Clinica Chimica Acta. 209 (1992) 169-177 0 1992 Elsevier Science Publishers B.V. All rights reserved. 0009-8981/92/$05.00


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Lipid and apolipoprotein changes after orthotopic liver transplantation for end-stage liver diseases Claude L. Malrnendiera, Jean-F. Lontiea, Denis MathCb, RenC Adam” and Henri Bismuth” ‘Fondation de Recherche sur I’AthProsckkose, 1050 Brussels (Belgium), bINSERM U32. Hbpital Henri Mondor. CrPteil, 94010 (France) and Woupe de Recherche de Chirurgie Hepatique, Hbpital PaulBrowse. Villejuif 94800 (France)

(Received 7 October 1991; revision received 29 May 1992; accepted 3 June 1992)

Key words: Lipid; Apolipoprotein;

Liver diseases; Transplantation

Summary Orthotopic liver transplantation was performed in 37 patients with different endstage liver diseases. Changes in lipid and apolipoprotein concentrations were followed daily from day 1 to 20 after surgery and regularly thereafter until 12 months. When the acute effects of surgery had cleared away, there was a sharp drop in HDLC, apo A-I and A-II from day 1 to 5, a stabilization at their lowest values from day 5 to 15 and then a progressive rise. Contrasting with this drop, triglycerides, apo B, C-II and C-III increased from day 1 to 5 with variable concentrations thereafter. Apo SAA considerably increased early after surgery and remained significantly higher than normal in most patients after 12 months. All other parameters returned to normal from 3 to 6 months after transplant. The mechanism leading to these lipid and apolipoprotein changes are discussed with respect to the distant effect of infusions, re-alimentation, immunosuppressive therapy and lipoprotein metabolism. The apolipoprotein concentrations appear very useful indicators of functional liver recovery.

Correspondence to: Prof. CL. Malmendier, Research Foundation on Atherosclerosis, 21 avenue de I’Oree, B-1050 Brussels, Belgium. Abbreviations: Apo, apolipoprotein; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol; PL, phospholipids; SAA, serum amyloid A protein; TC, total cholesterol; TG, triglycerides.

Introduction The liver plays a crucial role in the synthesis and secretion of lipoproteins: hepatic disorders induce major metabolic alterations in lipid and apolipoprotein plasma levels [l-5]. The importance of the liver has been we11demonstrated by the effect of liver transplantation on the course of the homozygous form of familial hypercholesterolemia [6,7] in reducing LDL-C by more than 700/. The criteria used for the selection of recipients for liver transplant for reasons other than hypercholesterolemia do not usually include Iipid and apol~poprote~n concentrations. However, the determination of apol~poproteins seems to be important for the assessment of hepatic function [S]. Proper evaluation of the effects of liver transplantation need to be made and must differentiate the effects of the surgical procedure itself, the amount of infusions during surgery, the administration of immunosuppressors and steroids. To date there has been no published report of changes in lipids and apolipoproteins especially in the early posttransplant period. The present paper reports the precise course of plasma lipids and apolipoproteins following liver transplanatation in different hepatic conditions from day 2 up to 12 months and also attempts to estimate the best indices of recovery and the time required to restore normal liver function. Mate&d and Methods Patienrs

Liver transplantation was successfully performed in 37 patients (22 male, 15 female; mean age 43.2 f 10.4 years) with various hepatic disorders (18 ~sthepatitis cirrhosis, 7 primary biliary cirrhosis, 6 fulminant hepatitis, 3 sclerosing cholangitis, 2 hepatocellular carcinoma, 2 undetermined cirrhosis). Mean body weight was 65 i 11 kg and mean height was 170 f 7 cm. Body mass index (kg/m*) was 22.7 f 3.8 (range 16.4-28.6) and Broca index (re~o~ended weight = [height in cm - 1001 kg) 93 i f2%at the time of liver t~nsp~anta~on- The criteria adopted for the selection of candidates have been given elsewhere f9f. The surgical procedure has been described in detail in [RI]. During surgery and immediately after, transplanted patients received fresh frozen plasma and red blood cell infusions varying from subject to subject up to 36 1. Cyclosporine A (10 mg/kg per day) was started during surgery to maintain a plasma concentration around 1,000 @ml. Steroids (prednisolone) were started on the day of operation at 40 mglday. R~uction of the cyclosporine and steroids dosage was made on an individual basis. All the patients described in this paper survived for more than 1 year. Chemical de~errninai~~~~

Venous blood specimens were collected after a 12-h fast from the patients before hepatic replacement and periodically after transplantation: daily for the first 20 days and then at 1,3,6 and 12 months. Measurements of plasma triglycerides (TG), total

cholesterol (TC) and phospholipids {FL) were performed by the methods of the Lipid Research Clinics [ 11]. HDL-C was measured after precipitating the apo B containing lipoproteins with phosphotungstate and magnesium chloride 1121. LDL-C was determined from the formula of Friedewald et al. 1131. Apolipoproteins (A-I, A-II, B, C-II, C-III and SAA) was determined by ELISA [14-171. Thirty-two healthy volunteers served as controls for comparison.

