p<O.01 ) Plasma triglyceride levels appeared inversely correlated with synthesis rate of CDC (r = -0,64, p<O05). Conclusion: In pediatric OLT patients, CsA causes a sustained inhibition of bile salt synthesis and increased plasma levels of triglyeeridas and cholesterol. We hypothesize that suppression of bile ~:lt symhesis by, long-term CsA treatment contributes to hyperlipidemia and thus to increased risk for cardiovascular disease.,

W1393

ATP7B Mutations in Wilson Disease Patients Presenting with Liver Failure Janine Gensehel, Bettina Bochow, Maria Deguri, Grit Sommer, Eduardo L Cancado, Peter Neuhaus, Jnargen Klempnauer, Herbert Lochs, Hartmut H. Schrnidt

Wilson Disease (WD) is a rare inherited autosomal recessive disorder resulting in accumula- tion of copper wifhin various tissues and cells. Affected patients present usually with primary- hepatic disease and/or neurops),chiatric disease The ATPTB gene has been identified as the underlying defect in these patients. However, there is no explanation so far on the pathological mechanism determining the variable clinical symptoms in W D To address this question we evaluated the ATPTB mutations using direct sequencing of all exons in the selected cohort of WD patients with endstage liver disease and compared these mutations with the one identified in WD patients presenting primarily with neurological disease. Ends:age fiver disease without any major neuropsychiatric invoh.ement was identified in 41 subjects so far, either due to chronic, acute on chronic or acute liver failure. 29/41 patients received liver transplantation. Disease causing mutations were detected in 31 patients on both alleles, in 9 patients on one allele, and no mutation in one patient. Thus, in 72 out of 82 studied alleles (88%) we revealed disease cansing mutations. The identified mutations were H1069Q, 3204de1C, 2304insC, 2008-2013delTATATG, $932X, 2296insA, L708P, Rl151C, W779X, and 1285 + 2T>A. The more prevalent H1069Q mutation in central Europe on exon 14 was most contmonly detected on 22 alleles, the 3204delC mutation on exon 15 on 9 alleles, and both the 2304insC on exon 8 and the 2008-2013delTATAG on exon 7 on 3 alleles Although, some mutations seem to predispose more commonly for a specific major organ involvement in these patients, there was no mutational hot spot or type of mutation, which definitely results only in one specific major organ invoh, ement. Therefbre, these data highlight the presence of additional factors in WD, which determine disease phenotype.

W1394

The Efficacy of Antihypertensive Agents after Liver Transplant and Their Effect Upon Arterial Silliness David Neal, Morris Brown, lan Wilkinson, Graeme Alexander

Background: Hypertension develops in over 50 % of patients alter fiver transplant There is very little published data on optimum treatment. Arterial stiffness is an important measure of cardiovascular risk. Augmentation index (AI) is a reflection of arterial stiffness and can be determined by pulse wave analysis of the radial artery'. Methods: 21 hy~rtensive liver transplant recipients were commenced on the cakium-chatmel blocker amlodipine. 8 patients who were intolerant of or unrestxmsive to amlodipine were administered the beta-adrenocep- tot antagonist bisoprolol and the angiotensin-convemng enzyme inhibitor lisinopril in a cross-over study Systolic blood pressure (BP) and AI were measured before and after a median of 10 weeks on each drug. AI is expressed as a percentage of the central pulse pressure. No patient received any" additional antihypertensive therapy including diuretics. Results: Ai fell from 24 • 2 % to 16 • 2 % (P< 0.001) with amlodipine whilst BP MI from 156 • 2 to 133 • 2 mmHg (P<O 001). AI increased from 17 • 5 % to 26 +_ 3 % (P=0.015) with bisoprolol whilst BP fell from 158 _+ 5 to 142 _+ 3 mmHg (p=O.019) In contrast lisinopril reduced AI from 20 • 2 % m 13 + 3 % (P =0.021) and BP fell from 156 • 2 to 133 • 5 mmHg (P=0003) . 40 % experienced lower limb oedema with amlodipine BLsoprolol and lisinopril were both well tolerated. Creatinine clearance was unchanged after treatment with lisinopril. Discussion: Amlodipine reduces BP and AI but low doses are required in view of the frequency of leg oedema The choice of hisopmlol or lisinopril as second-line treatment is influenced by, the dfltering effects on augmentalion index The increase in AI with bisopmM implies that central aortic pressure is not reduced as much as appears from the Observed reduction in peripheral BP. kisinopril, by reducing A1 and arterial stiffness, may" therdbre be preferred to bisopmlol The king-term effects of these" drugs upon central aortic pressure warrants further study

