Transplantation Proceedings

Editorial Board

2009-12-01

Forty Years of Publication of Transplantation Proceedings—The Third Decade⁎: The Expansion of the Enterprise

B.D. Kahan — 2009-12-01

With the availability of cyclosporine (CsA; Novartis, Basle, Switzerland) therapy, the transplant enterprise was poised for expansion in its Golden Age. Investigators developed new immunosuppressive agents that even more effectively controlled acute rejection responses, sought additional sources of donor organs, particularly by increasing their interest in xenografts to meet the growing demand, and broadened immunobiologic studies, especially seeking to implement immunologic tolerance in man.

Current Surgical Management of Hilar and Intrahepatic Cholangiocarcinoma: The Role of Resection and Orthotopic Liver Transplantation

H. Petrowsky, J.C. Hong — 2009-12-01

Abstract: Cholangiocarcinoma (CCA) is a rare but devastating malignancy that presents late, is notoriously difficult to diagnose, and is associated with a high mortality. Surgical resection is the only chance for cure or long-term survival. The treatment of CCA has remained challenging because of the lack of effective adjuvant therapy, aggressive nature of the disease, and critical location of the tumor in close proximity to vital structures such as the hepatic artery and the portal vein. Moreover, the operative approach is dictated by the location of the tumor and the presence of underlying liver disease. During the past 4 decades, the operative management of CCA has evolved from a treatment modality that primarily aimed at palliation to curative intent with an aggressive surgical approach to R0 resection and total hepatectomy followed by orthotopic liver transplantation.

Hand-Assisted Laparoscopic Living-Donor Nephrectomy Versus Open Surgery: Evaluation of Surgical Trauma and Late Graft Function in 82 Patients

2009-12-01

Abstract: Objective: We evaluated and quantified surgical trauma and late graft function in cases of hand-assisted laparoscopic living-donor nephrectomy (HALLDN) versus open living-donor nephrectom (OLDN).Methods: This study is a retrospective nonrandomized single-center analysis. Between 1995 and January 2008, 82 patients with end-stage renal disease received kidney transplantations from living donors. Open living-donor nephrectomy was performed in 37 donors, and 45 underwent laparoscopic hand-assisted nephrectomy. Demographic data and perioperative and postoperative data, such as markers of acute phase (C-reactive protein; serum amyloid A) and biochemical markers of glomerular filtration (serum creatinine, serum cystatin C), were compared at serial time points.Results: The mean operative times for HALLDN and OLDN were 165 min and 195 min, respectively. The average warm ischemia time was 45 seconds for laparoscopy and 87 seconds for open surgery. The evaluation of acute phase markers demonstrated a minimally invasiven nature of laparoscopy, with same late graft function compared with open surgery.Conclusion: When the surgery was performed by experienced surgeons, hand-assisted living- donor nephrectomy showed shorter operative and warm ischemia times than open surgery, offering at least the same functional results and decreasing surgical complications compared with a completely laparoscopic technique.

Polyglactin Tie Added to Nonabsorbable Polymer Locking Clips to Control Artery in Laparoscopic Living Donor Nephrectomy: Better Safe Than Sorry

2009-12-01

Abstract: As Teleflex Medical contraindicates the use of Hem-O-Lok clips in laparoscopic living donor nephrectomy (LLDN), we report the feasibility of a simple surgical artifice that aims to preserve the advantages of lockable clips with increased safety while respecting the manufacturer's legal recommendations. Since January 2009, a polyglactin-0 tie was placed on the renal artery in addition to the two usual Hem-O-Lok clips in LLDN at our institution (n = 10) using a pre-tied loop suture (Endoloop ligature, Ethicon) placed on the artery stump, proximally to the aorta, after kidney removal. This artifice increased operating time of 65 seconds (range, 35–85 seconds) with no modification of warm ischemia time and led to visually decreased aortic pulsation transmitted to the clips. Without evidence of increased safety, we assume that this ruse may protect surgeons from prosecution in cases of clip displacement. It certainly decreases the risk of clip slippage and should be considered as a cheap, easy artifice to reduce the already low-risk of hemorrhage in LLDN.

