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Stefano MARCHINI

Personale tecnico amministrativo
Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto

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Pubblicazioni

2022 - Challenges in diagnosis and management of acute hepatic porphyrias: from an uncommon pediatric onset to innovative treatments and perspectives [Articolo su rivista]
Marcacci, Matteo; Ricci, Andrea; Cuoghi, Chiara; Marchini, Stefano; Pietrangelo, Antonello; Ventura, Paolo
abstract

Acute hepatic porphyrias (AHPs) are a family of four rare genetic diseases resulting from a deficiency in one of the enzymes involved in heme biosynthesis. AHP patients can experience potentially life-threatening acute attacks, characterized by severe abdominal pain, along with other signs and symptoms including nausea, mental confusion, hyponatraemia, hypertension, tachycardia and muscle weakness. Some patients also experience chronic manifestations and long-term complications, such as chronic pain syndrome, neuropathy and porphyria-associated kidney disease. Most symptomatic patients have only a few attacks in their lifetime; nevertheless, some experience frequent attacks that result in ongoing symptoms and a significant negative impact on their quality of life (QoL). Initial diagnosis of AHP can be made with a test for urinary porphobilinogen, -aminolaevulinic acid and porphyrins using a single random (spot) sample. However, diagnosis is frequently missed or delayed, often for years, because the clinical symptoms of AHP are non-specific and mimic other more common disorders. Delayed diagnosis is of concern as some commonly used medications can trigger or exacerbate acute attacks, and untreated attacks can become severe, potentially leading to permanent neurological damage or fatality. Other attack triggers include hormonal fluctuations in women, stress, alcohol and low-calorie diets, which should be avoided in patients where possible. For the management of attacks, intravenous hemin is approved, whereas new therapeutic approaches are currently being investigated as a baseline therapy for prevention of attacks and improvement of QoL. Among these, a novel siRNA-based agent, givosiran, has shown very promising results in a recently concluded Phase III trial and has been approved for the management of AHPs. Here, we propose a challenging case study-with a very unusual pediatric onset of variegate porphyria-as a starting point to summarize the main clinical aspects (namely, clinical manifestations, diagnostic challenges, and therapeutic management) of AHPs, with a focus on the latest therapeutic innovations.

2022 - Endothelial Dysfunction in Acute Hepatic Porphyrias [Articolo su rivista]
Ricci, Andrea; Sandri, Gilda; Marcacci, Matteo; Di Pierro, Elena; Granata, Francesca; Cuoghi, Chiara; Marchini, Stefano; Pietrangelo, Antonello; Ventura, Paolo
abstract

Background Acute hepatic porphyrias (AHPs) are a group of rare diseases caused by dysfunctions in the pathway of heme biosynthesis. Although acute neurovisceral attacks are the most dramatic manifestations, patients are at risk of developing long-term complications, several of which are of a vascular nature. The accumulation of non-porphyrin heme precursors is deemed to cause most clinical symptoms. AimWe measured the serum levels of endothelin-1 (ET-1) and nitric oxide (NO) to assess the presence of endothelial dysfunction (ED) in patients with AHPs. Forty-six patients were classified, according to their clinical phenotype, as symptomatic (AP-SP), asymptomatic with biochemical alterations (AP-BA), and asymptomatic without biochemical alterations (AP-AC). Results Even excluding those under hemin treatment, AP-SP patients had the lowest NO and highest ET-1 levels, whereas no significant differences were found between AP-BA and AP-AC patients. AP-SP patients had significantly more often abnormal levels of ED markers. Patients with the highest heme precursor urinary levels had the greatest alterations in ED markers, although no significant correlation was detected. Conclusions ED is more closely related to the clinical phenotype of AHPs than to their classical biochemical alterations. Some still undefined disease modifiers may possibly determine the clinical picture of AHPs through an effect on endothelial functions.

2020 - Clinical and molecular epidemiology of erythropoietic protoporphyria in Italy [Articolo su rivista]
Ventura, Paolo; Brancaleoni, Valentina; Di Pierro, Elena; Graziadei, Giovanna; Macrì, Annelise; Carmine Guida, Claudio; Nicolli, Annamaria; Teresa Rossi, Maria; Granata, Francesca; Fiorentino, Valeria.; Fustinoni, Silvia; Sala, Raffella; Calzavara Pinton, Piergiacomo; Trevisan, Andrea; Marchini, Stefano; Cuoghi, Chiara; Marcacci, Matteo; Corradini, Elena; Sorge, Fiammetta; Aurizi, Caterina; Grazia Savino, Maria; Cappellini, Maria Domenica; Pietrangelo, Antonello
abstract

Background: Erythropoietic protoporphyria (EPP) is a rare inherited disease associated with heme metabolism, characterized by severe life-long photosensitivity and liver involvement. Objectives: To provide epidemiological data of EPP in Italy. Materials and Methods: Prospective/retrospective data of EPP patients were collected by an Italian network of porphyria specialist centres (Gruppo Italiano Porfiria, GrIP) over a 20-year period (1996-2017). Results: In total, 179 patients (79 females) with a clinical and biochemical diagnosis of EPP were assessed, revealing a prevalence of 3.15 cases per million persons and an incidence of 0.13 cases per million persons/year. Incidence significantly increased after 2009 (due to the availability of alfa-melanotide, which effectively limits skin photosensitivity). Mean age at diagnosis was 28 years, with only 22 patients (12.2%) diagnosed ≤10 years old. Gene mutations were assessed in 173 (96.6%) patients; most (164; 91.3%) were FECH mutations on one allele in association with the hypomorphic variant, c.315-48C, on the other (classic EPP), and nine (5.2%) were ALAS2 mutations (X-linked EPP). Only one case of autosomal recessive EPP was observed. Of the 42 different FECH mutations, 15 are novel, three mutations collectively accounted for 45.9% (75/164) of the mutations (c.215dupT [27.2%], c.901_902delTG [11.5%] and c.67 + 5G > A [7.2%]), and frameshift mutations were prevalent (33.3%). A form of light protection was used by 109/179 (60.8%) patients, and 100 (56%) had at least one α-melanotide implant. Three cases of severe acute liver involvement, requiring OLT, were observed. Conclusions: These data define, for the first time, the clinical and molecular epidemiology of EPP in Italy.