W1395

A Study on Intrasplenic Transplantation of Hepatocytic STEM Cell in Rats with Partial Hepatectomy Jung Mynang Chung, Jae Kyung Lee Eun Tack Park, Sang Hyuk Lee, Jae Hong Park, Ki Won Bae, Young Chul Yang

AIM: In this experiment, pluripotent stem cells were isolated from the early embryos of rats and ditferentiated into hepatoc)~ic stem cells in vitro, After the hepatocytic stem cells were transplanted in the rat spleen with partial hepatectomy, the diflerentiation patterns, functional roles and viability of the transplanted cells were investigated by morphological methods. METHOD: The embryonic stem(ES)cells of rats were isolated from the blastocyst after 3,5 day's of fertilizatmn and attached onto their teeder cells, fibroblasts, Thereafter, the ES cells were co-cufiured with hepatocytes tor 8 days and differentiated into hepatocytic stem cells, which were transplanted in rat spleen with 75% hepatectomy. RESULTS: 1 The intrasplenic transplamatiun of hepatoc~ytic stem cell was pertormed in the ]0th day' after partial hepatec- tomy. 8 mice were dead out of the 20 rats, with one dead 20 days later and another dead 30 days later The remaining 10 rats survived till 80 days 2 The co-cultured ES cells showed increase in number from the first day after the cultivation. The ES cells were attached onto the edge of fhe hepatocytes cultivated for 3 day's and most of the ES cells were differentiated into hepatocytic stem cells from the 8th day' after the co-cuhure. 3. When the hepatocytic stem cells were transplanted, the infiltration of many lymphocytes developed and the transplanted stem cells were distributed around the periarterial lymphatic sheath

of the spleen. As time went by, they were growing like lobule around trabeculae. 4. In electronic microscopic examination, the remarkable development of granular cytoplasmic reticulum was noticed in the cytoplasm of the differentiated stem ceils in the 20th day' after the transplantation, while non-granular cytoplasmic reuculum was developed 30 days later. After 40 days, peroxisomes and mitochondriae were observed and bile canaficuli were differentiated after 80 days 5. The EGF response showed strong posirivity after 20 days and TGF response and apoptosis increased after 40 days. CONCLUSION: When the phiripo- tent stem cells were derived from the early embryo of rat, differentiated into primary hepatocyte in vitro and transplanted in rat spleen, it is possible that proper differentiation and functioning as hepatocytes could be observed over a long term

W1396

Changes in Serum VEGF and SCF during Liver Regeneration in Humans Gustav A. Decker Allan B. Dicta, Gregory J. Gores, Scott L. Nyberg, Stanimir Vuk- Pavlovic

The liver is characterized by a umque capacity to regenerate. After resection, the remaining cells profiterate to replace the lost hepatocytes, chofangtocytes, sinusoidal endothelial cells, Kuppter ceils and stellate cells. Vascular endothelial growth factor (VEGF) and stem cell factor (SCF) are now recognized for their possible role in liver regeneration, but it is not clear if the serum levels of these molecules correlate ~itb liver injury and regeneration. SCF has also been implicated in liver fibrogenesis. Consequently, we sought to determine the correlation between the levels of these molecules in peripheral blood of patients with various modes of liver iniury. Methods: By a chemiluminescence enayn:e immunoassay (R&D Systems) we measured the concentrations of VEGF and SCF in sera of nine living related donors (LRD) before and after right hepatectomy. We compared the results with the serum levels of VEGF and SCF in ten end-stage alcoholic cirrbotics before and after cadaveric orthotopic liver transplantation (OLT). Results: The levels of VEGF m LRD sera increased fi'om 199_+ 139 pg/mL before hepatectomy to 523 • 536 pg/mL at a median of 15 days after the procedure, a mean increase of 266 percent (p = 0013). Concomitantly, the levels of SCF in sera decreased from 831 _+ 290 pg/mL to 587-+ 279 pg/mL, a mean decrease of 60 percent (p = 0.002). in alcoholic cirrhotlcs, VEGF levels increased t?com 111 • 101 pg/ mL before OLT to 306 • 235 pg/mL on day 14 after transplantation (p = 0.012) while the SCF levels were unchanged. The mean pre-transplant sermn levels of VEGF or SCF were indistinguishable between LRD and alcoholic cirrhotics Conclusion: Serum VEGF levels increased in patients with regenerating livers. This positive correlation may reflect the role of VEGF in this process. Immnnosuppression did not appear to affect circulating VEGF levels after OLT. The cause for and the role of reduced levels of SCF in the course of liver regeneration are re:clear, but may reflect reduced release and/or production by the regenerat- ing liver so as to suppress fibrogenesis