Renal Cysts in Living Donor Kidney Transplantation: Long-Term Follow-up in 25 Patients

2009-12-01

Abstract: Introduction: The acceptance of a living donor kidney bearing cysts might implicate complications after the transplantation due to the natural history of renal cysts. We have presented our experience with transplantation of living donor kidneys containing cysts but not polycystic disease.Patients and methods: We retrospectively reviewed donor and recipient records of all living kidney transplants performed between January 1997 and April 2008. We analyzed serum creatinine and urea levels, as well as ultrasound scans concerning cyst size and morphology at hospital discharge as well as at 12 and 24 months after transplantation.Results: Among 268 living kidney transplantations, we noted 25 donors with renal cysts. In the computed tomography scan reports, 19 kidneys were described to show a single and six, multiple cysts. The size of 10 single cysts was <5 mm; the other nine were a mean of 17.33 mm. Two of the multiple cyst kidneys had lesions <5 mm; in four kidneys, the mean cyst size was 27.25 mm. The renal function of the recipients was normal or almost normal at discharge with a tendency to lower levels at 12 and 24 months after transplantation. Ultrasound revealed changes in cyst diameter among 6/23 kidneys; the mean diameter increased after 12 months, namely, 8.25 mm to 11.5 mm after 24 months. The subgroup of patients with enlarged cysts showed creatinine and urea levels slightly higher than in the entire group. No aspects of malignancy were found, according to the Bosniak and Israel classification system. One suspicious cyst was tomographically confirmed to be hemorrhagic without any need for treatment. None of the living donors had any problems related to the donor nephrectomy or a need for dialysis due to renal insufficiency in the long term. In addition, the living donors who had even beforehand cystic lesions in their contralateral nonremoved kidney at the time of transplantation did not show complications upon follow-up.Conclusions: In our study, 25 living donor kidneys carried cysts. Neither cyst-related complications nor dysfunction of the transplanted organs occurred. An unroofing or excision of the cyst was generally not necessary. Regular ultrasound scans and optional computed tomography scans are recommended for follow-up. Based on this experience, we concluded that kidneys presenting cystic diseases should be considered to be suitable for transplantation without a hazard to the recipients, thus extending the pool of organs.

Estimation of Standard Liver Volume in Chinese Adult Living Donors

2009-12-01

Abstract: Aim: To determine a formula predicting the standard liver volume based on body surface area (BSA) or body weight in Chinese adults.Materials and Methods: A total of 115 consecutive right-lobe living donors not including the middle hepatic vein underwent right hemi-hepatectomy. No organs were used from prisoners, and no subjects were prisoners. Donor anthropometric data including age, gender, body weight, and body height were recorded prospectively. The weights and volumes of the right lobe liver grafts were measured at the back table. Liver weights and volumes were calculated from the right lobe graft weight and volume obtained at the back table, divided by the proportion of the right lobe on computed tomography. By simple linear regression analysis and stepwise multiple linear regression analysis, we correlated calculated liver volume and body height, body weight, or body surface area.Results: The subjects had a mean age of 35.97 ± 9.6 years, and a female-to-male ratio of 60:55. The mean volume of the right lobe was 727.47 ± 136.17 mL, occupying 55.59% ± 6.70% of the whole liver by computed tomography. The volume of the right lobe was 581.73 ± 96.137 mL, and the estimated liver volume was 1053.08 ± 167.56 mL. Females of the same body weight showed a slightly lower liver weight. By simple linear regression analysis and stepwise multiple linear regression analysis, a formula was derived based on body weight. All formulae except the Hong Kong formula overestimated liver volume compared to this formula.Conclusions: The formula of standard liver volume, SLV (mL) = 11.508 × body weight (kg) + 334.024, may be applied to estimate liver volumes in Chinese adults.

