Himmelreich, G.

Jochum, Marianne

Machleidt, W.

Riess, H.

Slama, R.

Steffen, R.

English

Universität München: Elektronischen Publikationen

TRANSPLANTATION PROCEEDINGS 
An Official Publication of The Transplantation Society 
The Japan Society for Transplantation · The Hellenic Transplantation Society 
The European Society for Transplantation · The Canadian Transplantation Society 
The Transplantation Society of Australia and New Zealand 
The Scandinavian Transplantation Society · The Latin American Transplantation Society 
The Pan-American Society for Dialysis & Transplantation · The Society for Organ Sharing 
The Catalan Transplantation Society · The Asian Transplantation Society 
VOL ΧΧΙΠ, NO 1 
Possible Role of the Phagocytic Proteinases, Cathepsin Β and 
Elastase, in Orthotopic Liver Transplantation 
H. Riess, M. Jochum, W. Machleidt, G. Himmelreich, R. Slama, and R. Steffen 
PREVIOUS studies have suggested that disseminated intravascular coagulation (DIC) is a causal factor for 
bleeding complications during orthotopic liver transplan­
tation (OLT). It seems likely that inflammatory mediators 
(eg, proteinases of phagocytes) in the perfusate released by 
the grafted liver may enter the circulation and induce the 
deterioration in hemostasis. The aims of our study were (1) 
to prove the presence of the cystein proteinase cathepsin Β 
from macrophages and the serine proteinase elastase from 
granulocytes in liver graft perfusate and (2) to evaluate the 
correlation of these proteinases with coagulopathy in OLT. 
MATERIALS AND METHODS 
Between August and November 1989, 10 consecutive patients 
undergoing primary O L T were studied. They received packed red 
blood cells (RBC) and fresh frozen plasma (FFP) , but neither 
platelets nor concentrates of coagulation factors. Eight blood 
samples were collected: (1) preoperatively, (2) 5 minutes before 
and (3) 10 minutes after removal of the liver, (4) 5 minutes before 
and (5) 5 minutes, (6) 15 minutes, (7) 1 hour, and (8) 12 hours after 
reperfusion of the liver graft. In addition, a sample of the perfusate 
was obtained after flushing of the graft with systemic blood. 
Antigen levels of D-dimer, thrombin-antithrombin Ill-complex 
(TAT) , von Willebrand factor (vWF), and elastase (in complex 
with alpha I-protease inhibitor, E P I ) , as well as activities of 
fibrinogen, protein C, änlithroffibifl III (AT III), CrinhibitGT, and 
cathepsin Β were determined. Wilcoxon's rank-sum test was used 
to analyze the data. Ρ values < .05 were considered to be 
significant. 
RESULTS 
Levels of νWF and fibrinogen were lower in the perfusate 
samples than in the corresponding plasma specimen, col­
lected 5 minutes before reperfusion of the graft (Table 1). 
Table 1. Coagulation Profiles of Venous Blood (5 minutes 
Before Reperfusion) and Perfusate 
Before Reperfusion Perfusate 
Mean Range Mean Range 
vWF (%) 317 94^05 275 3G-446 
Fibrinogen (g/L) 1.9 1.1-2.7 1.5* 0.5-2.2 
AT III (%) 66 35-89 38* 26-56 
(^-inhibitor (%) 78 55-107 64* 27-92 
Protein C (%) 27 8-54 10* 0-24 
TAT (ng/mL) 59 15-270 121* 10-324 
D-dimer (mg/L) 1.7 0-4.0 3.3 0-16.0 
EPI (ng/mL) 452 231-766 553 136-904 
Cathepsin Β (U/mL) 0.2 0.1-0.2 27.6* 7.0-75.8 
*P < .05 compared with the value of venous blood sample. 
mU/ l (cath .B) , ng/ml (EPI ) (TAT) ng/ml 
1 2 3 4 5 6 7 8 
1 - 8: number of s a m p l e , ^ r e p e r f u s i o n 
Fig 1. Concentrations of cathepsin B, thrombin-antithrombin 
complex (TAT), and elastase alpha 1-protease inhibitor complex 
(EPI) during orthotopic liver transplantation. 