W1397

Resonance Arteriography as a Prognostic Index in Patients Considered for Transcutaneous Intrahepatic Portosystemic Shunt (TIPS) Leka Gajula, Syed A. Raza, Eric M. Walser, Ned Snyder, Roger D. Soloway

Expensive and invasive procedures such as TIPS for intractable ascites would be most efficient if patterns had reasonable survival after procedure. The MELD score has been used for this purpose. Use of hepatic blood flow as a pathophysiological measure of hepatic function might pmv-Lde an independent predictive method We previously reported use of nudear medicine imaging to achieve this goal. AIM: To use a non radioactive measurement of vascular flow using magnetic resonance imaging with gadolinium enhancement to measure flmv in a group of patients with refractory ascites. METHODS: Patients were reierred to The University of Texas Medical Branch at Galveston, Department of Radiology', with refractory ascites after maximum medical therapy" was implemented. These patients had no contraindica- lion for pfacement of TIPS such as portal vein thrombosis or hapatocellular carcinoma. Magnetic resonance angiography was performed prior to TIPS placement in all patients. The ratio of the hepatic artery to renal artery" blood tlo.,,' was calculated by separate windows over the liver and kidney Results: Patients were divided into survivors and patients who died within six months of the procedure'. Thirteen sur~4vors had a ratio of less than 0.66 with a mean of 0.4 while seven patients who died had a ratio of greater than 0.8 with a meat: of 1 2 The distribution of values for these two groups was widely separated without overlap Conclusion: We confirmed that patients with a hepatic artery flow greater than renal artery flow, indicating arterialization of the liver, have a very poor prognosis and should be treated by alternative measures such as repeated paracentesis. This seems physiolog- ically sound because increased hepatic artery flow signifies reduction in portal vein flow, crucial tbr normal hepatic function. The presence of much less portal venous flow in the patients that died vs those that fired supports arterialization of the liver as a bad pmgnostic sign

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Impact of Transjugular lntrahepatic Portosystemic Shunting on Thrombocytopenia due to Cirrhosis Saad Khna, Satheesh Hair

Thrombocytopenia is common in patients with cirrhosis and portal hypertension Occasmn- ally thmn:bocytopenia can be very severe and contribute to epistax:s, and chronic gastrointes- final bleeding front portal gastropathy Transjugnlar intrahepatic portosystemic shunting (TIPS) decreases portal hypertension in patients with variceal Needing and ascitas. There are conflicting reports in the literature regarding the impact of TIPS on platelet count. A European study using age matched controls with cirrhosis found that patients who had TIPS had a higher platelet count compared to controls (J Hepatol 1999:30:254-9) Two studies from the United States have tound that TIPS had no impact on platdet counts. (Dig Dis Sci 1998;43:2459-62; Dig Dis Sci. 2000;45:1971-6) The aim of the present study was to determine whether TIPS improves thrombocytopema and if so whether the severity of

