Pathophysiology and treatment of multiple organ failure among hepatectomized cirrhotic patients

Our previous studies have claimed that cirrhotic rats, induced with CCl4, showed depressed reticuloendothelial system (RES) function and increased susceptibility to infection. We have also shown that OK-432, a non-specific immunopotentiator, and ATP-MgCl2, which improves depressed intracellular energy metabolism, improve RES function of cirrhotic rats and that thereby improve survival following peritonitis or hepatectomy. The present study was undertaken to investigate whether OK-432 or ATP-MgCl2 could be beneficial for the prevention of multiple organ failure (MOF) following hepatectomy among the cirrhotics. The cirrhotics with hepatocellular carcinoma, who underwent partial hepatectomy (segmentectomy or subsegmentectomy) were given OK-432 (5 KE/day for 4 days) preoperatively or ATP-MgCl2 (50 mumole/kg) within 24 hours following the operation. The rates of postoperative pulmonary complication and the operative mortality were compared among OK-432 group, ATP-MgCl2 group and controls. The rates of posthepatectomy pulmonary complication and operative mortality were decreased with these treatments compared to the controls. The RES function was also improved with these treatments. These data suggest that the cirrhotic patients are the immunocompromised hosts showing the depressed RES function and that the enhancement of RES function with OK-432 or ATP-MgCl2 is beneficial for the prevention of posthepatectomy MOF among cirrhotics.     

Effect of activation of the reticuloendothelial system on hepatocyte regeneration in partially hepatectomized rats

Enhanced effect on rat hepatocyte regeneration through activation of the reticuloendothelial system (RES) was investigated. RES was activated using by OK-432 and the phagocytic activity (K-value) increased 2-fold over control rats 24 hours after intraperitoneal injection of OK-432. In OK-432 treated rats, the amount of cyclic AMP in the regenerating liver also increased 1.5-fold higher than in control rats 14 hours after hepatectomy. After 70% partial hepatectomy, liver DNA synthesis in OK-432 treated rats increased 2 to 5-fold higher than in control rats. There was a good correlation between the K-value before hepatectomy and DNA synthesis 24 hours after hepatectomy (r = 0.96). Therefore the RES is one of the most important regulatory factors in liver regeneration. Augmentation of RES before hepatectomy may prevent hepatic failure after resection in liver diseases.     

Impaired Kupffer cell function and effect of immunotherapy in obstructive jaundice

BACKGROUND: Obstructive jaundice is frequently associated with septic complications. This study examined the influence of biliary obstruction on bacterial clearance and translocation. The study focused on the phagocytic and killing activities of Kupffer cells and the preventive effect on bacterial translocation of OK-432, which is a hemolytic streptococcal preparation developed as a biological response modifier. METHODS: To study the mechanism of sepsis in obstructive jaundice, two groups of Wistar rats were examined: rats subjected to common bile duct ligation (CBDL) and rats subjected to a sham operation. Bacterial clearance, organ distribution, hepatic blood flow, and phagocytic function of Kupffer cells were examined. To evaluate the effect of OK-432 on bacterial translocation, rats were divided into three groups: sham operation + phosphate-buffered saline (PBS), CBDL + PBS, and CBDL + OK-432. RESULTS: In this study, clearance of Escherichia coli. from the peripheral blood in CBDL rats was decreased significantly compared with that in sham-operated rats. Significant decreases in E.coli trapped in the liver and in hepatic blood flow were observed in CBDL rats compared with sham-operated rats. Phagocytic activity and superoxide production of Kupffer cells isolated from CBDL rats were significantly lower than in sham-operated rats. The incidence of bacterial translocation in CBDL rats was increased significantly, and oral administration of OK-432 prevented it. CONCLUSION: The results suggest that susceptibility to infection in obstructive jaundice is due to impaired phagocytic function of Kupffer cells. Furthermore, obstructive jaundice promotes bacterial translocation, and OK-432 may be useful in preventing this translocation.     

Clinical studies on streptococcal preparation (OK-432) combined with mitomycin-C, 5-FU and cytosine arabinoside in advanced cancer patients.