2020 - Hyperhomocysteinemia in patients with acute porphyrias: A potentially dangerous metabolic crossroad? [Articolo su rivista]
Ventura, P.; Corradini, E.; Di Pierro, E.; Marchini, S.; Marcacci, M.; Cuoghi, C.; Buzzetti, E.; Pietrangelo, A.
abstract

Background: Acute porphyrias (AP) are characterized by heme deficiency and induction of hepatic 5-aminolevulinate synthase (ALAS1). Hyperhomocysteinemia (HHcy) is associated with endothelial damage, neurotoxicity and increased risk for vascular diseases. Interestingly, both heme biosynthesis and sulphur amino acid metabolism require vitamin B6, (Pyridoxal-phosphate, PLP) an important cofactor of ALAS1 and of cystathionine β-synthase (CBS) and cystathionine γ-lyase (CGL) enzymes that catabolize homocysteine (Hcy). Moreover, heme itself is an important cofactor for CBS. Aim: to assess plasma Hcy status and HHcy main determinants in patients with AP. Materials and methods: A total of 46 patients with AP (31 with Acute Intermittent Porphyria,15 with Variegate Porphyria) were assessed for clinical status (symptomatic vs. asymptomatic), serum Hcy, Cysteine (Cys), Vit.B6, Vit.B12, red blood cell folates and urinary delta-aminolevulinic acid (ALA) and porphobilinogen(PBG) levels (mean of six measurements). Results: Symptomatic AP patients had significantly higher urinary ALA and PBG levels, plasma Hcy, HHcy prevalence and Hcy/Cys ratio when compared to asymptomatic carriers of AP. Even though no significant correlation was observed between ALA/PBG urinary levels and serum Hcy levels, patients with higher levels of ALA and PBG had significantly higher levels of Hcy, a higher prevalence of moderate-to severe HHcy and serum PLP levels below the 25th percentile of a reference assessment with 300 healthy Italian subjects(<45nmol/L). Conclusions: Most patients with symptomatic AP present HHcy resulting from alterations in sulphur amino acid metabolism. HHcy may represent an indirect marker of ALAS1 induction and its prevalence may be suggestive of a role of HHcy in the pathogenesis and/or comorbidities of AP.

2017 - Acute Intermittent Porphyria in a Child with Severe Neuropathy [Articolo su rivista]
Di Pierro, Elena; Granata, Francesca; Rosafio, Cristiano; Marchini, Stefano; Guerra, Azzurra; Brancaleoni, Valentina; Iughetti, Lorenzo; Ventura, Paolo
abstract

Clinical presentation of acute intermittent porphyria before puberty is unusual. We diagnosed the non-erythroid variant form of this disease in a male child, who first presented, at the age of 6 years, with unexplained neurological symptoms and behavioural abnormalities. We also report the successful treatment, and the long-term clinical management.

2016 - HYPERHOMOCYSTEINEMIA AND MTHFR C677T POLYMORPHISM IN PATIENTS WITH PORTAL VEIN THROMBOSIS COMPLICATING LIVER CIRRHOSIS [Articolo su rivista]
Ventura, Paolo; Venturelli, Giorgia; Marcacci, Matteo; Fiorini, Massimo; Marchini, Stefano; Cuoghi, Chiara; Pietrangelo, Antonello
abstract

Background: Portal vein thrombosis (PVT) is serious complication of liver cirrhosis (LC), especially in the presence of hepatocellular carcinoma (HCC). The liver plays a key role in homocysteine (Hcy) metabolism: mild hyperhomocysteinemia (HHcy) has been described in LC. HHcy is a risk factor for deep vein thrombosis. Methylentetrahydrofolate- reductase (MTHFR) C677T polymorphism is the commonest determinant of mild HHcy and has been involved also in cancer development. Aim: To investigate a possible relation between HHcy, MTHFR status, HCC and PVT in patients affected by LC. Materials and methods: 100 patients affected by LC, 38 with (PVT group, 24 with HCC) and 62 without PVT (LC group, 14 with HCC) sex-, age-, liver disease stage and etiology-matched were assessed for thrombophilia, smoking status, plasma Hcy, MTHFRC677T polymorphism and homocysteine-related vitamin status. Results: A higher prevalence of HCC, HHcy and MTHFR TT status was observed in PVT group. No significant difference in vitamin statuswas observed between groups. PatientswithHCC showed significantly higher plasma Hcy and higher prevalence of HHcy than patients without HCC. They had also higher prevalence of MTHFR TT status. In patients with TT status (n = 11) and HCC, 10 had HHcy e 9 had PVT. Conclusions: Mild HHcy is associated to LC may have a role in PVT development and assessment of plasma Hcy may be suggested in patients with LC (especially if complicated by HCC). Association between HCC and MTHFR TT status is intriguing, due the postulated role for this polymorphism in cancer: it may represent a possible link between HCC and PVT.

