Stem cells have the capability of forming different types of cells in our body. In this project, their role in treatment Liver Cirrhosis as a replacement of organ transplant is emphasized.

By

Acknowledgements

I am highly indebted Mrs. for her guidance and constant supervision as well as for providing necessary information regarding the project & also for her support in completing the project.I would also like to thank my parents for their support.

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Certificate of Appreciation

I,*** , certify that the project is authentic in its entirety and was completed under my constant supervision by **

Mrs. ***

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IndexSerial No.

Title Page No.

1 Liver Cirrhosis- Questions We come across

5

2 What Is Liver Cirrhosis? 73 Causes 84 Symptoms 95 Is transplant the only

option?11

6 Success of Live transplant 147 Mechanism 168 Search For Donors 199 Limitations 2110 Stem Cells: Definition 2211 Importance 2312 Types 2413 Source 2514 Liver Regeneration 2715 Cell Based Strategies 2916 Different Types of cells

used in Stem Cell therapy31,33,35-37

17 Stem Cell Therapy 3718 Overview 3819 Stem Cell Research Data 39-4120 Case Study-9 year old

requiring immediate transplant.

42-44

21 Summery & Conclusion 45

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22 Bibliography 46-47

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Questions we come across.

What is Liver

Cirrhosis?

Causes?

How does it affect the

individual?

Symptoms

Feasibility of

Transplant

Is transplant the only option?

Normal Liver

Cirrhotic Liver

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What is Liver Cirrhosis?

Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver.

How does it affect the individual

Cirrhosis affect's the liver's ability to:control infectionsremove bacteria and toxins from the bloodprocess nutrients, hormones, and drugsmake proteins that regulate blood clottingproduce bile to help absorb fats—including cholesterol—and fat-soluble vitaminsAlso Increases the pressure in portal venous system.

Causes of liver cirrhosis

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Hepatitis C Virus

Long term Alcohol abuse

Autoimmune inflammatio

n of liver

Hepatitis B Virus

Metabolic Diseases of Copper -Wilson's

DiseaseIron-

Hemochromatosis

Nonalcoholic fatty liver

disease(NAFLD)

Nonalcoholic Steatohepati

tis(NASH)

Reaction to certain

Medicines.

Symptoms may develop gradually, or there may be no symptoms.When symptoms do occur, they can include:

Abdominal indigestion or pain Confusion or problems thinking Impotence, loss of interest in sex, and breast

development (gynecomastia) in men Nausea and vomiting Ascites(Ascites is excess fluid in the space

between the tissues lining the abdomen and abdominal organs (the peritoneal cavity).

Nosebleeds or bleeding gums Pale or clay-colored stools Small, red spider-like blood vessels on the

skin Vomiting blood or blood in stools

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Symptoms

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Ascites

In early stages, no. Following changes in life style may slow down the progression of the disease. Stop drinking alcohol. Get vaccinated for hepatitis A and hepatitis B, and

pneumococcal pneumonia Tell your doctor about all prescription and

nonprescription medications, and any herbs and supplements you take now or are thinking of taking.

Other treatment options are available for the complications of cirrhosis:

Bleeding varices -- upper endoscopy with banding and sclerosis

Excess abdominal fluid (ascites) -- take diuretics, restrict fluid and salt, and remove fluid (paracentesis)

Confusion or encephalopathy -- lactulose medication and antibiotics

But in end stages,yes, Liver transplant is the only viable option.

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Is liver transplant the only option?

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The liver is the second most commonly transplanted major organ, after the kidney, so it is

clear that liver disease is a common and serious problem in this country. It is important for liver

transplant candidates and their families to understand the basic process involved with liver transplants, to appreciate some of the challenges

and complications that face liver transplant recipients (people who receive livers), and to

recognize symptoms that should alert recipients to seek medical help.