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underlying portal h)?ertension is predictwe of improvement Methods: 70 patients, who underwent TIPS at our institution were studied Ptatelet counts were recorded at 30 days, 3 month and 6 months. The patients were divided inlo three groups: those with moderate hrombocyopenia (platelet count < 80,00Cvmm i) and those with nrfld thrombocytopenia (platdet count 80q50,OOO/mm ~) and those with normal cmmt (> 150,000/ram ~) Results: 80% of the TIPS were done for GI bleeding and 20% tot asc~tes. Hepatitis C and alcoholic cirrhosis were the most common etiologies of cirrhosis. 70% had Child Pugh class B cirrhosis, 20% had Child Pugh class C cirrhosis and 10% had Child Pugh class A cirrhosis. All patients except three had a portosystemic gradient of > 12 mmHg, The platelet counts as well gradients in each group of patients are presentad m the table Conclusions: TIPS improved the piatelet count in patients wltb moderate to severe thrombocyropenia. Maxinmm improve- ment is seen n one month, In patients with relatively nornlal pIatelet count, TIPS did not have any eflect despite signihcant reduction in portosystenuc gradmnt.

Pit s t Pit count 8~5~" P~t count >150~ Pm TIPS Pit Couatt 5517 11020 21760 ~ u ~ l m ~ N t B235" 12338 170r Pit ~unl 3 mo~hst 87'35' 110~ 173~ Pit r 4 mom~t 8538* 10539 18183 P~T~P$ Gradient (ram Hg) 19,25,5 17.6 4,9 1BA 5,5 Post Oradi~ (ram I~) 7.7 2.6 6,9, Z6 9~0 3.3 Reduclion In G~dient {ram 11,5 5.2 106,5,5 9,1~5.9

PI~ Piglet, 1 : X lO00/mm a, * P va~ue < 0.05 ~mpared to pre TiPS value (W~oxon signed rank test)

W1399

The Augioteusin II Receptor Blocker (ARB) Candesartan Cilexetil Decreases Portal Vascular Resistance in Liver Cirrhosis Miyako Ire, Akihiko Hachtya, Shigeru Nakano, Man Hanzaw~, Masato Katagin, Toshio Kmita, Hiroshi Matsuzaki, Yoshinori Igapashi, Kazunafl lida, Kazumasa Miki

Background: There has been some controversy as to whether ARB reduces portal hypertension in patients with liver cirrhosis, Reduction in portal pressure after administration of ARB is beiieved to be due to relao:ation of hepatic stellate cells and a decrease in sinusdidat resistance. Aims: To determine whether candesartan cilexetil (1) reduces portal vascular resistance (PVR), (2) all'nets portal venous flow and hepatic function; and (3) whether PVR correlates with plasma levels of vasoconstrictors, Patients and methods: Thirty cirrhotic patients were enrolled in this study Hepatic venous pressure gradient (HVPG), portal venous hemodyuam- ics (using Doppler-nhrasonograpby), biochemical variables, and plasma angiotensin Ii (ANG[I) and endothelm-l(ET-l) were measured before, and 2weeks after, admmlstration of daily oral candesartan 4mg. Results Afler administration of candesartan, HVPG decreased from 18.0+/-6,0 to 1564-/-5.8 mmHg (p<0 01) with an average % change of .13.0+/- 20.5%. Mammnm velocity of portal vein increased from 191 +/-5,1 to 235 +/-5.0 cm/sec (p<0.01) P\rR (calculated as }-tVPWportaI venous flow volume) decreased from 939.{5 +/- 447,5 to 741.0+/- 327,8 mmHgxmirJIxkg(p<0.05) Plasma ammonia level significantly decreased (p<0.05) and serum albumin level increased (p<0.01). There were significant correlations between % change in PVR to % change in both ANGII and ET-] levels (r = 0.89, p<0.005; r = 0 7 8 p<0.0I , respectively). Conclusions: These results indicate fl~at candesa> tan cilexetil decreased P'vT',, thereby nicreasnig portal vein maximum velocity and moderately reducing portal hypertension. PIasnm ANGII and ET-1 levels appear to be satisfactory predictors of the eflicacy of thls ARB. Moreover, there is a good possibility that candesartan preserves hepatic function in liver cirrhosis.