2015 - Markers of Endothelial Dysfunction in patients with liver cirrhosis with anh without portal hypertension [Abstract in Rivista]
Marcacci, Matteo; Fiorini, Massimo; Marchini, Stefano; Cuoghi, Chiara; Pietrangelo, Antonello; Ventura, Paolo
abstract

Studio sulla determinazione qualitativa e quantitativa dei marcatori di disfunzione endoteliale in pazienti affetti da cirrosi epatica con senza ipertensione portale significativa

2009 - Clinical, biochemical and genetic characteristics of Variegate Porphyria in Italy [Articolo su rivista]
E., Di Pierro; Ventura, Paolo; V., Brancaleoni; Moriondo, Valeria; Marchini, Stefano; D., Tavazzi; Nascimbeni, Fabio; Ferrari, Mariachiara; Rocchi, Emilio; M. D., Cappellini
abstract

Variegate Porphyria (VP) is an autosomal dominant disorder found worldwide but is rare in Italy. In this study we provide an overview of clinical, biochemical and genetic background of 33 Italian VP patients diagnosed in the last fifteen years. About 70% of patients had experienced clinical symptoms: 43.4% had photosensivity, 8.7% acute attacks and 47.8% both. Among the 33 patients, 14 different mutations were identified. Of these only 6 defects have been previously described in other countries and 8 are unique having been identified for the first time in Italy. Two of these, the c.851G>T and the c.1013C>G, were found in two and four unrelated families respectively. No mutation has been found in homozygosis and no significant correlation has been observed between specific clinical and biochemical manifestations and the type of mutation. In contrast, normal faecal protoporphyrin excretion was high predictive of silent phenotype. Normal urinary excretion of PBG and ALA, predicted absence of neurovisceral symptoms. This paper represents the first compilation of data on genotype-phenotype relation in Italian patients with VP.

2009 - MTHFR C677T polymorhism and hyperhomocysteinemia in patients with liver cirrhosis complicated by portal vein thrombosis and hepatocellular carcinoma [Abstract in Rivista]
Nascimbeni, Fabio; Ventura, Paolo; Moriondo, Valeria; Marchini, Stefano; M. C., Rosa; Ferrari, Mariachiara; G., Abbati; Romagnoli, Elisa; Pietrangelo, Antonello
abstract

BACKGROUND: Mild hyperhomocysteinemia (HHcy) is an independent risk factor for deep vein thrombosis; the liver plays a key role in homocysteine (Hcy) metabolism, being the sole tissue provided with the whole enzymatic set of transsulfuration and remethylation pathways; the liver has also a key-role in storage and metabolism of vitamins needed as cofactor in sulphur aminocid metabolism. Among different determinants of HHcy, the methylen-tetrahydrofolate reductase (MTHFR) C677T polymorphism has an high prevalence in general population (the homozygous state (TT) have been estimated in about 18% of italians). MTHFR gene anomalies have been also involved in cancer development, through a mechanism involving the impairment of folate metabolism and hence inducing alterations in DNA repair and methylation. Liver cirrhosis (LC) is by far the most important risk factor of portal vein thrombosis (PVT) especially if complicated by hepatocellular carcinoma (HCC). AIM: Considering the complex interaction between HHcy, MTHFR status and liver function impairment , aim of our study was to investigate a possible relation between HHcy, MTHFR status, HCC and PVT in patients with liver cirrhosisMATERIALS and METHODS: To these purposes, we have studied 86 patients (35 f, mean age 65±10 years) affected by LC, 53 without portal thrombosis (LC group) and 33 with portal thrombosis (doppler ultrasonography, angio-CT or angiography dcumented) (PVT group) . Patients in the two groups were age- ,Child Pugh score- , etiology- and sex–matched. All patients were assessed for plasma homocysteine (HPLC) , MTHFR C677T and vitamin (reb blood cell folate, serum B12 and B6) status. RESULTS: The table resumes the results regarding HCC presence and homocysteine parameters in the two studied groups.PVT (n=33)LC (n=53)pOR (95% CI)HCC presence (y/n)21/12 (63.6 %)12/41 (22.6%).0073.26 (1.31÷8.12)Mean plasma Hcy16.4 ± 6.112.1 ± 6.1.0151.07 (1.01÷1.15)HHcy prevalence (y/n)§21/12 (63.6%)15/38 (28.3%).0023.08 (1.61÷7.41)MTHFR status (CC/CT/TT)8/12/1335/14/4.001* .013***TT prevalence; **CT plus TT status vs. CC prevalence; §= >15 nmol/mlNo significant differences in vitamin status (red blood cell folate, and serum B12 and B6) were observed between groups. Patients with HCC (n=33) showed significant higher levels of plasma Hcy (17.7±5.9 vs. 13.5±5.8, p.039) and significant higher prevalence of HHcy (19/33, 57.5% vs.17/53, 32.1%, p=.025, OR 1.79, 95% CI 1.12÷2.99) than patients without HCC(n=53). Patients with HCC had also a significant higher prevalence of MTHFR TT status (10/33, 30.3% vs. 7/53, 13.2 %, p=.044, OR 2.67, 95% CI 1.07÷6.67). Interestingly, all patients with MTHFR TT status had HHcy and all patients MTHFR TT and HCC had PVT.CONCLUSION: Mild HHcy associated to liver cirrhosis may play a possible role for PVT development. Even if confirmations by larger and prospective studies are needed, assessment of homocysteine (simple and cheap) may be suggested in patients with liver cirrhosis (especially in case of advanced liver disease or in the presence of HCC).Our data concerning the association between HCC and MTHFR TT status is intriguing, due the postulated role for this polymorphism in cancerogenesis: it may represent a further link between HCC and PVT

2009 - Novel human pathological mutations. Gene symbol: PPOX. Disease: porphyria, variegate [Articolo su rivista]
S., Ausenda; V., Moriondo; Marchini, Stefano; V., Besana; E., Di Pierro; V., Brancaleoni; Ventura, Paolo; Rocchi, Emilio; M. D., Cappellini
abstract

New mutation in protopoprhyrinogen-oxidase gene responsable for overt clinical form of Porphyria Variegata is described

2009 - Role of Multidrug-Resistance Protein 2 in coproporphyrin transport: results from experimental studies in bile fistula rat models [Articolo su rivista]
Moriondo, Valeria; Marchini, Stefano; P., Di Gangi; Ferrari, Mariachiara; Nascimbeni, Fabio; Rocchi, Emilio; Ventura, Paolo
abstract

