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IASG  Romanian Society of Surgery   Romtransplant The V-th Symposium and   P ost graduate Course of  IASG Bucharest 9-11 April 2003
“ DOMINO”  LIVER TRANSPLANTATION WITH PARTICULAR INDICATION (FAMILIAL HYPERCHOLESTEROLEMIA) I POPESCU, M SIMIONESCU,  D TULBURE, A SIMA, C CATANA,  L NICULESCU, N HANCU, L GHEORGHE, M MIHAILA, S CIUREA, V VIDU,  D HREHORET CENTER OF GENERAL SURGERY AND LIVER TRANSPLANTATION DEPARTMENT OF INTENSIVE CARE AND ANESTHESIOLOGY CENTER OF GASTROENTEROLOGY FU N DENI  CLINICAL INSTITUTE INSTITUTE OF CELLULAR BIOLOGY AND PATHOLOGY "NICOLAE SIMIONESCU“ INSTITUTE OF DIABETES AND NUTRITIONAL DISEASES CLUJ-NAPOCA
INTRODUCTION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ALTERNATIVES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
“ DOMINO” LIVER TRANSPLANTATION: REASONS ? ,[object Object],[object Object],[object Object],[object Object],[object Object]
Homozygous Familial Hypercholesterolemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PATHOGENESIS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
HOMOZYGOUS TYPE ,[object Object],[object Object],[object Object],[object Object],[object Object]
HETEROZYGOUS TYPE ,[object Object],[object Object],[object Object]
TREATMENT ,[object Object],STARZL TE, BILHEIMER DW, BAHNSON HT, SHAW BW, Jr., HARDESTY RL, GRIFFITH BP, IWATSUKI S, ZITELLI BJ, GARTNER JC, Jr., MALATACK JJ. - Heart-liver transplantation in a patient with familial hypercholesterolaemia.  Lancet , 1984, 1(8391):1382-1383
CASE PRESENTATION
DOMINO LIVER TRANSPLANTATION - THE DONOR -
HISTORY OF THE DISEASE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Genealogical tree of the patient with homozygous familial hypercholesterolemia
SYMPTOMATOLOGY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
BIOLOGY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],other liver tests within normal limits
INDICATION FOR LIVER TRANSPLANTATION ,[object Object],[object Object]
The donor liver normal histology on biopsy
DOMINO LIVER TRANSPLANTATION - THE RECIPIENT -
HISTORY OF THE DISEASE ,[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],intraarterial chemoembolization (Doxorubicin 50 mg - 2 sessions )
INDICATION FOR LIVER TRANSPLANTATION CHILD B LIVER CIRRHOSIS HEPATOMA DEVELOPED ON CIRRHOSIS MARGINAL CANDIDATE
MACROSCOPIC ASPECT OF RESECTED LIVER 5 cm tumoral nodule in segment VIII
MICROSCOPIC ASPECT ,[object Object],[object Object]
SURGICAL TECHNIQUE
P2 – FHC P3  P4 – HEPATOMA SPLIT SPLIT DOMINO P1 - CADAVER
Pa tient with familial hy perc h olesterol emia Child with glycogenosis Pa tient with hepatoma developed  on cirrhosis domino split split
BIOCHEMICAL ASSAYS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],ASSAY FOR EXTRAHEPATIC LDL RECEPTORS BY  FLOW-CYTOMETRY
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],QUANTIFICATION AND GENE EXPRESSION OF LDL RECEPTORS
RESULTS
POST-TRANSPLANTATION EVOLUTION IN THE  DONOR ,[object Object],[object Object],[object Object]
[object Object],AFTER  TRANSPLANTATION
[object Object],[object Object],[object Object],[object Object]
Current therapy ,[object Object],[object Object],[object Object],[object Object],[object Object]
POST-TRANSPLANTATION EVOLUTION IN THE  RECIPIENT ,[object Object],[object Object],[object Object],[object Object],[object Object]
Current therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Quantification of the expression of LDL-R on monocytes by flow-cytometry analysis, one year after the transplant operations *mean value given by LDL receptor kit 71 153.5 Patient B  (Cirrhosis) 6.7 14.4 Patient A  (FHC) 100.0 130 - 277 (mean 216) Control* LDL-R (%) Mean fluorescence (arbitrary units) Monocytes
Histogram showing quantification of LDL receptors on monocytes isolated from patient A (familial hypercholesterolemia) and B (cirrhosis) by flow cytometry, using an anti-LDL receptor monoclonal antibody
Gene expression of LDL-R of  monocyte-derived macrophages  isolated from patient A (familial hypercholesterolemia) and B (cirrhosis); agarose gel electrophoresis of RT-PCR products. Note the presence of LDL receptor (LDL-R) expression in both cases, although apparently reduced in the case of patient B due to the reduced activation of monocytes.  GAPDH and LDL-R gene expression are identified by comparing with a ladder DNA (lane 1)
Gene expression of LDL-R  in fibroblasts  obtained from patient A (familial hypercholesterolemia) and B (cirrhosis). Agarose gel electrophoresis of RT-PCR products of RNA isolated from primary culture fibroblasts from the two subjects. Expression of mRNA coding for the LDL receptor (LDL-R) as compared with the GAPDH expression.  Lane 1: ladder DNA
DISCUSSION
[object Object],[object Object],[object Object],[object Object],[object Object],T he  FHC  patient
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],The  domino – recipient  patient
CONCLUSIONS (1) ,[object Object],[object Object]
[object Object],CONCLUSIONS ( 2 ) END
 