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Success of liver transplant procedures

Liver transplantation has in the past few years evolved from a semi-experimental procedure practiced in only a few European and North American centers to an almost routine worldwide treatment for a whole range of liver diseases.The number of cases saw a huge jump especially in India and other south asian countries.Concurrently, one year survival has improved from less than 50% to more than 90% for certain diagnoses such as biliary atresia, most survivors being able to resume a normal lifestyle. The rate of liver graft loss beyond one year is much lower than for renal and other grafts. Although the surgery and immediate postoperative care are confined to specialist units, further follow up is often undertaken in the patient's local hospital and so more and more clinicians and pathologists are coming into contact with this group of patients.The large majority of liver transplants use the entire liver from a non-living donor for the transplant, particularly for adult recipients.

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Basic m echanism of liver transplantaion

Virtually all liver transplants are done in an orthotopic fashion, that is, the native liver is rem oved and the new liver is placed in the sam e anatom ic location. The transplant operation can be conceptualized as consisting of the hepatectom y (liver rem oval) phase, the anhepatic (no liver) phase, and the postim plantation phase. The operation is done through a large incision in the upper abdom en. The hepatectom y involves division of all ligam entous attachm ents to the liver, as well as the com m on bile duct, hepatic artery, hepatic vein and portal vein. The donor's blood in the liver w ill be replaced by an ice-cold organ storage solution, such as UW (Viaspan) or HTK until the allograft liver is im planted. Im plantation involves anastom oses (connections) of the inferior vena cava, portal vein, and hepatic artery. After blood flow is restored to the new liver, the biliary (bile duct) anastom osis (link) is constructed, either to the recipient's own bile duct or to the sm all intestine.

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Hepatocytes- Normal Liver Cells

Liver Cirrhosis at 40x Magnification

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The search for a donor

Once a person is accepted for transplantation, the search for a suitable donor begins. All people waiting are placed on a central list at UNOS. Local and national agencies are involved in finding suitable livers. The United States has been divided into regions to try to fairly distribute this scarce resource. Many donors are victims of some sort of trauma and have been d eclared brain dead. A donor with the right blood type and similar body weight is sought to help reduce the risk of rejection. Rejection occurs when the patient's body attacks the new liver.With the shortage of donor organs and the need to match donor and patient blood and body type, the waiting time may be long. A patient with a very common blood type has less chance of quickly finding a suitable liver because so many others with his or her blood type also need livers.Thus we see that transplantation is not the best possible treatment for Liver Cirrhosis.

Diagrammatic representation of liver transplantation.

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Limitations Of Liver Transplantation.

Lifelong ImmunosuppressionCostAvailabilityShortage of donorsHigh mortality during waiting period

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Definition

Stem cells are biological cells found in all multicellular organisms, that can divide (through mitosis) and differentiate into diverse specialized cell types and can self-renew to produce more stem cells.

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Importance

They are capable of forming most of the cells in our body and thus can be used in replacement of dead/ non-functional cells and can miracuosly save individuals who might be paralysed for life.

Types of Stem Cells

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Totipotent

Can construct a complete, viable organismEg.cells of first few divisions of fertillised egg.

PluripotentCan form most of the cells.Eg. cells obtained from the three germ layers.

MultipotentCan diffrentiate into a number of cells but belong to a similar family of cells.Eg. cells obtained from liver, Bone Marrow.

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Sources of

Stem Cells

Placenta

Blood

Adipose

TissueBone Marro

w

Foetus

Liver

Umbilical

cord

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Placenta and Embryo- Sources of Totipotent Stem Cells

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L iv e r R e g e n e ra tio n