Coproporphyrin (CP) is one of the main by-products of heme biosynthesis and its abnormal accumulation is associated with different forms of porphyria. Indirect data obtained from animal and human models have suggested a possible role for Multidrug Resistance-associated Protein 2 (MRP2) and other MRPs in hepatocyte excretion of CP. Using normal, MRP2-deficient and a cholestatic rat model, we have assessed the role of MRPs in CP disposition. MRP levels were assayed using immunofluorescence. Biliary and urinary excretion patterns of CP and conjugate bilirubin were measured during equimolar infusions of CP isomers with and without phenoldibromopthalein sulfonate (BSP), a well-known MRP2 substrate. Our results suggest a role for the MRP system as a possible regulator of CP traffic and accumulation in normal and pathological conditions. Alteration in this systems (as observed in cholestatic disease) may play an important role in triggering clinical expression of porphyria in individuals with underlying mutations leading to porphyrin accumulation and may help explain the phenotypic heterogeneity in patients affected by different forms of porphyrias.

2009 - Terapia antialadosteronica e prevenzione della cardiomiopatia cirrotica [Abstract in Rivista]
Ferrari, Mariachiara; Ventura, Paolo; A., Nuzzo; Nascimbeni, Fabio; Romagnoli, Elisa; Vegetti, Alberto; Rossi, Rosario; Moriondo, Valeria; Marchini, Stefano; Modena, Maria Grazia; Pietrangelo, Antonello
abstract

BACKGROUND: La “cardiomiopatia cirrotica” [CC] comprende una serie di alterazioni funzionali (disfunzione sistolica ma soprattutto diastolica; presenza di alterazioni strutturali e morfologiche a carico degli atri e dei ventricoli; allungamento del tratto QT all’elettrocardiogramma; presenza di markers sierici suggestivi di sofferenza e/o fibrosi cardiaca) che si instaurano a livello miocardico col progredire della malattia epatica. Poiché la CC è indipendente dall’eziologia dell’epatopatia, diversi fattori bioumorali cirrosi-associati sono stati considerati responsabili del suo sviluppo.SCOPO DEL LAVORO: (1) valutare la prevalenza di CC nei pazienti ricoverati presso un centro epatologico specialistico (2) valutare il grado di correlazione e importanza relativa dei vari fattori bioumorali CC-associati (3) costruire un algoritmo predittivo della presenza di coinvolgimento miocardico nel paziente con cirrosi.MATERIALI E METODI : Abbiamo studiato 50 pazienti (17 donne, età media 65 ± 9 anni) affetti da cirrosi epatica. Abbiamo escluso dallo studio pazienti affetti da cirrosi con storia o evidenza clinica di cardiopatia, pneumopatia, anemia grave, o altra patologia sistemica infiammatoria. Lo studio ha incluso anche un secondo gruppo di 17 pazienti (6 donne, età media 63 ± 7 anni) affetti da epatite cronica attiva (ECA) non cirrotica (biopsia con stadio ISHAK ≤ 4) non in trattamento attivo con terapia antivirale (interferone e/o antivirali) al momento dell’inclusione nello studio e senza storia clinica di cardiopatia, pneumopatia o altra patologia sistemica infiammatoria. Tutti i pazienti arruolati sono stati sottoposti a (1) determinazione della pressione arteriosa (2) ECG per valutazione del QT e QT corretto; (3) valutazione dello stadio di malattia (score Child-Pugh Turcotte e MELD); (4) determinazione dei livelli plasmatici di diverse sostanze coinvolte nella patogenesi della CC e/o considerate come marcatori bioumorali di insufficienza cardiaca [Fattori natriuretici (ANF e BNF), Epinefrina (E), Norepinefrina (NE), attività reninica plasmatica (PRA), Aldosterone (A), Ossido nitrico (NO), Interleuchina 6 (IL-6) e Tumor necrosis factor alfa (TNF-)]; (5) determinazione plasmatica di indici diretti [determinazione del pro peptide n-terminale del pro collagene di tipo III (PIIINP)] e indiretti di fibrosi (score non invasivi di fibrosi APRI, 4-parametrs e Fibroscore). (6) anamnesi farmacologica. Tutti i pazienti sono inoltre stati sottoposti a ecocardiogramma mono e bidimensionale per la determinazione degli indici di funzionalità sistolica e diastolica [FE, Ea, TAPSE, E/A ratio, Deceleration time (DT)].RISULTATI : La prevalenza di deficit diastolico nella nostra popolazione di cirrotici è risultata elevata (il 50% dei pazienti con cirrosi epatica presenta un E/A ratio patologico e il 62% presenta un DT patologico); per entrambi i parametri la prevalenza tende ad aumentare col peggiorare dello stadio di malattia (il 100% dei soggetti in Child C hanno un E/A ratio patologico e il 92% dei pazienti un DT patologico). QT allungato era presente in 19 pazienti con cirrosi epatica (38%) rispetto a 1/16 soggetti con ECA (6.25%) (p<.001). All’analisi univariata gli indici di funzione diastolica (DT e E/A ratio) apparivano significativamente correlati coi livelli di NO r=.414, p=.000 e r=.395, p=.001), TNF-alfa r=-514, p=.000, r=.481, p=.000) , NE r=-.615, p=.000, r=.-569, p=.000), E(r= -.605, p=.000, r= -.569,p=.000) Aldosterone (r= -.476,p=.000; r=.587, p=.000) PRA, (r= -.512, p= .012; r=-656, p=.001), ANP (r= - 521, p=.000; r=.560, p=.000) e BNP (r=-574, p=.001; r=669, p=.000); apparivano inoltre entrambi correlati agli indici di fibrosi diretti (PIIINP) (r=-546, p=.000; r=.524, p=.000) e al punteggio ottenuto con gli scores Fibroscore (r=-.490, p=.000) e 4-parameters (r= - .490, p=.000; r= .583, p=.002). Abbiamo osservato una associazione significativa fra presenza di QT lungo e pun