Streptococcal preparation (OK-432), a new type of anti-cancer agent, was given to the patients with advanced cancer in combination with Mitomycin-C, 5-FU and Cytosine arabinoside. OK-432 was administered intramuscularly with a daily dose of 2.0 KE consecutively or locally into the tumor with a large-dose of 100 KE. Most cases tolerated the long term administration of OK-432 without any severe side effects and the highest dose reached was 314 KE during 161 days of treatment. Of the 53 patients evaluated, 31 were given the initial large dose intratumoral OK-432. Thirteen were judged 0-C and Category 1 according to the Karnofsky criteria for a response rate of 44.8 per cent as compared with 12.5 per cent in the group without the initial large-dose administration.     

Intracavitary administration of OK-432 with subcutaneous priming for malignant ascites in a case of advanced renal cell carcinoma

The intracavitary injection of OK-432 (a streptococcal preparation) with subcutaneous priming has been shown to be an effective immunotherapy for patients with malignant effusion. We applied this treatment in a case of advanced renal cell carcinoma with massive ascites. The patient received 0.2 Klinishe Einheit (KE) OK-432 in the subcutaneous injection twice (day 1 and day 7) followed by 10KE OK-432 intra-abdominal administration (day 9). The treatment was performed safely without major side-effects except for transient pyrexia. A significant reduction of ascites was noted 1 month after the treatment without subsequent re-accumulation. Intracavitary injection of OK-432 with subcutaneous priming seems to be a simple, safe and effective treatment for ascites in advanced renal cell carcinoma.     

Clinical studies on streptococcal preparation (OK-432) combined with mitomycin-C, 5-FU and cytosine arabinoside in advanced cancer patients

Streptococcal preparation (OK-432), a new type of anticancer agent, was given to the patients with advanced cancer in combination with Mitomycin-C, 5-FU and Cytosine arabinoside. OK-432 was administered intramuscularly with a daily dose of 2.0 KE consecutively or locally into the tumor with a large-dose of 100 KE. Most cases tolerated the long term administration of OK-432 without any severe side effects and the highest dose reached was 314 KE during 161 days of treatment. Of the 53 patients evaluated, 31 were given the initial large dose intratumoral OK-432. Thirteen were judged 0-C and Category 1 according to the Karnofsky criteria for a response rate of 44.8 per cent as compared with 12.5 per cent in the group without the initial large-dose administration.     

Experimental study concerning safety dosage of OK-432 for intrauterine treatment

OBJECTIVE: Clinical intrauterine treatment for fetal cystic hygroma has so far been performed in a few patients; however, it is still difficult to evaluate the results. The aim of this study is to establish the safe dosage of OK-432 in the intrauterine treatment of fetal cystic hygroma. METHODS: OK-432 was injected either subcutaneously behind the neck of the fetuses or into the amniotic cavity through the uterine wall of pregnant Japanese white rabbits at 27 days of gestation. Saline was administered to the controls. The dosage and the site of injection were as follows: group 1, OK-432, 0.01 KE (0.25 KE/kg) in 0.2 mL saline per fetus, subcutis; group 2, OK-432, 0.02 KE (0.5 KE/kg) in 0.2 mL saline per fetus, subcutis; group 3, OK-432, 0.04 KE (1 KE/kg) in 0.2 mL saline per fetus, subcutis; group 4, OK-432, 0.01 KE in 0.2 mL saline per fetus, amniotic cavity; group 5, OK-432, 0.04 KE in 0.2 mL saline per fetus, amniotic cavity; group 6, saline, 0.2 mL per fetus, subcutis; group 7, saline, 0.2 mL per fetus, amniotic cavity. All fetuses were delivered at 29 days of gestation. RESULTS: The mother's rectal temperature was mostly in the normal range throughout the experiment. There was no significant difference between any of the seven groups in fetal body weight. The C reactive protein values of all fetuses were negative. The appearance of the skin of all the fetuses was normal. The histopathological findings of the skin in the OK-432 groups showed a moderate infiltration of monocytes and plasma cells. No pathological changes were observed in the heart, lung, liver or kidneys of any of the fetuses. CONCLUSION: Based on this rabbit experiment, we determined that OK-432 may be safely used at a dose of up to 1 KE/1 kg of fetal body weight as an intrauterine treatment for fetal cystic hygroma.     