O n e o f th e d e fi n in g fe a tu re s o f th e liv e r is th e c a p a c ity to m a in ta in a co n s ta n t s ize d e sp ite in ju ry . A lth o u g h th e p re c ise m o le c u la r s ig n a ls in v o lv e d in th e m a in te n a n c e o f liv e r s ize a re n o t c o m p le te ly k n o w n , it is c le a r th a t th e liv e r d e lic a te ly b a la n ce s re g e n e ra tio n w ith o v e rg ro w th . M a m m a ls , fo r e x a m p le , ca n su rv iv e su rg ic a l re m o v a l o f u p to 7 5 % o f th e to ta l liv e r m a ss . W ith in 1 w e e k a fte r liv e r re se c tio n , th e to ta l n u m b e r o f liv e r c e lls is re s to re d . M o re o v e r , liv e r o v e rg ro w th c a n b e in d u ce d b y a v a r ie ty o f s ig n a ls , in c lu d in g h e p a to c y te g ro w th fa c to r o r p e ro x iso m e p ro life ra to rs ; th e liv e r q u ick ly re tu rn s to its n o rm a l s ize w h e n th e p ro life ra tiv e s ig n a l is re m o v e d . O n e o f th e p r im a ry re a so n s fo r th is c o n tro v e rsy is th e u se o f m u ltip le d e fi n it io n s fo r th e h e p a tic s te m ce ll. D e fi n it io n s fo r th e liv e r s te m c e ll in c lu d e th e fo llo w in g :(1 ) ce lls re sp o n s ib le fo r n o rm a l t is su e tu rn o v e r(2 ) ce lls th a t g iv e r ise to re g e n e ra tio n a fte r p a rt ia l h e p a te c to m y ,(3 ) ce lls re sp o n s ib le fo r p ro g e n ito r -d e p e n d e n t re g e n e ra tio n , (4 ) ce lls th a t p ro d u ce h e p a to c y te a n d b ile d u c t e p ith e lia l p h e n o ty p e s in v itro , a n d(5 ) tra n sp la n ta b le liv e r -re p o p u la tin g c e lls .

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Cell based strategies are of two types :1.      Direct infusion of adult /fetal hepatocytes.2.      Infusion of stem cells.

1. Hepatocyte transplant as an alternative a. It has been in use for more than 30 years. However

the problem with hepatocyte transplantation is that of availability of adult/fetal human hepatocytes in adequate numbers. The other problem is that they still require immune-suppression.). Xenogenic hepatocyte transplantation has also been tried however it has got lurking fear of retroviral transmission and tumor genesis.

2. Stem cell therapy as an alternative of liver transplantation

a. Cellular based therapies promise a great future for a variety of diseases involving various organs. It has been used in conditions as diverse as degenerative disorders of musculoskeletal system and CNS, cardiomyopathy and trauma. In liver diseases the stem cells have been utilized in various metabolic genetic diseases with presentation of proof of principle.

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Cells Responsible for Normal LiverTissue Turnover

Hepatocyte replacement occurs relatively slowly; the average life span of adult hepatocytes ranges from 200 to 300 days. A number of different hypotheses have been proposed to explain hepatocyte turnover. In one of the earliest models, called “streaming liver,” normal liver turnover was proposed to be similar to intestinal regeneration, with young hepatocytes originating in the portal zone and then migrating toward the central vein.

Cells That Give Rise to RegenerationAfter Partial HepatectomyCells That Give Rise to Regeneration After Partial Hepatectomy Partial hepatectomy is a surgical procedure in which specific liver lobes are removed intact without damage to the lobes left behind. The process has been extensively studied and is the subject of several excellent reviews. The excised liver lobes never grow back, but the remaining lobes grow to compensate for the mass of the resected tissue. Reconstitution of the entire liver mass, which is complete within 5–7 days in rodents, is mediated by mature cell types (ie, without stem cells).

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Multipotent adult progenitor cells as hepatocyte progenitors

Multipotent adult progenitor cells are a unique population of progenitors from multiple mammalian species that are generated in long-term culture by plating nonhematopoietic adherent cells from the bone marrow.These cells have been reported to have properties similar to embryonic stem cells in that they can be differentiated toward multiple lineages in vitro under the appropriate conditions. When grown on Matrigel with fibroblast growth factor 4 and hepatocyte growth factor, multipotent adult progenitor cells generate hepatocyte-like cells that synthesize urea, secrete albumin, and induce cytochrome p450 in response to phenobarbital.

Amniotic stem cells.

Human amniotic fluid and membranes have been used as sources of pluripotent cells, which are capable of differentiating into endoderm. Specific protocols for the induction of the hepatic phenotype have been developed and are similar to the differentiation regimens used for other progenitors.79 The hepatocyte- like cells that have been generated using the most optimized regimens express cytochrome p450 and other genes that are typical of hepatocytes

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Hepatocytes as Liver-Repopulating Cells

Liver repopulation is unique among organ systems. In contrast to the hematopoietic system, where mature adult blood cells have minimal proliferative capacity, differentiated hepatocytes themselves have high capacity for liver repopulation. First, mature hepatocytes (identified by size fractionation, retroviral marking, or serial transplantation) were transplanted into livers of Fah knockout mice. Large, binucleated hepatocytes that represented 70% of the hepatocyte population were found to mediate most of the liver repopulation.