These differences, however, were significant only for 
fibrinogen. In addition, the activities of AT I I I , protein C, 
and C,-inhibitor were significantly reduced in the perfus­
ate. On the other hand, levels of TAT and D-dimer 
(indicating activated coagulation), as well as EPI and 
cathepsin Β (indicators of activated phagocytes) in the 
perfusate, were significantly increased (Table 1). Plasma 
levels of cathepsin Β remained unchanged until the reper­
fusion phase. At that time a significant increase in the 
extracellularly released phagocytic proteinase cathepsin Β 
was evident. EPI plasma levels increased steadily for up to 
60 minutes after reperfusion. At the end of the observation 
period the plasma concentrations of both phagocytic en­
zymes—especially of EPI—were significantly greater than 
the preoperative levels (Fig 1). TAT level slowly increased 
during the anhepatic phase but showed a highly significant 
increase, reaching its maximal level 15 to 60 minutes after 
reperfusion followed by a decrease to the preoperative 
level 12 hours after reperfusion (Fig 1). 
From the Departments of Internal Medicine (H.R., G.H.) and 
Surgery (R.S.), and the Institute of Anesthesiology (R.S.), Univer­
sity Hospital Rudolf Virchow, Berlin; the Department of Clinical 
Chemistry and Clinical Biochemistry (M.J.), Surgical Clinic; and 
the Department of Physiological Chemistry (W.M.), University of 
Munich, Germany. 
Address reprint requests to Priv Doz Dr H. Riess, UKRV-C, 
Spandauer Damm 130, D-1000 Berlin 19, Germany. 
© 1991 by Appleton & Lange 
0041-1345/91 /$3.00/+0 
Transplantation Proceedings, Vol 23, No 3 (June), 1991: pp 1947-1948 1947 
1948 RIESS, JOCHUM, MACHLEIDT ET AL 
DISCUSSION 
Flushing of the liver graft removes most, but not all, of the 
preservation fluid. This is demonstrated by the decreased 
levels of coagulation proteins in the perfusate compared 
with those in the systemic circulation. On the other hand, 
significantly elevated levels of phagocytic proteinases, 
well known as potent inflammatory mediators, were found 
in the perfusate, and they may enter the systemic circula­
tion. Cathepsin Β is an effective lysosomal cysteine pro­
teinase of broad specificity, without an adequate inhibitory 
potential in plasma.1 The release of cathepsin Β from the 
liver macrophages, reflected by the excessive elevation in 
the perfusate, results in a steep and sustained increase in 
cathepsin Β activity in plasma. Therefore, cathepsin Β 
may play an important role in the activation and consump­
tion of plasma factors and may be responsible for the 
decompensation of preexisting low-grade DIC. Elastase, a 
lysosomal proteinase from granulocytes,2 may be released 
from such cells still sticking in the liver graft vessels. On 
the other hand, the protracted increase in EPI may reflect 
an ongoing inflammation response of leukocytes entering 
the operative field and liver graft. Activation of the coag­
ulation system, demonstrated by the highly significant 
increases in TAT (Fig 1) and fibrin monomers and D-dimer 
(not shown), as well as the pronounced decrease in the 
activities of the coagulation inhibitors, is consistent with 
the hypothesis that the coagulation system becomes fur­
ther activated by mediators released from the liver graft. 
REFERENCES 
1. Katunuma N, Kominami E : In Weber G (ed): Advances in 
Enzyme Regulation. Oxford: Pergamon Press, 1985, ρ 159 
2. Fritz H , Jochum M, Duswald K H , et al: In Goldberg D M , 
Werner Μ (eds): Selected Topics in Clinical Enzymology. New 
York: Walter de Gruyter, 1984, ρ 306 