2008 - Insulin resistance in advanced liver cirrhosis : the role of liver dysfunction and the “dissociated” effect on glucose versus lipid and amino acid metabolism [Abstract in Rivista]
Ventura, Paolo; Romagnoli, Elisa; Nascimbeni, Fabio; Ferrari, Mariachiara; Moriondo, Valeria; Marchini, Stefano; G., Pacini; E., Ventura; M. L., Zeneroli
abstract

Background: Chronic liver failure is characterized by the progression of multiple important metabolic derangements, simultaneously interesting all main metabolic pathways. In liver cirrhosis, an impaired glucose tolerance with insulin resistance is frequently observed (20% of these patients may develop overt diabetes mellitus during the disease progression). Aim: to evaluate (1) the role of liver dysfunction in inducing the alteration of insulin sensitivity in patients with advanced stage of liver cirrhosis and (2) the effect of this metabolic derangement on amino acid and lipid metabolism in patients with liver cirrhosis with respect to healthy controls and to patients with type II diabetes mellitus.Materials and methods: To this purpose 23 subjects with documented advanced liver cirrhosis (LC), 14 age and sex-matched healthy subjects (controls) and 10 patients with type II diabetes mellitus without liver disease (DM) were studied. A FSIVGTT test (Frequently Sample Intravenous Glucose Tolerance Test) with simultaneous evaluation of glucose, lipid and amino acid metabolism parameters was performed and the results for glucose, Insulin and C-peptide were analyzed by the MINMOD program, able to adapt data to three different mathematical models, generating predictions of kinetic of glucose disappearance and insulin and C-peptide production; FSIVGTT lipid metabolism parameters (NEFA levels) were measured by colorimetric kit and FSIVGTT amino acid metabolism parameters [Branched Chain Amino Acid, (BCAA) and Aromatic Amino Acid, (AAA) profile], by Amino Acid Analyzer. Results: The MINMOD integration of data concerning secretion and kinetics of C-peptide with those of insulin, confirm that advanced-stage liver cirrhosis is characterised by significant insulin-resistance with hyperinsulinemia and suggest the main role of reduction of insulin liver extraction (h) in insulin-resistance syndrome of liver cirrhosis. The effects of this liver-failure inducted insulin-resistance seem to have some peculiarities concerning lipid and amino acid metabolism, consisting in a relative conservation (greater effect than that observed in DM subjects) of insulin effect in peripheral tissues: in LC patients insulin seems to maintain a relative greater capacity to promote both BCAA and NEFA utilization by muscle and fat tissue (“dissociated effect”) with respect to patients with type II diabetes mellitus. Conclusion: The relative preservation of insulin sensibility by peripheral tissues represents an important and a positive fact, as rationalizes the use, for example, of BCAA solutions for nutritional purposes in presence of starvation or negative azoth balance, all conditions known to negatively influencing some neuropsychological complications of liver cirrhosis.

2008 - Portal vein thrombosis and thrombophilia in liver cirrhosis: a role for hyperhomocysteinemia ? [Abstract in Rivista]
Ventura, Paolo; M. C., Rosa; Romagnoli, Elisa; Tremosini, Silvia; Marchini, Stefano; E., Grandone; Moriondo, Valeria; P., Vergura; Zeneroli, Maria Luisa
abstract

Background: Hyperhomocysteinemia (HHcy) is a risk factor of venous thrombosis. Liver plays a key role in homocysteine (Hcy) metabolism. Portal vein thrombosis (PVT) is a serious complication of liver cirrhosis (LC). Different prothrombotic conditions have been considered as risks factors of PVT in LC; a few data are available about HHcy. Materials and Methods: we studied consecutively 86 cirrhotic patients [33 with PVT (PVT, mean age 64±11, 13 females) and 53 without PVT (LC, mean age 66±9, 22 females), no differences in cirrhosis aetiology among groups]; disease stage (Child-Pugh score), HCC presence, smoking, natural anticoagulants (protein C, S and ATIII) and other thrombophilic factors (Factor VIIIc, LAC , FVL, PTHR A20210), plasma Hcy, Hcy-related vitamin status and MTHFR C677T mutation prevalence were assessed in all patients (table 1). Results: A progressive increase in plasma Hcy levels, an higher prevalence of HHcy with the worsening of liver function; an high prevalence of HHcy in PVT group vs. LC group (63.6% vs.28.3%, p=.002) and a significant association of HHcy with PVT [OR=3.26 (95% CI 1.3 ÷ 8.1, p=.003) were observed.PVT (n=33)CC (n=53)pFVL4 (12.1 %)6 (11.3 %).983°PTHR A2021012 (36.4%)5 (9.4%).004°MTHFR C677→T§25 [13] (75.7%)18 [4] (33.9%).013°High Factor VIIIc**19 (57.5%)19 (35.8%).048°LAC3 (9.1 %)4 (7.5%).893°HCC presence (Y/N)12 (57.1%)17 (47.2%).815°Smokers (Y/N)11 (33 %)18 (33.9%).921°Protein S (%)69.5 ± 21.572.8 ± 23.8.565*Protein C (%)54.5 ± 20.5 56.4 ± 25.1.744*AT III (%)62.8 ± 18.865.3 ± 25.2.662*Factor VIIIc (IU/dl)203 ± 59176 ± 65.062*Homocysteine (mol/L)16.4 ± 6.112.0 ± 6.1.015*§Between square brackets is indicated the prevalence of homozygosis; ** High Factor VIIIc = > 170 IU/dl *** HHcy = > 12 mol/L; °test ; *T-testConclusion: According to our data, HHcy, similarly to other thrombosis risk factors, may play a role in the pathogenesis of TVP in patients affected by liver cirrhosis. Identification of this risk group may be essential to plan clinical prevention strategies especially in patients candidates for surgery or other intervention at risk of PVT.