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Types Of Stem Cells em ployed in Liver transplantation

Basically three typesEm bryonicFetal AdultEm bryonic: Om nipotentCan differentiate into any cell typeLim itations of availability, ethical issuesFetal: TotipotentSource is 20-24 week fetusLim ited supplyADULT HEPATOCYTESM ature hepatocytes : Problem sM aintaining the stability of m etabolic functionDifficulties in cryopreservationIm m unogenicityCannot proliferate in vitro

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Stem C ell therapy

Transplantab le L iver-R epopu lating C ells O ne of the hallm arks of tissue-specific stem cells is the ir capacity to repopu late a specific organ and restore its function . H SC s, for exam ple , w ere identified based on their ab ility to reconstitu te b lood lineages in lethally irrad iated hosts. O ver the past 2 decades, sim ilar assays w ere developed to identify liver stem cells; a sm all num ber of transp lanted donor cells w ere found to engraft in the liver and expand to rep lace 50% of the liver m ass. Such m odels a llow for the rep lacem ent of on ly hepatocytes by transp lanted ce lls. E ff icient repopu lation of the b iliary system has not been reported , but it is possib le to functionally evaluate hepatic stem cell populations based on their capacity for liver repopulation .

Overview:

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Problems with Liver

Transplantation:High cost.(20 lakhs in India)Prolonged and complicated surgery.High mortality , high morbidity and variable success rate.Post transplant immunosupression is a problemRejction can occur.Lack of available of cadaveric livers and/or live related donors.Donor morbidity/ mortality.

Stem Cells overcomes most of

the limitations:Relativity low cost (1.25 lakh)No surgical complications involvedAge is not a barrier100% success rateCases where the patient has died and very rare

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Case Study

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Clinical PresentationNine year old childFever. Jaundice.Blood tests: features of acute hepatitis.Admitted to nursing home.Became drowsy and confused.Referred to Sir Ganga Ram Hospital

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At Sir Ganga Ram Hospital

Comatose.Intubated and put on ventilator.Seizure like movements. Started on medication to prevent seizures.Panel of blood tests sent.Met criteria for liver transplantation.Less than 10% chance of surviving without liver transplant.Family counseled.

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During the SurgeryLow Hb (5 g/dl) due to blood loss or breakdown of blood cells.Low BP requiring repeated injections of medicines to maintain BP.“Toxic” liver removed rapidly.Shunt procedure performed.Donor liver split. Left lobe removed.

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RecoveryLiver function rapidly returned to normal.Slow return to consciousness.Severe asymmetric weakness which slowly resolved.Seizure like movements which turned out to be due to profund weakness.Taken off the ventilator 6 days after the transplant.Subsequent recovery uneventful.

Summary & Conclusion:

The ability of stem cells to form new hepatocytes has proved to be a boon for patients all over the world suffering from a number of liver related diseases such as Liver Cirrhosis.

In the past, liver transplantation was the only option, but with the help of latest technology and our knowledge of stem cells, we can now use Stem Cell Therapy as a new methodology of curing liver diseases.

In the overview section, we saw how they are beneficial over transplantation and thus we can conclude that stem cells have a bright future not just in hepatology but in a wide variety of fields.

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Bibliography:

Stem Cells and Liver Regeneration- Andrew W. Duncan, Craig Dorrell, Markus Grompe. The copyright is free of charge. http://www.gastrojournal.org/article/S0016-5085%2809%2900818-X/abstract

Www.Wikipedia. com –some basic definitons

http://www.microscopyu.com/galleries/pathology/ index.html image of cirrhotic liver cell.

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http://www.vivo.colostate.edu/hbooks/pathphys/ digestion/liver/histo_glycopas.jpg image of normal liver cell

http://liver-transplantation.blogspot.com/ diagram of liver transplantation.

Special thanks to Dr. *** for data and Case Studies.

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