Statistical analysis Student’s t-test and paired t-test were used to determine statistical signi~~a~~e of changes. Correlations between parameters were calculated using Pearson’s correlation test. Remits The similarity of post-transplant apolipoprotein curves in all patients despite very different pre-transplant values suggested that the changes are almost due principally to the effects of liver transplantation and not to the condition of the liver or to the specific liver disease justifying the transplant. The mean effects of liver transplantation on the concentrations of HDL-C, a~lipoproteins A-I and A-II in plasma are illustrate in Fig. 1. From day 1 to 5 or 6 after surgery there was a very sharp drop in concentration representing > 50% for HDL-C, apo A-I and apo A-II (P c 0.001). Then from day 6 to 15 the concentrations were stable at their lowest values. From day 15 to 30 or 60 there was a progressive rise to values still about 20% lower than normal. By contrast the 4 parameters illustrated in Fig. 2 (TG, apo B, C-II and C-III) showed a continuous rise in concentration from day 1 to 5 despite the huge perfusions of plasma. Then from day 6 to 20, TG, apo C-II and apo C-III did not alter significantly whereas apo B continued to increase at least until day 17. After day 20 to 60, all values reached about their normal values. Before surgery, a~lipoprotein SAA values were only slightly increased (0.9 f 1.8 mgldl) compared to normal (0.1 f 0.1 mgldl). Its concentration reached its hi~est value l-2 days after operation (15.8 i: 10.2 mg/dI) but high levels (> 2.6 mgldl) persisted in many patients for months after grafting, irrespective of rejection and/or infection episodes. All lipid and apolipoprotein values (excluding apo SAA which remained at a value of 3.7 f 7.1 mg/dl) returned to normal 12 months after surgery, in all patients except those who did not recover at all or showed a rejection of the graft. Discussion Short-term effects (l-30 days) of liver transplantation must be distinguished from medium (3 months or more) or long-term effixts (years). During the lirst week following renal transplantation there was an initial fall in serum cholesterol and then from 1 to 8 weeks the level regularly increased whereas the triglyceride level fell during the 4 weeks and then progressively increased fig], This is in opposition with


20-m HDL-C lO--



20 25



TIME (DAYS) Fig. 1,The effect of transplantation of HDL-C (U), apolipoproteins A-I (0) and A-II (0) plasma levels (mean f S.E.M.) in 37 patients. The preoperative values are indicated before the arrow representing the time of surgery (TO).


TG 80 60 40


t t








I 10












I 1



Fig. 2. The effect of transplantation on triglycerides (4, apolipoproteins B (U), C-II (0) and C-III (0) plasma levels (mean f S.E.M.) in 37 patients. The preoperative values are indicated before the arrow representing

the time of surgery



the results of Savdie et al. [ 191who mentioned a low total cholesterol and higher TG than normal 1 month after renal transplantation; at this time they found reduced concentrations of HDL-C and apo A (A-I + A-II). The only studies reported lipid and apolipoprotein changes after liver transplant compared pre-surgery values to values determined 3 and 6 months after [20] and showed that total cholesterol, phospholipid and apo A-I concentrations returned to normal at 3 months and did the amount of LCAT activity [20]. In our study a similar normalization was observed also for LDL-C, apo B and C-II but at 3 months TG and apo C-III remain elevated above normal and HDL-C, apo A-I and A-II are still significantly lower than that of healthy controls. Numerous factors acting in cooperation or in opposition must be considered for explaining the drastic changes affecting very differently the various apolipoproteins and the timing of their appearance: (i) The effect of the operation itself and of accompanying perfusions is illustrated by the delay observed from the day of operation and the appearance of the drop in apo A-I, A-II and HDL-C levels. The amount of perfusions was adapted according to the gravity of the patient’s condition, varying from 4 to 36 1. (ii) The effect of cyclosporin transported by all plasma lipoproteins [21] and metabolized in the liver [22] was studied in several diseases in absence of any transplantation. After 4 weeks of therapy in patients with psoriasis this drug increased cholesterol by 19% and to a minor degree triglycerides [23]. In another study realized in men with amyotrophic lateral sclerosis the effect was similar causing an increased of 21% in TC, 31% in LDL-C and 12% in apo B but no significant change in HDL-C or TG levels [24]. In kidney transplanted patients LDL-C was significantly increased 3 months after surgery only in patients receiving cyclosporine [25]. Only very high levels of cyclosporine given after a bone marrow graft are associated after more than 2 months with very high triglyceride levels [26]. Prednisone therapy given isolately to an heterogeneous group of patients [27] causes a highly significant increase of HDL-C with a slight increase in total cholesterol, but no change in the levels of apo A-I, A-II and E was evident. In patients undergoing renal transplantation high dosage of prednisone maintained for months was considered responsible for a relatively small elevation in serum lipids (cholesterol and triglycerides) [ 18,28,29]. Reduction of both cyclosporine [30] and steroids doses was associated with a return of total cholesterol to normal [31]. The increase was more important after combined cyclosporine + prednisone treatment [32]. It is not excluded that cyclosporine might be responsible for the increase in TG 5 days after liver transplant when the patients were given high doses. The significant increase in triglycerides (up to a value of 485 mg/dl) observed in most cases already 8 days after liver transplant and lasting 12 months after, may be partly the result of the combined immunosuppressive and steroid therapy. Anyway, as immunosuppressive therapy and corticosteroids are used in all organ transplants (kidney, heart and liver) at similar dosages, although they have been suggested as representing independent risk factors for the development of hyperlipidemia, the so different drastic modifications observed in lipids and apoproteins after each type of graft allow to distinguish the role of the specific organ in the metabolism. The consequences of this type of therapy on the other parameters (apoproteins A-I, A-II . . .) were not addressed in preceding studies.