2007 - Urinary coproporhyrin isomers during therapy with IFn-RIBA in patients with chronic hepatitis due to HCV infection [Abstract in Rivista]
Ventura, Paolo; C., Sardini; Romagnoli, Elisa; Moriondo, Valeria; Marchini, Stefano; Tremosini, Silvia; A., Borghi; M. L., Zeneroli; Rocchi, Emilio
abstract

Background : MRP2 transporter has a proven role in biliary export of many different products of hepatocytic metabolism. Particularly, human and animal models have demonstrated MRP2 role in biliary excretion of coproporhyrins: its preference for isomer I (CPI) export with respect to isomer III (CPIII) is responsable for the biliary CPI/CPIII ratio about 2-3:1 and the plasma and urinary CPI/CPIII ratio about 1:2-3. A significant reduction of MRP2 expression has been described in many different acquired cholestatic liver diseases and in patients with chronic hepatitis (CH) due to HCV infection. Aim of our study was to evaluate quantitative and qualitative (CPI/CPIII ratio) urinary CP excretion in patients with CH due to HCV before (T0), at 3 months (T3) and at the end of antiviral therapy (ET) (peg-IFN + Ribavirin)Materials and Methods: 60 patients (18 females, aged 46±11 years, genotype: 1 (31); 2(10); 3(15); 4(4); 51 naive) with istologically proven HCV-inducted CH were consecutively enrolled; 5 (8.4%) did not conclude the study. 10 healthy subjects sex- and age-matched were also considered for comparing the basal values. None of considered subjects had overt laboratory [i.e. serum alkaline phosphatase (AP) over the normal range] or clinical signs of cholestasis. All patients underwent a urinary evaluation (HPLC) of CPI excretion at T0, T3 and ET. SVR (n=34) was defined as serum HCV-RNA undetectable after 6 months of follow-up. Results: Basal serum FA levels resulted significantly related both to basal urinary total CPI (r=.405, p=.001), and basal CPI/CPIII ratio (r=.692, p=.000). Table I show Total urinary CPI e urinary CPI/CPIII ratio in controls and in HCV patients with respect to serum PA percentile.Table IPA ≥ 75°percentile(≥ 232 u/L) (n=16)(group A)PA < 75° percentile (<232 U/L) (n=44)(group B)Controls(n=10)Urinary CPI (g/g urinary creatinine)66.6 ± 29.4142.4±21.2232.6±12.3CPI/CPIII ratio1.71±0.610.75±0.510.38±0.121p<.012p<.05 with respect to controlsDuring IFN therapy, patients in group A significantly reduce both urinary CPI excretion (45±21 at T3 and 38±18 g/g urinary creatinine at ET, p<.05 and <.01 vs. T0, respectively) and CPI/CPIII ratio (1.1±0.4 at T3 and 0.55±0.32 at ET p<.05 and <.01 vs. T0, respectively) in case of SVR (n=10), whereas no significant effect was observed in subjects non responders to antiviral therapy (NR, n=6) . Patients of group B show a similar trend for normalization of CPI/CPII ratio and CPI/CPIII ratio (0.60 ±0.3 at T3 and 0.41±0.22 at ET, p<.05 and <.05 vs. T0, respectively) and reduction of CPI (39±12 at T3 and 36±11 g/g cretinine at ET, p<.07 and <.06 vs. T0, respectively) in case of SVR (n=24). Also in group B no significant modification of total CPI urinary excretion nor of CPI/CPIII ratio was observed in NR. Overall, a reduction of CPI/CPIII ratio >60% at T3 showed a 88% PPV for SVR, reaching 95% if considering only patients in group A.Our data indirectly confirm the effect of liver chronic infection due to HCV on MRP2 expression, whose alteration may be considered as the main responsible for the observed urinary CPI modifications (greater excretion with CPI/CPIII ratio inversion). Even if more confirmative data are needed, monitoring of urinary CPI excretion (especially CPI/CPIII ratio) may be a useful, cheap and simple tool in early prediction of the response to antiviral therapy in subjects affected by HCV CH, especially in the presence of mild laboratory signs of cholestasis.

2005 - Hyperhomocysteinaemia in chronic liver diseases: role of disease stage, vitamin status and methylenetetrahydrofolate reductase genetics [Articolo su rivista]
Ventura, Paolo; Rosa, Maria Cristina; G., Abbati; Marchini, Stefano; E., Grandone; P., Vergura; Tremosini, Silvia; Zeneroli, Maria Luisa
abstract

Background/Aims: The liver plays a key role in sulphur aminoacid metabolism hence, homocysteine metabolism may be impaired in chronic liver diseases. The aim of this study was to investigate, in patients affected by chronic liver diseases, (1) the prevalence of hyperhomocysteinaemia and (2) the role of its determinants such as the stage and the aetiology of disease, vitamin status, genetic documented alterations (methylenetetrahydrofolate reductase deficiency) and presence/absence of documented malignant evolution (hepatocellular carcinoma). Materials and methods: One hundred and thirty patients with chronic liver disease (34 with chronic active hepatitis, 12 with fatty liver and 88 with liver cirrhosis) and 50 healthy age-matched control subjects were included into the study. Results: Hyperhomocysteinaemia was defined as homocysteine plasma levels greater than 12.6 mumol/l. Hyperhomocysteinaemia prevalence in liver cirrhosis group was 40.9%, significantly higher (all P<0.01) with respect to controls (12%), chronic active hepatitis (14.7%) and fatty liver (25%) groups and increased with Child-Pugh stage [Child A: 22.2%, Child B (50%); Child C (58.3%)]. In chronic-active hepatitis and liver cirrhosis, the prevalence of subjects with methylenetetrahydrofolate reductase C677-->T mutation (both as CT and as TT) and hyperhomocysteinaemia results in significantly higher levels with respect to controls. Methylenetetrahydrofolate reductase C677-->T mutation and disease stage showed to be the most important predictive factors of hyperhomocysteinaemia in liver cirrhosis whereas the influence of homocysteine-related vitamin status seems to have a secondary role. Conclusions: In conclusion hyperhomocysteinaemia is highly prevalent in liver cirrhosis but not in other chronic liver diseases; it may contribute to fibrogenesis and vascular complication of liver cirrhosis.