Facilitation of tumor metastasis to the lung by operative stress in the rat--influence of adrenocortical hormones and preoperative administration of OK-432

Experimental studies were performed to clarify the mechanism of facilitation of tumor metastasis to the lung by operative stress, using an experimental model in which 5-week old female Sprague-Dawley (SD) rats were inoculated with a low antigenic and easily metastasizable tumor, MRMT-1. In particular, relevance of adrenocortical hormones to the facilitation of tumor metastasis was examined. Furthermore preventive effects of preoperative administration of a nonspecific immunopotentiator, OK-432, were examined. Number of metastatic nodules was increased significantly by operative stress and the increase was proportionate to severity of the stress. The facilitation of metastasis by operative stress was significantly inhibited by preoperative OK-432 administration. In adrenalectomized rats, no such facilitation of metastasis by operative stress was observed. After administration of 2.5 to 20mg of hydrocortisone, number of metastatic nodules increased dose-dependently. The increase in metastatic nodules by administration of 5mg of hydrocortisone was inhibited by preoperative OK-432 administration. Thus it was concluded that facilitation of tumor metastasis by operative stress was proportionate to severity of the stress, and one of its essential causative factors was the stress-induced adrenocortical hypersecretion, which suppressed immunity of the host. Administration of OK-432 was effective for counteracting the stress-induced facilitation of metastasis.     

The clinical efficacy of intratumoral OK-432 administration in advanced cancer patients

The clinical efficacy of intratumoral (IT) OK-432 immunotherapy in advanced cancer patients was investigated. Furthermore, the infiltration of lymphocyte subsets into the tumor tissues after the IT administration of OK-432 was also immunohistologically examined in order to analyze the mechanism of action of OK-432 immunotherapy. Forty-four patients with advanced cancer were treated with IT OK-432 immunotherapy. Ten KE (1 mg) of OK-432 was given either daily or on every second day and repeated as often as possible, the mean frequency of OK-432 injections being 18.1±14.5 times, ranging between 5 and 25 administrations. Thirty-one of the 44 patients were evaluable, 3 of whom (9.7 per cent) developed a partial response and 5 (16.1 per cent) a minor response. Intratumoral OK-432 immunotherapy, however, did not necessarily prolong the survival time. Leu 1, 3 and 7 reactive cells infiltrated into the tumor tissues treated by OK-432 injection, more frequently, when compared with cells which had been treated by recombinant TNF injection. Thus, it was suggested that IT OK-432 immunotherapy might be effective for the local control of tumor growth through the host mediated action, and that, in combination with systemic therapy, may enhance the clinical effects and prolong the survival time in advanced cancer patients.     

The clinical efficacy of intratumoral OK-432 administration in advanced cancer patients

The clinical efficacy of intratumoral (IT) OK-432 immunotherapy in advanced cancer patients was investigated. Furthermore, the infiltration of lymphocyte subsets into the tumor tissues after the IT administration of OK-432 was also immunohistologically examined in order to analyze the mechanism of action of OK-432 immunotherapy. Forty-four patients with advanced cancer were treated with IT OK-432 immunotherapy. Ten KE (1 mg) of OK-432 was given either daily or on every second day and repeated as often as possible, the mean frequency of OK-432 injections being 18.1 +/- 14.5 times, ranging between 5 and 25 administrations. Thirty-one of the 44 patients were evaluable, 3 of whom (9.7 per cent) developed a partial response and 5 (16.1 per cent) a minor response. Intratumoral OK-432 immunotherapy, however, did not necessarily prolong the survival time. Leu 1, 3 and 7 reactive cells infiltrated into the tumor tissues treated by OK-432 injection, more frequently, when compared with cells which had been treated by recombinant TNF injection. Thus, it was suggested that IT OK-432 immunotherapy might be effective for the local control of tumor growth through the host mediated action, and that, in combination with systemic therapy, may enhance the clinical effects and prolong the survival time in advanced cancer patients.     