(iii) The patients generally resumed a normal alimentation 4 days after surgery, providing thus through chylomicrons TG and apoproteins of intestinal origin. This intestinal contribution of apoproteins is however limited. The increase in TG must be multifactorial. In renal allograft patients (331 a decreased catabolism of triglyceride-rich lipoproteins in peripheral tissue may be an important mechanism as it appears to be related to reduced lipoprotein lipase activity. In some patients significantly reduced plasma postheparin lipoiytic activity was found but partly related to high-dose corticosteroid therapy [34]. Savdie et al. [35] found an impaired capacity for VLDL-TG removal with lipase activities (LPL and hepatic lipase) similar to normal in renal transplant group. The heterogeneity of the group with respect of time elapsed since grafting, the daily dose of cortisone and the renal function may have been responsible for the failure of statistical trends to emerge. Again the steroid therapy may cause resistance to insulin which may be necessary for the induction of adipose tissue iipase in vivo. We think as Savdie that in our group hypertriglyceridemia may be related to high VLDL-TG pool with a reduced FCR, the delayed VLDL removal explaining the increased levels of apo B, apo C-II and apo C-III, ail components of VLDL. The explanation of the sharp drop and very low level of HDL-C, apo A-I and A-II lasting 15 days or more may also be multifactorial. A major determinant of the apolipoprotein level is the balance between synthesis and catabolism. Immediately after the removal and graft of the new liver, the synthesis is stopped but partially compensated for the first 2 days by the contribution of perfusions. These perfusions contributed more to HDL constituents than to other lipoproteins (low concentration of apo B in fresh frozen plasma). Meanwhile the apolipoproteins present in plasma might be catabolized at the normal rate (about 3.5 days for apo B and 5 days for apo A-I and apo A-II). In a heart-liver transplantation for familial hypercholesterolemia, Starzl et al. [36] showed that from day 2 after surgery the total cholesterol level was almost normal and remained in normal range for 80 days. This reduction was likely due to plasma dilution by the volume of perfusions, but the persistance of normal values shortly after surgery indicates the presence of functional hepatic receptors. In posttransplant patients for causes other than familial hyper~holesterolemia the slow increase in apo B levels may thus result from an impaired lipolysis of VLDL explaining the rise in apo B and TG despite low LDL-C levels. The reduction of apo A-I and A-II between day 2 and 5 is consistent with a normal HDL catabolism and thus might result mostly from an impaired hepatic synthesis which is restored slowly from day 10. SAA was established as an apolipoprotein associated to HDL 137-391 and is one of the inflammatory acute phase proteins partially synthesized at extrahepatic sites 1401.This apo SAA early increase result from the surgical procedure itself 141,421 and, although its concentration decreased regularly until the 3rd month, it remained more than lo-fold higher than normal even 12 months after surgery without any sign of transplant rejection. This may be due to the immunosuppressive therapy [43]. The time required for a total restoration of normal apolipoprotein values may vary from an exceptionally short time of 3-12 months, much longer than that necessary for a complete clinical recovery and the monitoring of these parameters (particularly apo A-I and A-II) at 3, 6, 9, 12 months may thus be the most useful analysis for detecting a normal functional recovery much better than the long-


established liver function tests (SCOT, SGPT, LDH, bilirubin) which indicate only liver injury. References 1 2 3

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8 9 10 11 12 13


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Lipid and apolipoprotein changes after orthotopic liver transplantation for end-stage liver diseases.

Orthotopic liver transplantation was performed in 37 patients with different endstage liver diseases. Changes in lipid and apolipoprotein concentratio...
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