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7

  • 1. IASG Romanian Society of Surgery Romtransplant The V-th Symposium and P ost graduate Course of IASG Bucharest 9-11 April 2003
  • 2. “ DOMINO” LIVER TRANSPLANTATION WITH PARTICULAR INDICATION (FAMILIAL HYPERCHOLESTEROLEMIA) I POPESCU, M SIMIONESCU, D TULBURE, A SIMA, C CATANA, L NICULESCU, N HANCU, L GHEORGHE, M MIHAILA, S CIUREA, V VIDU, D HREHORET CENTER OF GENERAL SURGERY AND LIVER TRANSPLANTATION DEPARTMENT OF INTENSIVE CARE AND ANESTHESIOLOGY CENTER OF GASTROENTEROLOGY FU N DENI CLINICAL INSTITUTE INSTITUTE OF CELLULAR BIOLOGY AND PATHOLOGY "NICOLAE SIMIONESCU“ INSTITUTE OF DIABETES AND NUTRITIONAL DISEASES CLUJ-NAPOCA
  • 3.
  • 4.
  • 5.
  • 6.
  • 7.
  • 8.
  • 9.
  • 10.
  • 13.
  • 14. Genealogical tree of the patient with homozygous familial hypercholesterolemia
  • 15.
  • 16.
  • 17.
  • 18. The donor liver normal histology on biopsy
  • 19. DOMINO LIVER TRANSPLANTATION - THE RECIPIENT -
  • 20.
  • 21.
  • 22. INDICATION FOR LIVER TRANSPLANTATION CHILD B LIVER CIRRHOSIS HEPATOMA DEVELOPED ON CIRRHOSIS MARGINAL CANDIDATE
  • 23. MACROSCOPIC ASPECT OF RESECTED LIVER 5 cm tumoral nodule in segment VIII
  • 24.
  • 26. P2 – FHC P3 P4 – HEPATOMA SPLIT SPLIT DOMINO P1 - CADAVER
  • 27. Pa tient with familial hy perc h olesterol emia Child with glycogenosis Pa tient with hepatoma developed on cirrhosis domino split split
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  • 37. Quantification of the expression of LDL-R on monocytes by flow-cytometry analysis, one year after the transplant operations *mean value given by LDL receptor kit 71 153.5 Patient B (Cirrhosis) 6.7 14.4 Patient A (FHC) 100.0 130 - 277 (mean 216) Control* LDL-R (%) Mean fluorescence (arbitrary units) Monocytes
  • 38. Histogram showing quantification of LDL receptors on monocytes isolated from patient A (familial hypercholesterolemia) and B (cirrhosis) by flow cytometry, using an anti-LDL receptor monoclonal antibody
  • 39. Gene expression of LDL-R of monocyte-derived macrophages isolated from patient A (familial hypercholesterolemia) and B (cirrhosis); agarose gel electrophoresis of RT-PCR products. Note the presence of LDL receptor (LDL-R) expression in both cases, although apparently reduced in the case of patient B due to the reduced activation of monocytes. GAPDH and LDL-R gene expression are identified by comparing with a ladder DNA (lane 1)
  • 40. Gene expression of LDL-R in fibroblasts obtained from patient A (familial hypercholesterolemia) and B (cirrhosis). Agarose gel electrophoresis of RT-PCR products of RNA isolated from primary culture fibroblasts from the two subjects. Expression of mRNA coding for the LDL receptor (LDL-R) as compared with the GAPDH expression. Lane 1: ladder DNA
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Hinweis der Redaktion

  1. A girl aged 6 years 9 months with severe heart disease secondary to homozygous familial hypercholesterolaemia underwent orthotopic cardiac transplantation and her liver was replaced with the liver of the same donor. In the first 10 weeks after transplantation serum cholesterol fell to 270 mg/dl from preoperative concentrations of more than 1000 mg/dl
  2. Flow-cytometry analysis allowed the quantification of LDL receptors on monocytes isolated from both patients as compared with the mean value given by the kit
  3. The amplified sequences coding for LDL-R and GAPDH from each patient were visualized following their electrophoretic migration in 1% agarose gel. As shown in Figure 4, the MDM obtained from FHC patient presented normal LDL-R gene expression. The domino recipient patient expressed LDL-R as well, but the expression was apparently diminished due to the fact that, in this case, the activation of monocytes was slightly reduced and this may explain the apparently diminished LDL-R expression in MDM obtained from the recipient patient (Fig.4).
  4. These results were confirmed by the RT-PCR products from RNA isolated from primary culture fibroblasts obtained from the skin explants of patients A and B. The data showed the positive expression of mRNA coding for LDL-R in the fibroblasts of the two patients (Fig. 5).