Significance of perioperative nutritional support and activation of the reticuloendothelial system on the resection of the cirrhotic liver

The cirrhotic patients were in poor nutritional condition and deteriorated reticuloendothelial function, which were further aggravated after hepatic resection. Preoperative nutritional repletion treatment as well as preoperative administration of OK-432 improved the nutritional condition and reticuloendothelial function of the patients, resulting in uneventful postoperative courses. In experimentally induced liver cirrhosis, however, an excessive amount of glucose administration in the early postoperative period induced the reduction of hepatic energy charge and ATP content. An adequate amount of glucose should be administered in a period associated with marked glucose intolerance. To determine daily glucose disposal rate rapidly, blood glucose curve obtained from intravenous glucose tolerance test (IVGTT) and insulin tolerance test (ITT) was analyzed in hepatectomized cirrhotic rats. It was possible to calculate prospected values of glucose disposal rate by the analytic index of IVGTT and ITT. An adequate perioperative nutritional support and the activation of the reticuloendothelial system are thought to have important therapeutic value to prevent complications of liver cirrhosis after resection.     

Polymorphonuclear leukocyte function and serum opsonic activity in surgical patients

Thirty-six patients who underwent major surgery were studied in order to clarify the perioperative changes in polymorpho-nuclear leukocyte (PMNL) function and serum opsonic activity. In patients without postoperative infection, the PMNL phagocytic-bactericidal capacity and plasma elastase levels significantly increased, while the serum opsonic index remarkably decreased just after surgery, however, all returned to the preoperative levels within 1 or 2 weeks. Conversely, in patients with postoperative infection, the PMNL bactericidal capacity and plasma elastase levels remained at high levels even after 1 or 2 weeks, while the PMNL phagocytic capacity and serum opsonic index substantially decreased after 2 weeks compared with the patients without postoperative infection. Plasma leukotriene B₄, which is a potent chemo-attractant for PMNL, noticeably decreased in the patients with postoperative infection on the first postoperative day compared with that in the patients without postoperative infection. Our data suggests that the most important predisposing factors to postoperative infection may be a depressed PMNL phagocytic capacity and a lower serum opsonic activity after surgery, and that the increased PMNL bactericidal capacity and high plasma elastase levels during postoperative infection may contribute to the susceptibility to multiple organ failure.     

Reticulo-endothelial function in obstructive jaundice

A study of reticulo-endothelial function was performed in 30 patients with obstructive jaundice. Reticulo-endothelial phagocytic function, measured by the clearance of intravenous human micro-aggregated albumin, was significantly depressed in jaundiced patients compared with non-jaundiced controls (P less than 0.001). There was a significant correlation (P less than 0.001) between phagocytic function and plasma bilirubin level but not with transaminase or bile salt level. Phagocytic function was not related to the presence of malignancy, but was markedly reduced in patients with cholangitis. There was no reduction in hepatic sinusoidal blood flow, opsonin levels (fibronectin, IgG, complement) or serum opsonic activity to account for the reticulo-endothelial dysfunction.     

Prevention of Liver Reticuloendothelial Systemic Host Defense Failure after Surgery by Intravenous Opsonic Glycoprotein Therapy

Depression of the reticuloendothelial system (RES) was observed in rats following operative trauma consisting of laparotomy and jejunal enterotomy. This RES depression was manifested as a significant impairment in the phagocytic clearance of intravenously injected blood-borne test colloid mediated by a decline in hepatic Kupffer cell phagocytosis. Reticuloendothelial systemic host defense depression was correlated with a significant decline in bioassayable and immunoreactive opsonic α₂SB glycoprotein concentration over a 1-3 hr postoperative period with rebound elevation in opsonic activity by 24 hr postsurgery. Intravenous administration of purified opsonic α₂SB glycoprotein at the end of the operation prevented postoperative opsonic deficiency and restored normal hepatic RES phagocytic function. These studies coupled with previous observations in patients following surgery or after severe multiple trauma suggest that reticuloendothelial depression during and after operation mediated by opsonic deficiency may lead to a precarious imbalance between systemic host defense and the dissemination of blood-borne foreign and effete particulate matter such as injured platelets, fibrin microaggregates and immune complexes. Immunoreactive serum opsonic α₂SB glycoprotein determinations may serve as a valuable index of hepatic RE clearance capacity and opsonin therapy may potentially be a selective means to augment systemic host defense.     