Attitudes and Behaviours of Students From the Faculty of Theology Regarding Organ Donation: A Study From Turkey

M. Naçar, F. Çetinkaya, Z. Baykan, S. Poyrazoğlu — 2009-12-01

Abstract: The aim of this study was to investigate the knowledge and attitude of students from the Faculty of Theology of Erciyes University regarding organ donation. This study comprising all students (n = 264) showed that 51.6% of subjects to the kidney is an organ that may be donated; other organs were less known. 16.5% of the students thought that organ donation is not in accord with Islamic beliefs; 22.0% thought that it is permitted in Islam for Muslims to donate to non-Muslims, and 23.6% were willing to accept organs from non-Muslims. 23.6% of the students were willing to donate their organs, whereas 57.3% were undecided. None of the students had an organ donation card. Among students who did not consider donation or were undecided, 16.5% stated that it was “religiously inappropriate” and 13.3% stated that they did not “approve the loss of body integrity.” Students declared that they had little knowledge regarding organ/tissue donation: 67.9% about the religious aspect, 78.9% about the legal aspect, and 80.5% about the scientific aspect. Only 24.6% of the group noted school education as their source of information, with 51.2% stating that they had been questioned about organ donation by society. With this study, we concluded that the student's knowledge regarding organ donation was not sufficient.

Effects of Delayed Rapamycin Treatment on Renal Fibrosis and Inflammation in Experimental Ischemia Reperfusion Injury

M. Liu, P. Agreda, M. Crow, L. Racusen, H. Rabb — 2009-12-01

Abstract: Ischemia reperfusion injury (IRI) has long-term sequelae on kidney allograft function. Early initiation of rapamycin can retard surgical wound healing and recovery from IRI. In contrast, rapamycin may paradoxically retard long-term fibrotic effects of kidney IRI. We, therefore, hypothesized that delayed initiation of rapamycin after kidney ischemia, started after the initial week of wound healing, would decrease the long-term inflammation and fibrosis caused by IRI. C57BL/6 male mice were subjected to either 45 or 60 minutes of unilateral kidney ischemia or a sham operation. Mice were given rapamycin (subcutaneous, 1.5 mg/kg/d) or vehicle starting at 1 week after IRI surgery for 3 weeks. Urine albumin excretion, kidney histology, and kidney cytokine proteins were examined at 4 weeks after surgery. The 3-week treatment course of rapamycin significantly reduced body weight gain in all 3 groups and reduced postischemic kidney weight in both the 45- and 60-minute ischemia groups, but unexpectedly increased urine albumin excretion in all rapamycin-treated sham or IRI mice compared with vehicle-treated mice. Rapamycin treatment showed minimal effects on postischemic kidney fibrosis with variable effects on various cytokine/chemokine protein expressions, namely, decreasing interleukin (IL)-1α, IL-6, tumor necrosis factor (TNF)-α, and regulated on activation normal T cell expressed and secreted (RANTES) while increasing IL-4, keratinocyte-derived chemokine (KC), macrophage inflammatory protein (MIP-1α), and IL-10 in the ischemic kidney. These data demonstrated that rapamycin reduced mouse body weight and ischemic kidney weight, while increasing urinary albumin excretion. Delayed initiation of rapamycin after IRI had a minimal effect on renal fibrosis and mixed effects on proinflammatory mediator production. These data do not support delayed initiation of rapamycin after IRI to attenuate IRI-induced progressive fibrosis and inflammation, and They raise further caution regarding rapamycin and albuminuria.

Comparison of Preservation Solutions for Washout of Kidney Grafts: An Experimental Study

M.C.J.M. Schreinemachers, B.M. Doorschodt, S. Florquin, R.H. Tolba — 2009-12-01

Abstract: Objective: The impact of different preservation solutions for washout of kidney grafts was evaluated regarding temperature, kidney weight, remaining red blood cells (RBCs) and histological evaluation after ex vivo washout using 500 mL cold preservation solution at 4°C followed by 24 hours cold storage (CS).Methods: Kidneys retrieved from Landrace pigs (20–30 kg) were immediately washed (warm ischemic time 0 min [WIT 0]), using 500 mL cold University of Wisconsin solution (UW), histidine-tryptophan-ketoglutarate (HTK), or Polysol (PS) followed by 24 hours, CS. Also, kidneys were retrieved after a WIT of 30 minutes followed by washout using HTK or PS.Results: After washout, the weight of kidneys washed out with HTK had increased, whereas that of organs in the UW or PS group had decreased. After washout with UW, the core temperature of WIT 0 kidneys was lower than that with HTK. The time needed for washout using 500 mL solution was shorter using PS compared with HTK for both WIT 0 and WIT 30 groups. The amount of remaining RBCs was similar between all WIT 0 groups; whereas in the WIT 30 groups the amount was higher in kidneys washed out using HTK compared with PS. Histological evaluation showed less tissue injury among PS-washed kidneys compared with UW or HTK.Conclusion: Overall, kidneys washed-out with PS showed better preservation of structural integrity after 24 hours, CS compared with either UW or HTK. Washout of warm ischemically damaged kidneys was more effective using PS compared with HTK.

