 gene in British HCC. Furthermore, the finding of low expression of mutant p53, TGF-a and the c-erb B-2 oncoprotein in HCC from Britain compared to HCC from the Far East and Africa suggests geographical differences in the molecular mechanisms involved in hepatocarcinogenesis between areas of high and low HCC prevalence.

Orientador: Luiz Shiguero Matsubara / Banca: Andre Semidt / Banca: Eros Antonio de Almeida / Banca: Antonio Pazin Filho / Banca: Giovanni de Faria / Resumo: A cirrose hepática é definida como um processo difuso de fibrose intersticial associada à formação de nódulos regenerativos e à modificação na fígado, a repercussão da cirrose hepática é sistêmica. Assim, na fase avançada da doença são descritas alterações cerebrais como a encefalopatia hepática, renais ..• como a síndrome hepato-renal, pulmonares como a síndrome porto-pulmonar e cardíacas como a cardiomiopatia cirrótica. Os objetivos do trabalho são caracterizar as alterações hemodinâmicas e cardíacas de pacientes com cirrose hepática e verificar se houve evidência de cardiomiopatia própria da cirrose hepática. Foram estudados 66 pacientes portadores de cirrose hepática (CH), sendo 54 (82 %) homens e 12 (18 %) mulheres. O grupo controle (CONT) foi constituído de 32 indivíduos sadios, sendo 21 (66 %) homens e 11 (34 %) mulheres. Os indivíduos foram submetidos a exames clínicos e cardíacos por meio de doppler-ecocardiograma. As variáveis estudadas foram analisadas pelo teste ANOVA de duas vias considerando-se os fatores sexo (Masc e Fem) e grupo (CH e CONT) seguido pelo teste de comparações múltiplas de Tukey ao nível de significância de 0,05. As médias e desvios padrões das idades (anos) foram: CH Masc = 49 ± 10; CH Fem = 47 ± 14; CONT Masc = 52 ± 9; CONT Fem = 53 ± 8. Não foram observadas diferenças estatisticamente significantes entre os grupos, quanto a idade. As variáveis... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Cirrhosis is a liver disease characterized by diffuse interstitial fibrosis associated with, regenerative nodules and with intra-hepatic circulation changes. Although the primary damage occurs in the liver, cirrhosis is associated with systemic repercussions. For instance, in the advanced stages of the disease, it has been are described hepatic encephalopatphy syndrome, renal failure such as that accompany the hepato-renal syndrome, pulmonary hypertension observed in portopulmonary syndrome and cardiac alterations. The presence of a specific cardiomyopathy related to the cirrhosis is a matter of controversy. The present study was undertaken to evaluete the cardiac and hemodynamic alterations in patientes suffering from hepatic cirrhosis to analyse the evidence of cirrhotic cardiomyopathy... (Complete abstract click electronic access below) / Doutor

Patients with liver cirrhosis are susceptible to fungal infections. Due to low sensitivity of culture-based methods, we applied a real-time PCR assay targeting the 18S rRNA gene in combination with direct sequencing and terminal-restriction fragment length polymorphism (T-RFLP) in order to establish a novel tool to detect fungal DNA and to quantify and differentiate Candida DNA, also in polyfungal specimens. In total, 281 samples (blood n=135, ascites n=92, duodenal fluid n=54) from 135 patients with liver cirrhosis and 52 samples (blood n=26, duodenal fluid n=26) from 26 control patients were collected prospectively. Candida DNA was quantified in all samples. Standard microbiological culture was performed for comparison. Blood and ascites samples, irrespective of the patient cohort, showed a method-independent low fungal detection rate of approximately 1%, and the Candida DNA content level did not exceed 3.0x101 copies ml-1 in any sample. In contrast, in duodenal fluid of patients with liver cirrhosis high fungal detection rates were discovered by using both PCR- and culture-based techniques (81.5% vs. 66.7%; p=0.123) and the median level of Candida DNA was 3.8x105 copies ml-1 (2.3x102-6.3x109). In cirrhosis and controls, fungal positive culture results were confirmed by PCR in 96% and an additional amount of 44% of culture negative duodenal samples were PCR positive. Using T-RFLP analysis in duodenal samples, overall 85% of results from microbial culture were confirmed and in 75% of culture-negative but PCR-positive samples additional Candida species could be identified. In conclusion, PCR-based methods and subsequent differentiation of Candida DNA might offer a quick approach to identifying Candida species without prior cultivation.

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In clinical findings, complications are the major cause of death in cirrhotic patients. Among all the complications, ascites is most frequent type. All cirrhotic patients with ascites could develop spontaneous bacterial peritonitis (SBP). The hospitalized prevalence of SBP was high (30%) in cirrhotic ascites patients. However, the outcome of cirrhotic SBP patients has been improved because of using the antibiotics cephalosporins. Furthermore, treatment with intravenous albumin in addition to cephalosporins reduced the incidence of renal impairment and the mortality in SBP patients in a multicentre study. However, other studies showed that administration of albumin might not work as effectively as other plasma expanders do. Moreover, administration of large volume albumin would make the medication very expensive and might have potential risk of infectious disease, since the therapeutic albumin is extracted from human plasma. Therefore, to treat patients with large volume albumin become disputable. In this study, we evaluated the effects of small volume intravenous albumin with cephalosporins treatments through monitoring patients¡¦ renal and hepatic functions and related inflammatory markers. Results showed that plasma TNF-£\, £LL-6 and ascites endotoxin, TNF-£\ and IL-6 levels were significantly reduced in patients treated with cephalosporins plus small volume albumin, but not in those treated with cephalosporins alone. Also, the combination therapy of cephalosporins and small volume albumin avoid the dramatically elevation of plasma and ascites nitric oxide, as well as the further degree of renal function impairment. The positive results of this study laid a solid foundation for a large scale investigation.