Oversaturation Status of Reticuloendothelial System Following Cardiopulmonary Bypass

Abstract: In the past, it was generally believed that the phagocytic function of the reticuloendothelial system (RES) was depressed after cardiopulmonary bypass (CPB), but several investigators reported differing results. Therefore, this study was performed to determine the effect of CPB on RES function, experimentally and clinically. Six dogs undergoing CPB (CPB group) were compared with an identical number of dogs subjected to thoracotomy without CPB (control group). A lipid emulsion test was performed in all dogs before and after the surgical procedure to measure RES phagocytic function. Any ultrastructural changes in Kupffer cells were observed by electron microscopy. In both groups, the RES phagocytic index showed a significant decline after surgery. However, comparison of the 2 groups revealed that there was a significantly greater decrease in the CPB group (p < 0. 05). Electron microscopy of the Kupffer cells showed that the number of phagosomes, especially those containing deformed erythrocytes, increased after CPB. Twenty patients undergoing cardiac surgery requiring CPB (Group A) and 8 patients undergoing pulmonary resection (Group B) were studied. RES phagocytic function was determined 3 days prior to surgery and 3 days postoperatively using the lipid emulsion test. No significant difference was observed in the preoperative phagocytic indices between the 2 groups. The phagocytic function remained almost unchanged in Group A on the third postoperative day, compared with the preoperative value, but it increased significantly in Group B on the third postoperative day, compared with the preoperative value. The intergroup difference was significant on the third postoperative day (p < 0. 01). These findings suggest that phagocytic activities of RES are not depressed but stimulated by CPB and that the phagocytic ability of RES is saturated by formed microparticles after CPB, such as residual of hemolyzed erythrocytes, protein aggregates, and microbubbles, among others. “Depressed RES phagocytic function” after CPB may not be a proper expression of this situation. It should be considered that the status of RES function after CPB is not functionally depressed but functionally oversaturated.     

The three different phases of reticuloendothelial system phagocytic function in rats with liver injury

In the present study, reticuloendothelial system (RES) phagocytic function of rats with partial hepatectomy or experimentally induced liver cirrhosis was investigated by determining the phagocytic index, the opsonic index, and uptake rate in liver, spleen, and lung of a 51Cr-labeled endotoxin-injected rat. In both the partially hepatectomized and the cirrhotic rats, all three indicators varied markedly according to the elapsed period since liver injury. The changes in RES phagocytic function were classified into three different phases: compromised, compensatory, and enhanced. The compromised phase, consisting of a decrease in the phagocytic index, was observed during the first 24 hr after 67% hepatectomy and in advanced liver cirrhosis. This represented the failure of RES phagocytic function. The compensatory phase, in which the phagocytic index was maintained at nearly normal levels mainly by a compensatory enhancement in the opsonic index, was seen during the first to second postoperative day and in moderate liver cirrhosis. The enhanced phase, with a high phagocytic index, was observed from Day 4 to approximately Day 14 after surgery, and in the cases of mild liver damage. In the compromised and compensatory phases, the liver uptake rate was significantly decreased compared with the control. However, the uptake in the spleen and lung were markedly increased. In conclusion, the phagocytic function of the RES was significantly affected to a degree which changed with the extent of liver damage.     

Antitumor effect of direct intra-tumor administration of OK-432 on malignant glioma: basic and clinical observations

In this study, we tried to examine the efficacy of a cytotoxic factor which is induced by periodic, repeated local administration of OK-432 into the tumor cavity of malignant glioma patients. OK-432 was administered intratumorally via a tube to 4 malignant glioma patients on Days 1, 3, 5, 7 and 12 in doses of 0.5 KE, 1 KE, 2 KE, and 3 KE, respectively. Cerebrospinal fluid (CSF) was collected several times during the 24-hour period beginning immediately after the administration on Day 12. The CSF was added to the culture medium of rat glioma cells (GA-1 and C-6) in order to observe the cytotoxic effect morphologically. The clinical efficacy in the patients was evaluated from the changes in tumor size observed by CT. CSF collected from the tumor cavity of 3 patients was bloody. By adding this bloody CSF, a significant morphological cytotoxic effect was observed on both the GA-1 and C-6 glioma cells in culture. The level of cytotoxicity was higher with the bloody fluid collected at 4 to 24 hours after the final administration than with the bloody fluid collected immediately after the final administration. The cytotoxic effect of this fluid was stronger than that of rabbit TNF (tumor necrosis factor) serum induced with P. acnes and LPS.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute liver failure in rats inhibited by intrasplenic administration of OK-432