Remifentanil, Isoflurane, and Preconditioning Attenuate Renal Ischemia/Reperfusion Injury in Rats

2009-12-01

Abstract: Background: The purpose of this investigation was to examine the effect of isoflurane, remifentanil, and preconditioning in renal ischemia/reperfusion injury (IRI).Methods: All 52 male Wistar rats were anesthetized with isoflurane, intubated and mechanically ventilated. The animals were randomly divided into: S group (sham; n = 11) that underwent only right nephrectomy; as well as the I group of right nephrectomy and ischemia for 45 minutes by clamping of left renal artery. (n = 11); the IP (n = 9), the R (n = 10), and the RP (n = 11) groups. In addition, the R and RP animals received remifentanil (2 μg·kg−1·min−1) during the entire experiment. The IP and RP group underwent ischemic preconditioning (IPC = three cycles of 5 minutes). Serum creatinine values were determined before and after IRI, as well as 24 hours later. In addition to an Histological study, cells from the left kidney were evaluated for apoptosis by flow cytometry (FCM).Results: The Creatinine value of 0.8 ± 0.2 mg/dl in the S group was significantly lower at 24 hours than the I 3.9 ± 1.5 mg/dl; IP 2.6 ± 1.7 mg/dl; R 3.3 ± 2.8 mg/dl; or RP 1.8 ± 0.5 mg/dl groups. The RP group value was significantly lower than those of the I, IP, and R groups (p < 0.05). The S group showed less proximal tubular cell damage than the I, IP, R, and RP groups (p < 0.05). The percentages of apoptotic cells (FITC+/PI−) were: S group = 11.6 ± 6.5; I = 16.7 ± 7.3; IP = 37.0 ± 28.4; R = 11.7 ± 6.6, and RP = 8.8 ± 1.5. The difference between the IP vs RP group was significant. Similar percentages of necrotic cells (FITC+/PI+) and intact cells (FITC−/PI−) were observed among the groups.Conclusions: Ischemic preconditioning showed no protective effect in the isoflurane group (IP) but when isoflurane was administered associated with remifentanil (RP), there was a beneficial effect on the kidney, as demonstrated by flow cytometry and serum creatinine values.

Comparison of Two Models for Evaluation Histopathology of Experimental Renal Ischemia

2009-12-01

Abstract: Renal ischemia/reperfusion (I/R) injury is one of the frequent causes of acute renal failure (ARF) due to the complex, interrelated sequence of events, that result in damage to and death of kidney cells. Cells of the proximal tubular epithelium are especially susceptible to I/R injury, leading to acute tubular necrosis, which plays a pivotal role in the pathogenesis of ARF. Several models have been explicated to assess morphological changes, including those of Jabonski et al. and Goujon et al. We compared the 2 models for histopathological evaluation of 30- or 120-minute periods of renal ischemia followed by 24-hour reperfusion in rats. Several changes were observed after application of the 2 models: proximal tubular cell necrosis, loss of brush border, vacuolization, denudation of tubular basement membrane as a consequence of flattening of basal cells, and presence of intratubular exfoliated cells in the lumen of proximal convoluted tubules at various stages of degeneration (karyorexis, kariopyknosis and karyolysis). Evaluating tubular lesions after 2 periods of experimental ischemia with light microscopy allowed us to conclude that the Goujon classification better characterized the main changes in cortical renal tubules after ischemia.