W1400

Balloon Ultrasound System to Measure VarLx pressure: An ln-Vitro Validation Study, Janres L Puckett Jianmin Liu, Vikas Bhalla, Mary KrinskT, Tarek Hassanein, Ramnder K Mittal

Background: Vain: pressure may predict its rapture, A rmmber of methods to measulv vanx pressure have been reported but to date none are ni wide use because their ability to measure accurate pressure is suspect Aims: We report our experience with a novel balloon/uhrasound technique to measure vanx pressmv in an in-vitro system Methods: The balloon/uhrasound system consisted of three catheters, a 12-MHz transducer ultrasound (US) catheter, a water intusion catheter and a n:tauometry catheter, whmh were placed inside a latex balloon. The esophagus and external jug.dar vein were haraested from three pigs. The vein was connected to a water rese*5~oir to modulate its pressure to i0, 15, 20, 25, 30, 35, 40, 45 and 50 mmHg The vein and balloon/ultrasound &vice wm~ placed inside the esopflagus and tbe entire system was placed inside an organ bath filled with wamr The balloon was inflated with water, using a slow mtusion method (0 5ml/min), until the US images showed complete occlusion. In some experiments the balloon pressure was raised to 20 mm Hg higher than the varix pressure and tEe balloon was then allowed to deflate slowly to determine the balloon pressure at which there was opening of the vein. Data Analysis: One US image for each 1 mm tlg change in balloon pressure was digitized and analyzed for the vein cross sectional area(CSA) Resnlts: The US images clearly xasuaIized the vein and changes in Iumnial CSA v<h inflation and dd]ation of the balloon The vein CSA decreased slowly as the balloon pressure began to increase (approxm~ately 50% reduction in CSA at the balloon pressure within 5 mmttg of the vein pressure), ie~iIowing which there `*'as a rapid reduction in the vein CSA In 36 tunis the complete vein occlusion occurred when the balloon pressure was slightly greater (1.5 _+ 4 rnmHg) than the vein pressure. (Correlation coefficients, Observer 1: W = ,99, Observer 2: R} = .99) Complete occlusion el the vein rasulted in cessatnin of flow through the vein Vein opening pressure correlated more closely to tim actual veto pressure than the veto closing p~vssure, Conclusions: Pressure gauge and endo- scopic balloon systems (other non-invasive methods to measure varix p~vssure) reIy on the prniciple ffiat the balloon pressure that causes a partial collapse of varix is a measure of varix pressure To h e contrary, our hndings indicate that balloon pressure which causes

complete vein occlusion is the true determinant of the varix pressure Studies are in progress to determine the accuracy of balloon/US technique to measure varix pressure in-rave.

W1401

Expression of a 72-kDa Heat Shock Protein and Protection in Gastric Mucosa of Portal Hypertensive Rats Daisuke Watanabe, Ken-Ichiro Mikarni, Kazuo Yoneyama Takashi Goto, Kouichi Miura, Shigetosh~ Ohshima, Jinn-Gney Lin, Daisuke Segawa, Ei Kataoka, Noriaki Konishi, Masam Odashima, Masashiro 5ogawara, Michiro Otaka, Sumio Watanabe

Background & Aims: Portal hypertensive gastropathy (PHG) is a clinical entity that is observed frequently in patients vd(b flyer cirrhosis. In PHG , gastric mucnsa is highly susceptible to mucosal injury caused by noxious agents. Many studies, including ours, have reported that a 72-kDa heat shock protein (HSP72) has a crucial cytoprotective function in gastric mucosa. However, its cytopmtective eftect in PHG has not yet been studied In this study, we investigated the expression and cytoprotective eflect of HSP72 on gastric mucosa in portal hypertensive rats Methods: PHG was produced by the bile-duct ligauon (BDL) model in male Sprague-DawIey rats. In sham-operated (SO) rats, the bile duct was isolated but not ligated The expression of HSP72 in the gastric mucosa was evaluated by Western blotting 1, 2, 4 or 7 weeks after the operation induction of gastric mucosal HSP72 by 6 hrs Water-immersion (WI) stress was cmnpared between BDL and SO rat.s, Also, mucosal protective abilities against HCI (0.6 N) or aspirin (200mg/kg) followed by pretreatment with WI stress to reduce HSP72 were studied in both groups Resuhs: Portal pressure was significantly higher in BDL rots compared with SO rats at each week atier the operation (p<0.05) Basal expression (befbre WI) and inducibility (after Wl) of mucosal HSP72 were significantly lower in BDI. rats compared with SO mrs. HCI or aspirin-induced gastric mucosal lesions ,*'ere significantly suppressed in SO rats compared w~th BDL rats especially HSP72 was premduced by Wl stress Conclusion: In the portal hypertensive rats, basal expression and inducibility of HbP72 in the gastric mucosa was lmver compared with SO rats Mucosa] protective ability against noxious agents was also lower in portal hypertensive rats These t~ndnigs suggest that HSP72 in the gasnic mucosa plays cmdal role wub respect m cytoprotection, and of induction HSP72 may provide therapeutic strategies for protection against mucosal injury in PHG.