Intrasplenic administration of OK-432, an immunostimulant derived from Streptococcus, prevented hepatic failure induced in rats by D-galactosamine. When OK-432 was given 1.0 K.E. (Group I) or 0.1 K.E. (Group II) into the subcutaneously transpositioned spleen three times prior to dosing with D-galactosamine, survival rates were 100 and 87%, respectively. On the contrary, with a splenic injection of saline (Group III), the survival rate was 47 and 32% in rats given OK-432 1.0 K.E. intraperitoneally (Group IV). The poisoned rats given no pretreatment (Group V) survived at a rate of 26%. These results show that intrasplenic administration of OK-432 leads to a significant enhancement of survival. Metabolic data and histological findings were compatible with survival rates, in each group. Activation of the reticuloendothelial function by the intrasplenic administration of this immunostimulant seems to have prevented acute liver failure.     

Correlation between anti-tumor effect and delayed hypersensitivity induced by topically applied OK-432 with histological findings

Delayed hypersensitivity (DH) against OK-432 was induced in BALB/c mice by injecting 2 KE of OK-432 with Freund's incomplete adjuvant into foot pads. One week after presensitization with OK-432, 2 X 10(5) cells of Meth A tumor were implanted subcutaneously in all mice, followed by intratumoral injection of 1 KE of OK-432 five times every other day starting at 7th day in experimental group. Tumor growth was significantly inhibited in the OK-432 presensitized group comparing to non-sensitized group. In experimental groups marked inhibition was observed in mice which were injected with OK-432 intratumorally 2 to 3 weeks after presensitization. This effect correlated well with delayed hypersensitivity against OK-432. Histological changes after intratumoral injection of OK-432 were examined in order to analyse the mechanism of this effect. The main finding of OK-432 injected specimen by H.E. staining were degeneration of tumor cells and infiltration of inflammatory cells. These changes were stronger in OK-432 presensitized mice. By beta-D-galactosidase staining accumulation of macrophages was found both inside the tumor and the surrounding tissue, and these macrophages increased in OK-432 presensitized mice. Immunoperoxidase staining with antiasialo GM1 anti-serum was also performed. Greater number of activate macrophages were observed to accumulate in the specimen of OK-432 presensitized mice than that of control mice. Some T cells were observed only around tumor tissues and not in the tumor of both presensitized and unsensitized mice. These results suggest that the activated macrophages play a major role in the augmentation of antitumor effect by presensitization with OK-432.     

Anti-tumor effects of the oral administration of the streptococcal preparation OK-432 (PICIBANIL)--the inhibition of carcinogenesis and growth in rats with ENNG-induced gastrointestinal tumors

We examined whether the Streptococcal preparation OK-432, an immunopotentiating agent, increases immunocompetence of the gut-associated lymphoid system (GALS), inhibits gastrointestinal carcinogenesis, and has an anti-tumor effect. 14C-labelled OK-432 was orally and intraperitoneally administered to rats, and the distribution of the agent in various organs then serially evaluated. The concentration of OK-432 in Peyer's patches and mesenteric lymph nodes was higher after oral administration than after intraperitoneal administration, and showed a biphasic pattern peaking at 30 minutes and 5 hours following administration, in the Peyer's patches. With regard to immunocompetence, PHA- and PWM-stimulated blastogenesis of lymphocytes derived from the mesenteric lymph nodes and peripheral blood enhanced, and the helper/suppressor T-cell ratio was elevated after the oral administration of OK-432. Moreover, chemotactic activity of peritoneal macrophages was also increased. ENNG-induced gastrointestinal carcinogenesis was observed in 60 per cent of the rats orally administered OK-432 as compared with 88 per cent of the controls. The 13-month survival rate of the rats with gastrointestinal cancer was 50 per cent in those administered OK-432 as compared with 25 per cent in those administered OK-432 as compared with 25 per cent in the controls. When administered orally, the agent prevented reduction in immuno-competence in the course of carcinogenesis, suppressed carcinogenesis, and prolonged the survival of animals with cancer without any of the side effects associated with injection. The oral administration of OK-432 is thus considered to be an effective non-specific immunotherapy against gastro-intestinal malignancies.