2005 - Isomeri urinari della Coproporfirina in pazienti con Epatopatie Colestatiche Acquisite e sindrome di Dubin-Johnson [Abstract in Rivista]
Tremosini, Silvia; Ventura, Paolo; Casalgrandi, Giovanna; Marchini, Stefano; E., Ventura; Rocchi, Emilio
abstract

Argomento della nostra comunicazione è la valutazione dell’escrezione urinaria degli isomeri della coprorporfirina in pazienti affetti da diverse forme di epatopatia colestatica o da sindrome di Dubin-Johnson. Esistono diverse dimostrazioni (basate su studi di cinetica combinata di escrezione biliare, su modelli animali e umani) che suggeriscono che l’MRP2, l’unico trasportatore di membrana della famiglia dei trasportatori delle Multidrug Resistance Protein presente sul polo biliare dell’epatocita (gli altri sono normalmente ben rappresentai sul versante baso-laterale dell’epatocita) sia il trasportatore biliare più specifico per gli isomeri della CP. Tale trasportatore condivide la sua specificità anche con altre sostanze, come la BSF e la bilirubina coniugata. E’ oggi ben dimostrato che il suo deficit congenito è alla base della sindrome di Dubin-Johnson. Va inoltre ricordato che tutti gli MRPs hanno una notevole omologia strutturale pertanto non è sorprendente come in condizioni particolari ciò possa riflettere anche un certo grado di analogia funzionale (possono cioè condividere stessi substrati).Ci siamo chiesti se questi dati possano avere un utilizzo nella pratica clinica. Basandoci sulla dimostrazione delle reversibilità dell’espressione dell’espressione bilare dell’MRP2 in caso di eliminazione della causa scatenante, ci siamo focalizzati (XXIII) sui pazienti affetti da Epatite cronica attiva in terapia con IFN. Si tratta di dati preliminari e su pochi casi ma potete vedere che i soggetti con HCV-RNA negativizzato a tre mesi di terapia (e con alta probabilità di essere”responders”) vanno incontro a una progressiva normalizzazione nel tempo del rapporto CPI / CPIII urinario, cosa che non abbiamo osservato in coloro che a tre mesi sono risltati HCV RNA negativi (non repsonders).(XXIV) In conclusioneLa diversa regolazione sia a livello intracellulare che intraorgano dei sistemi di trasporto (MRP) può spiegare le caratteristiche alterazioni del profilo urinario della CP osservabili in corso di DJS a di epatopatie colestatiche acquisiteConsiderando il relativo basso costo e la semplicità della determinazioni quali-quantitativa degli isomeri delle CP nelle urine , unitamente alla dimostrazione della precoce alterazione (o normalizzazione) in seguito a induzione (o risoluzione) di colestasi, tale determinazione potrebbe avere un significato nella diagnosi, prognosi e monitoraggio di diverse forme di epatopatia colestatica.

2003 - Plasma nitric oxide production during acute hyperhomocysteinemia in atherosclerotic patients and controls [Abstract in Rivista]
Ventura, Paolo; M., Turci; Marchini, Stefano; G., Casalgrandi; Salvioli, Gianfranco; Rocchi, Emilio
abstract

The work deals with the different production of nitric oxide by vascular endothelium during hyoerhomocysteinemia induced by oral methionine load in patiemts affected by diffuse atherosclerosis and in sex amd age -matched controls

2003 - Portal vein thrombosis and hyperhomocysteinemia in patients with liver cirrosis [Abstract in Rivista]
Ventura, Paolo; M. C., Rosa; Marchini, Stefano; G., Abbati; A., Borghi; M. L., Zeneroli
abstract

Background: Portal vein thrombosis (PVT) is a severe complication of liver cirrhosis (LC), especially in presence of hepatocarcinoma (HCC). Liver is the main site of homocysteine (Hcy) metabolism and Hcy-related vitamins (folate, B12) storage. Aim: Assessment of possible association of moderate hyperhomocysteinemia (HHcy) (> 15 mol/L), risk factor for deep venous thrombosis, and TVP in different stage LC patients, with and without HCC.Methods: 16 (aged 60±12, 8 f) LC patients with documented (doppler ultrasonography) PVT and 32 (aged 64±11, 12f) without PT were studied [total plasma Hcy (HPLC), Hcy-related vitamin status (ELISA), stage of disease (Child-Pugh score), presence of HCC (radiological and/or histological diagnosis), ethiology (alcohol, viral, both, other)]. Results: Hcy levels significantly (corrected for vitamin status) increases with Child-Pugh score (A: 11.84±4.2, n=12; B=16.5±8.2, n=22; C=18.5±8.1, n=14, mol/L. p=0.021); HCC patients (n=18) showed higher Hcy than those without HCC (17.7±7.4vs.13.5±5.9,p=ns,after vitamin status correction). As expected, prevalence of HCC was higher in PVT group (10/16 (62.5%) vs. 8/32 (25%) ,p <0.01). TVP group presented lower serum folate (3.8±1.2 vs. 5.5±1.8 nmol/ml, p=0.017) and B12 levels (352±89 vs. 516±125, p=.038), with no differences for different ethiologies, and a higher prevalence of folate and B12 deficit. After correction for vitamin status, Child-Pugh score, and prevalence of HCC, TVP group showed higher Hcy (19.7±5.5 vs. 13.81±7.8 mol/L, p=0.015) and an higher prevalence of HHcy (10/16 (62.5%) vs 8/32 (25%), p<.011). Association of HHcy and TVP resulted significant (OR=5.0,95%CI:1.4-18.2, p=0.014). Conclusions: Our data suggest the possible importance of raised Hcy levels in development of TVP in cirrhotic patients, especially in higher stadium of disease or complicated by HCC. Studies about the role of treatment of HHcy in LC patients for the prevention of TVP are underway.