Possible role of the phagocytic proteinases, cathepsin B and elastas, in orthotopic liver transplantation

Open Access LMU

TRANSPLANTATION PROCEEDINGS An Official Publication of The Transplantation Society The Japan Society for Transplantation · The Hellenic Transplantation Society The European Society for Transplantation · The Canadian Transplantation Society The Transplantation Society of Australia and New Zealand The Scandinavian Transplantation Society · The Latin American Transplantation Society The Pan-American Society for Dialysis & Transplantation · The Society for Organ Sharing The Catalan Transplantation Society · The Asian Transplantation Society VOL ΧΧΙΠ, NO 1 Possible Role of the Phagocytic Proteinases, Cathepsin Β and Elastase, in Orthotopic Liver Transplantation H. Riess, M. Jochum, W. Machleidt, G. Himmelreich, R. Slama, and R. Steffen PREVIOUS studies have suggested that disseminated intravascular coagulation (DIC) is a causal factor for bleeding complications during orthotopic liver transplan­tation (OLT). It seems likely that inflammatory mediators (eg, proteinases of phagocytes) in the perfusate released by the grafted liver may enter the circulation and induce the deterioration in hemostasis. The aims of our study were (1) to prove the presence of the cystein proteinase cathepsin Β from macrophages and the serine proteinase elastase from granulocytes in liver graft perfusate and (2) to evaluate the correlation of these proteinases with coagulopathy in OLT. MATERIALS AND METHODS Between August and November 1989, 10 consecutive patients undergoing primary O L T were studied. They received packed red blood cells (RBC) and fresh frozen plasma (FFP) , but neither platelets nor concentrates of coagulation factors. Eight blood samples were collected: (1) preoperatively, (2) 5 minutes before and (3) 10 minutes after removal of the liver, (4) 5 minutes before and (5) 5 minutes, (6) 15 minutes, (7) 1 hour, and (8) 12 hours after reperfusion of the liver graft. In addition, a sample of the perfusate was obtained after flushing of the graft with systemic blood. Antigen levels of D-dimer, thrombin-antithrombin Ill-complex (TAT) , von Willebrand factor (vWF), and elastase (in complex with alpha I-protease inhibitor, E P I ) , as well as activities of fibrinogen, protein C, änlithroffibifl III (AT III), CrinhibitGT, and cathepsin Β were determined. Wilcoxon's rank-sum test was used to analyze the data. Ρ values < .05 were considered to be significant. RESULTS Levels of νWF and fibrinogen were lower in the perfusate samples than in the corresponding plasma specimen, col­lected 5 minutes before reperfusion of the graft (Table 1). Table 1. Coagulation Profiles of Venous Blood (5 minutes Before Reperfusion) and Perfusate Before Reperfusion Perfusate Mean Range Mean Range vWF (%) 317 94^05 275 3G-446 Fibrinogen (g/L) 1.9 1.1-2.7 1.5* 0.5-2.2 AT III (%) 66 35-89 38* 26-56 (^-inhibitor (%) 78 55-107 64* 27-92 Protein C (%) 27 8-54 10* 0-24 TAT (ng/mL) 59 15-270 121* 10-324 D-dimer (mg/L) 1.7 0-4.0 3.3 0-16.0 EPI (ng/mL) 452 231-766 553 136-904 Cathepsin Β (U/mL) 0.2 0.1-0.2 27.6* 7.0-75.8 *P < .05 compared with the value of venous blood sample. mU/ l (cath .B) , ng/ml (EPI ) (TAT) ng/ml 1 2 3 4 5 6 7 8 1 - 8: number of s a m p l e , ^ r e p e r f u s i o n Fig 1. Concentrations of cathepsin B, thrombin-antithrombin complex (TAT), and elastase alpha 1-protease inhibitor complex (EPI) during orthotopic liver transplantation. These differences, however, were significant only for fibrinogen. In addition, the activities of AT I I I , protein C, and C,-inhibitor were significantly reduced in the perfus­ate. On the other hand, levels of TAT and D-dimer (indicating activated coagulation), as well as EPI and cathepsin Β (indicators of activated phagocytes) in the perfusate, were significantly increased (Table 1). Plasma levels of cathepsin Β remained unchanged until the reper­fusion phase. At that time a significant increase in the extracellularly released phagocytic proteinase cathepsin Β was evident. EPI plasma levels increased steadily for up to 60 minutes after reperfusion. At the end of the observation period the plasma concentrations of both phagocytic en­zymes—especially of EPI—were significantly greater than the preoperative levels (Fig 1). TAT level slowly increased during the anhepatic phase but showed a highly significant increase, reaching its maximal level 15 to 60 minutes after reperfusion followed by a decrease to the preoperative level 12 hours after reperfusion (Fig 1). From the Departments of Internal Medicine (H.R., G.H.) and Surgery (R.S.), and the Institute of Anesthesiology (R.S.), Univer­sity Hospital Rudolf Virchow, Berlin; the Department of Clinical Chemistry and Clinical Biochemistry (M.J.), Surgical Clinic; and the Department of Physiological Chemistry (W.M.), University of Munich, Germany. Address reprint requests to Priv Doz Dr H. Riess, UKRV-C, Spandauer Damm 130, D-1000 Berlin 19, Germany. © 1991 by Appleton & Lange 0041-1345/91 /$3.00/+0 Transplantation Proceedings, Vol 23, No 3 (June), 1991: pp 1947-1948 1947 1948 RIESS, JOCHUM, MACHLEIDT ET AL DISCUSSION Flushing of the liver graft removes most, but not all, of the preservation fluid. This is demonstrated by the decreased levels of coagulation proteins in the perfusate compared with those in the systemic circulation. On the other hand, significantly elevated levels of phagocytic proteinases, well known as potent inflammatory mediators, were found in the perfusate, and they may enter the systemic circula­tion. Cathepsin Β is an effective lysosomal cysteine pro­teinase of broad specificity, without an adequate inhibitory potential in plasma.1 The release of cathepsin Β from the liver macrophages, reflected by the excessive elevation in the perfusate, results in a steep and sustained increase in cathepsin Β activity in plasma. Therefore, cathepsin Β may play an important role in the activation and consump­tion of plasma factors and may be responsible for the decompensation of preexisting low-grade DIC. Elastase, a lysosomal proteinase from granulocytes,2 may be released from such cells still sticking in the liver graft vessels. On the other hand, the protracted increase in EPI may reflect an ongoing inflammation response of leukocytes entering the operative field and liver graft. Activation of the coag­ulation system, demonstrated by the highly significant increases in TAT (Fig 1) and fibrin monomers and D-dimer (not shown), as well as the pronounced decrease in the activities of the coagulation inhibitors, is consistent with the hypothesis that the coagulation system becomes fur­ther activated by mediators released from the liver graft. REFERENCES 1. Katunuma N, Kominami E : In Weber G (ed): Advances in Enzyme Regulation. Oxford: Pergamon Press, 1985, ρ 159 2. Fritz H , Jochum M, Duswald K H , et al: In Goldberg D M , Werner Μ (eds): Selected Topics in Clinical Enzymology. New York: Walter de Gruyter, 1984, ρ 306 

et al: In Goldberg DM, Werner Μ (eds): Selected Topics in Clinical Enzymology.

Kominami E: In Weber G (ed): Advances in Enzyme Regulation.

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Possible role of the phagocytic proteinases, cathepsin B and elastas, in orthotopic liver transplantation

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