W1402

Role of Afferent Nerves and Sensory Peptides in the Mediation of Hepatic Artery Buffer Response jarosiaw Biernat, Ryszard Sendur, RafaI Obuchowicz, Zygnunt Wa~zecha, Artur Dembinski, Wieslaw W. Pawlik

intrahepatic arteries are richly innervated by both admnergic and sensory vanilloid-sensitive (capsaicin-sensitwe) fibers. Stimulation of capsaicm sensiuve fibers have been shown to dilate the intrahepatic vessels by both releasing sensory neuropepfides and by modulating the adrenergic tone. However the participation of capsaicin-sensitive fibers in the mediation of hepatic artery bufier response (HABR) has not been investigated yet. To explore the participation of sensory innervation and sensory neuropeptides in the HABR we did experi- ments ni capsaicin-denervated Wistar rats. in addition we used sdective CGRP and tachyknini receptor antagonists to test the participation of' CGRP, Substance P and NK-A m HABR m the rat. We used 60 Wistar rats weighing 200-230g. Under pentobarbitai anesthesia (50 m.g&g) hepatic artery blood riow (FL4BF) and portal blood flow (PBF) using ultrasonic bloodflowmeter (AIrton T206) were measured. Microctmulato D, hepatic blood flow (HBF) was measured using Iaser-Doppter flowmet U (periflux 4001 master) HABR was reduced by constricting the portal vein and maintaining the PBF at 10% of control PBF value. Administering capsaicm in 5 consecutive doses s,c. from 2 5 Io 50 mg/$zg induced chrot:dc sensm'y denervation. In control HABR rats the hepatic artery blood flow increased by 89% whilst HBF decreased by 32% in comparison to control HBF values. In sensory-denervated rats the resting HBF and PBF were increased by 23 and 34% respectively in comparison to control HBF and PBF values In this group the induction of HABR increased the hepaUc artery blood flow by only 55%, whilst FIBF was reduced by 45%. Administration of CGRP 8-37 (CGRP receptor antagonist) and NKd but not NK-2 or NK-3 receptor antagonists significantly reduced the HABF by 43% and 25 % as compared to HABF value in control IK~BR group Hepatic artery bufier response induced by reduction of the portal inflow to the liver by 90% J.s partly mediated by stimulation of capsaicin-sensitive sensory fibers ni the liver, prnbably due to local tissue iscbemia and hypoxia. Tire observed vasodilation in the vascular bed ot the hepatic artery is mediated by CGRP and NK-] receptors.

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Baud Ligation Versus Medical Therapy in Prevention of Variceal Rebleediug: A Randomized Controlled Study in Schistosomal Hepatic Fibrosis and HCV Coin fection M. EbTahawy, S. Mahmoud, I Waked, Khaled Selim, Tarek Hassanein

Patients with variceal bleeding have a 70% risk of rebleednig after the initial bleed. Secondary prophylaxis using endoscopic therapy or Phamlacotharapy (beta-blockers and isosorbid-5- mononitrate) is known to be effective in reducing the rate of rebleeding. The aim of this study is to compare the efficacy of endoscopic eradication of the esophageal varices by band Iigation (EVL), and medical treatmeut in prevention of variceal rebleedmg over a sk~-month period after the initial control of the bleeding by band libation. Subject: One hundred patients were recruited b:om the National Liver institute hospital m Egla?t for tNs prospective controlled study. The sample comprised mostly men ranged li-om 18 to 65 years of age (M = 4 5 4 +/- 1006). Method: Following mnial evaluation and resuscitation each patient received band libation to control the acute bleeding. After the acute bleeding was controlled, patients were divided rote two groups 'repeated EVI_ group" who received repeated band libation or "standard medical treatment group" who received propranolol (dose gwen to slow HR 30% trom base bne) and IS5MN 20rag (twice daily) each of this group were

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