2003 - Trombosi portale e iperomocisteinemia in pazienti con cirrosi epatica [Abstract in Atti di Convegno]
Ventura, Paolo; M. C., Rosa; Marchini, Stefano; G., Abbati; G., Cioni; A. Borghi e. M. . L., Zeneroli
abstract

Premesse: La trombosi portale (TP) è una grave complicanza della cirrosi epatica (CE), spesso associata alla presenza di epatocarcinoma (HCC). Il fegato è la sede principale del metabolismo degli aminoacidi solforati e soprattutto (transmetilazione e transulfurazione) dell’omocisteina (Hcy), il cui incremento plasmatico, anche a livelli moderati, rappresenta un fattore di rischio di malattia tromboembolica; il fegato è inoltre la sede di accumulo e utilizzo dei principali fattori vitaminici essenziali al corretto metabolismo dell’omocisteina.Scopo: valutare una possibile associazione fra iperomocisteinemia moderata (>12 mol/L) e TP in pazienti affetti da CE in diversi stadi di malattia, con e senza HCC.Materiali e metodi:48 pazienti (età media 60 ± 10, 20 f) affetti da CE, di cui 16 (8 f) con documentata TP (ultrasonografia doppler) sono stati sottoposti a determinazione dei livelli circolanti di Hcy (HPLC con detector fluorimetrico), a determinazione dei livelli circolanti dei fattori vitaminici Hcy-relati (folati eritrocitari e vitamina B12) (ELISA), a valutazione della funzionalità renale (creatinine clearance), dello stadio di malattia (Child-Pugh Score), a screening diagnostico per HCC (diagnosi radiologica e/o istologica), valutazione eziologia (esotossica, virale, entrambe, altro). Tutti i pazienti sono stati contestualmente sottoposti a screening per trombofilia (determinazione proteina C, S, antitrombina III, resistenza proteina C attivata, ricerca di lupus anticoagulante).Risultati: I livelli circolanti di Hcy risultano aumentare significativamente con l’aumentare della gravità della malattia (Stadio A, 11.8 ± 4.2 n=12; B= 16.5 ± 8.2, n=22; C= 18.5 ± 8.1, n=14, mol/L, p=0.021, corretti per stato vitaminico e funzionalità renale); i pazienti con HCC (n=18, 8 Child B e 10 Child C) presentavano livelli più alti di Hcy di quelli senza HCC (17.7± 7.4 vs. 13.5 ± 5.9 mol/L, p=ns, dopo correzione per stato vitaminico e funzionalità renale). Come atteso, la prevalenza di TP risultava più alta nel gruppo con HCC [10/16 (62.5%) vs. 8/32 (25%), p<0.01). I soggetti con TP presentavano una disponibilità inferiore di folati (3.8 ± 1.2 vs. 5.5 ± 1.8 nmol/ml, p= 0.017) e di vitamina B12 (352 ± 89 vs. 516 ± 125 pmol/L, p=0.038) rispetto ai soggetti senza TP; non vi era nè differenza dei livelli vitaminici né una maggiore prevalenza di deficit vitaminico fra le diverse eziologie. Dopo correzione per stato vitaminico, Child-Pugh score, funzionalità renale e presenza di HCC, il gruppo con TP mostrava livelli di Hcy più alti 19.7±5.5 vs. 13.8± 7.8 mol/L, p=0.015) e una maggiore prevalenza di iperomocisteinemia [10/16 (62.5%) vs 8/32 (25%) , p=0.011). L’associazione fra HHcy e TP è risultata significativa (OR= 5.0, 95% CI: 1.4-18.2, p=0.014).Non sono risultate differenze significative nei livelli degli altri fattori trombofilici fra il gruppo con TP e quello senza.Conclusioni: i dati suggeriscono il possibile ruolo dell’iperomocisteinemia nello sviluppo di TP nei pazienti affetti da CE, specialmente nelle fasi avanzate della malattia o complicate da HCC. Ulteriori studi di conferma su casistiche più ampie, come pure studi sui possibili effetti preventivi del trattamento dell’iperomocisteinemia, sono tuttavia necessari prima di trarre conclusioni definitive.

2001 - Antioxidant liposoluble vitamins and carotenoids in chronic hepatitis. [Articolo su rivista]
Rocchi, Emilio; Casalgrandi, Giovanna; Ronzoni, Alessandro; Rosa, Maria Cristina; G., Cioni; A., Marazzi; Manenti, Antonio; Marchini, Stefano; Ventura, Ezio
abstract

Background: It is acknowledge that antioxidant liposoluble vitamins and carotenoids are reduced in liver cirrhosis, but little is known about chronic viral hepatitis, where oxidative damage has to be taken into account. Materials and methods: Fifty-five patients with chronic hepatitis, mainly C virus-related, were matched with 16 patients with biliary stones and 20 healthy controls. Plasma and liver analyses were carried out using a well-tried HPLC technique, which affords an accurate quantification of retinol, tocopherol, alpha- and betacarotene, cryptoxanthin and lycopene. Results: Plasma concentration of retinol, tocopherol, beta-carotene and lycopene was significantly decreased in both patient groups, particularly in those with chronic hepatitis. On the other hand, liver concentration of both esterified and free retinol, tocopherol and some carotenoid was better preserved in the hepatitis than in the cholelithiasis group. A strict correspondence between aminotransferases and the amount of liver-stored retinol was documented. Conclusions: Plasma vitamin and carotenoid depletion co-existing with preserved liver storage, may indicate a functional defect in liver pool mobilisation or even a real depletion of the antioxidant defences, which play a key role in averting cellular damage. The implications for nutrition and therapy need to be taken into account