Influence on Energy Kinetics and Histology of Different Preservation Solutions Seen During Cold Ischemia in the Liver

2009-12-01

Abstract: Background and Purpose: Cold flush preservation prolongs tissue viability during ischemia. However, there is little understanding of the effects of various preservation fluids on events during this period. A study of cold ischemia in rat livers was undertaken to compare biochemical and histological changes over time, using three preservation solutions: University of Wisconsin (UW), histidine-tryptophan-ketoglutarate (HTK), and Leeds solution (LS) under development at our institution. Leeds solution is a phosphate-based sucrose solution that like UW contains the impermeant lactobionate and the metabolite allopurinol (1,5-dihydro-4H-pyrazolo[3,4-d]pyrimidin-4-one) which acts as a competitive inhibitor of xanthine oxidase, stopping the breakdown of hypoxanthine to xanthine by oxidizing it to alloxanthine, inhibiting both the conversion of hypoxanthine to xanthine and the conversion of xanthine to uric acid.Materials and Methods: At various time points, samples were analyzed for adenosine triphospate (ATP) and metabolites by high-performance liquid chromatography as well as for histological changes.Results: In all livers, ATP, ADP, and AMP degraded over 4 hours. In UW and LS groups, degradation beyond hypoxanthine was halted, and it continued in the HTK group. This blockade led to a significant reduction in the accumulation of xanthine and uric acid. Histological analysis showed protected architecture and maintenance of reticulin scaffolds in the UW and LS groups, whereas tissue breakdown was seen from earlier time points in the HTK group. Additionally, throughout ischemia, signs of pathological injury were more pronounced with UW- than with LS-preserved tissue.Conclusions: These results implied that cold ischemia in the liver is characterized by dynamic biochemical changes coincident with pathological injury which are initiated from the time of organ perfusion and influenced by the choice of the perfusion fluid. Allopurinol in UW and LS appears to be critical. We hypothesized that it may also affect the degree of subsequent reperfusion injury. The data supported the assertion that LS offerred improved preservation over UW, adding to the impetus to shorten ischemic times in clinical transplantation.

Vitamin E Succinate Enhances Steatotic Liver Energy Status and Prevents Oxidative Damage Following Ischemia/Reperfusion

2009-12-01

Abstract: We have previously shown that treatment of steatotic livers with vitamin E succinate decreases liver injury and increases survival after ischemia/reperfusion (I/R). It is now understood that compromised energy status is associated with increased injury following liver ischemia in the setting of hepatic steatosis at least partially as a result of increased reactive oxygen species (ROS) and induction of mitochondrial uncoupling protein-2 (UCP2). Given the association between ROS, mitochondrial function, and UCP2, it was our goal to determine whether the protective effects of vitamin E succinate were associated with decreased ROS injury, down-regulation of UCP2, or improvement of ATP levels following I/R. To test this, leptin deficient (ob/ob) mice with steatotic livers that had received other 50 IU of vitamin E succinate supplement per day or control chow for 7 days were subjected to total hepatic ischemia (15 minutes) followed by reperfusion. We measured liver expressions of ATP, glutathione (GSH), and UCP2 as well as mitochondrial DNA damage. Vitamin E treatment decreased hepatic UCP2 expression and increased ATP and GSH levels prior to I/R. These levels were maintained at 1 hour after I/R. At 24 hours, while hepatic UCP2 expression, ATP, and GSH levels were similar to those of mice not receiving vitamin E, mitochondrial DNA damage was blocked. These results revealed that vitamin E succinate decreased hepatic UCP2 expression, reduced oxidative stress, and improved mitochondrial function in mice with steatotic livers before and after I/R, identifying mechanisms of protection in this setting.

Clotrimazole Protects the Liver Against Normothermic Ischemia-Reperfusion Injury in Rats

