Publications

The resident integral hepatic endoplasmic reticulum (ER) proteins, cytochromes P450 (P450s), turn over in vivo with widely varying half-lives. We and others (Correia et al., Arch. Biochem. Biophys. 297, 228, 1992; and Tierney et al., Arch. Biochem. Biophys. 293, 9, 1992) have previously shown that in intact animals, the hepatic P450s of the 3A and 2E1 subfamilies are first ubiquitinated and then proteolyzed after their drug-induced suicide inactivation. Our findings with intact rat hepatocytes and ER preparations containing native P450s and P450s inactivated via heme modification of the protein have revealed that the proteolytic degradation of heme-modified P450s requires a cytosolic ATP-dependent proteolytic system rather than lysosomal or ER proteases (Correia et al., Arch. Biochem. Biophys. 297, 228, 1992). Using purified cumene hydroperoxide-inactivated P450s (rat liver P450s 2B1 or 3A and/or a recombinant human liver P450 3A4) as models, we now document that these heme-modified enzymes are indeed ubiquitinated and then proteolyzed by the 26S proteasome, but not by its 20S proteolytic core. In addition, our studies indicate that the ubiquitination of these heme-modified P450s is preceded by their phosphorylation. It remains to be determined whether, in common with several other cellular proteins, such P450 phosphorylation is indeed required for their degradation. Nevertheless, these findings suggest that the membrane-anchored P450s are to be included in the growing class of ER proteins that undergo ubiquitin-dependent 26S proteasomal degradation.

Mechanism-based inactivation of liver microsomal cytochromes P450 3A (CYP 3A, P450s 3A) in vivo and/or in vitro, via heme modification of the protein, results in accelerated proteolytic degradation of the enzyme that is preceded by the ubiquitination of the protein, thereby implicating the ubiquitin-ATP-dependent 26S proteasomal system. In this study, this involvement is confirmed with the use of the proteasomal inhibitors aclarubicin and MG-132 as probes, in isolated rat hepatocytes treated with the P450 3A mechanism-based inactivator, 3,5-dicarbethoxy-2,6-dimethyl-4-ethyl-1, 4-dihydropyridine (DDEP). In addition, the findings reveal that during the course of this proteolysis, the endoplasmic reticulum (ER)-anchored DDEP-inactivated P450 3A is translocated from the ER to the cytosol in a brefeldin A-insensitive manner.

Unstable angina comprises a heterogeneous population of patients who present with a wide spectrum of underlying pathophysiology. The traditional treatment of these patients is based on both evidenced-based medicine as well as clinical experience. Despite the large population of patients admitted with this diagnosis, the scientific literature regarding its treatment is scarce. Therefore, the management of patients with unstable angina relies heavily on the clinical skills of the physician. One of the most important steps in this process involves risk stratification, especially in the current environment of cost containment. Those patients who are at low risk for adverse outcomes can be treated and evaluated safely as outpatients. Patients at high or moderate risk, however, should be treated intensively as inpatients. Although there appear to be many new promising therapies for unstable angina on the horizon, the traditional therapies still have a place. The use of aspirin in this population is well supported by the literature and appears to have a positive effect on mortality and cardiovascular events. The other traditional therapies, however, are not as well supported by the literature. They do appear to benefit the patient in terms of reducing symptoms, but their effects on reducing mortality and cardiovascular events are not clear. Therefore, the goal of medical therapy in this patient population should be to stabilize them so that they can proceed with an appropriate risk stratification procedure as soon as possible. This is especially true with performing coronary angiography or interventions because the risk of procedural complications is higher in patients with unstable angina and ongoing symptoms.

CONTEXT

Liver transplantation is among the most costly of medical services, yet few studies have addressed the relationship between the resources utilized for this procedure and specific patient characteristics and clinical practices.

OBJECTIVE

To assess the association of pretransplant patient characteristics and clinical practices with hospital resource utilization.

DESIGN

Prospective cohort of patients who received liver transplants between January 1991 and July 1994.

SETTING

University of California, San Francisco; Mayo Clinic, Rochester, Minn; and the University of Nebraska, Omaha.

PATIENTS

Seven hundred eleven patients who received single-organ liver transplants, were at least 16 years old, and had nonfulminant liver disease.

MAIN OUTCOME MEASURE

Standardized resource utilization derived from a database created by matching all services to a single price list.

RESULTS

Higher adjusted resource utilization was associated with donor age of 60 years or older (28% [$53813] greater mean resource utilization; P=.005); recipient age of 60 years or older (17% [$32795]; P=.01); alcoholic liver disease (26% [$49596]; P=.002); Child-Pugh class C (41% [$67 658]; P<.001); care from the intensive care unit at time of transplant (42% [$77833]; P<.001); death in the hospital (35% [$67 076]; P<.001); and having multiple liver transplants during the index hospitalization (154% increase [$474 740 vs $186 726 for 1 transplant]; P<.001). Adjusted length of stay and resource utilization also differed significantly among transplant centers.

CONCLUSIONS

Clinical, economic, and ethical dilemmas in liver transplantation are highlighted by these findings. Recipients who were older, had alcoholic liver disease, or were severely ill were the most expensive to treat; this suggests that organ allocation criteria may affect transplant costs. Clinical practices and resource utilization varied considerably among transplant centers; methods to reduce variation in practice patterns, such as clinical guidelines, might lower costs while maintaining quality of care.