A. Iannelli, G. de Sousa, N. Zucchini, L. Peyre, J. Gugenheim, R. Rahmani — 2009-12-01

Abstract: Objective: To investigate the possible antiapoptotic prosurvival role of the pregnane X receptor (PXR) in hepatic ischemia-reperfusion injury in rats using clotrimazole (CTZ), a strong PXR transactivator.Materials and Methods: Male Sprague-Dawley rats were divided into 3 groups of 6 each: sham-treated, control, and CTZ-treated animals. Control and CTZ-treated animals were subjected to 30 minutes of normothermic ischemia of the whole liver followed by 6 hours of reperfusion. The animals were then killed, and the liver was excised and blood samples collected.Results: Clotrimazole induced a significant increase in expression of the CYP3A gene, indicating PXR transactivation, whereas expression of the antiapoptotic Bcl-xL gene was not increased. Serum concentrations of aspartate aminotransaminase and alanine aminotransaminase were lower in CTZ-treated animals than in control animals (difference not significant). Levels of poly(adenosine diphosphate–ribose) polymerase, a caspase-3 substrate, remained significantly higher in the CTZ-treated group compared with controls (P < .05). Clotrimazole increased the expression of phospho-p 44/42 extracellular signal-regulated kinase 1,2 (P < .05). The gene expression of the heat shock proteins 27, 70 and 90 was significantly lower in CTZ-treated animals than in controls (P < .05).Conclusion: Clotrimazole-mediated PXR transactivation protects the liver against ischemia-reperfusion apoptosis in rats. Phospho-p 44/42 extracellular signal-regulated kinase 1,2 is activated, whereas gene expression of heat shock proteins 27, 70, and 90 is downregulated by induction of PXR.

Pioglitazone Attenuates Ischemia/Reperfusion–Induced Liver Injury in Rats

2009-12-01

Abstract: Introduction: Hepatic ischemia/reperfusion (I/R) injury leads to free radical generation and acute inflammatory responses that cause liver damage, an important problem for liver transplantation. Pioglitazone is known to protect I/R injury in various tissues; however, the mechanism of cytoprotection is not well understood. This study investigated the effects of pioglitazone administration in a warm hepatic I/R model on tumor necrosis factor (TNF)-α level, tissue injury, and antioxidant enzyme activity.Materials and Methods: Eighty wistar strain rats were divided into 4 groups (n = 20): Group 1 sham hosts; Group 2 hepatic I/R; Group 3 hepatic I/R + pioglitazone (10 mg/kg); and Group 4 hepatic I/R + vehicle. Rat livers were subjected to 30 minutes of ischemia followed by 6 hours of reperfusion. After reperfusion rats were humanely killed to obtain liver tissue to study glutathione peroxidase (GPx), superoxide dysmutase (SOD), malondialdehyde (MDA) levels and for histopathologic assessment. TNF-α, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were measured in serum.Results: Pioglitazone pretreatment significantly reduced liver enzyme content (ALT, 176.80 ± 13.75 vs 235.28 ± 31.92 and AST, 748.20 ± 79.29 vs 944.85 ± 101.87) and TNF-α level (9:8.60 ± 8.67 vs 138.28 ± 9.99) after I/R compared with the control group. MDA level (3.02 ± 0.37 vs 4.36 ± 0.38) and hepatocytic degeneration were reduced in the pioglitazone-treated group. GPx (2.40 ± 0.25 vs 1.36 ± 0.31) and SOD activity (2.22 ± 0.30 vs 1.40 ± 0.35) were significantly higher in the pioglitazone-treated group compared with the control group.Conclusion: The present study showed that pioglitazone administration improved hepatic I/R injury that was associated with enhanced antioxidant enzyme activities and suppression of TNF-α, ALT, and AST levels. Because peroxisome proliferator-activated receptor-γ agonists are widely used to treat diabetic patients, it may be relatively easy to expand their clinical indication. However, further investigations will be required to delineate protective mechanisms by which pioglitazone attenuates hepatic tissue injury after I/R.

Effects of the Antioxidants Lycium Barbarum and Ascorbic Acid on Reperfusion Liver Injury in Rats

N.T. Wang, H.I. Lin, D.Y. Yeh, T.Y. Chou, C.F. Chen, F.C. Leu, D. Wang, R.T. Hu — 2009-12-01

Abstract: Objective: Ischemia/reperfusion (I/R) of the rat liver can induce liver injury through mechanisms involving oxidative and nitrosative stresses. In this study we examined the effects of antioxidants Lycium barbarum (LB) and ascorbic acid on I/R-induced liver injury in rats.Methods: Liver ischemia was induced by clamping the common hepatic artery and portal vein of rats for 40 minutes. Thereafter, flow was restored with reperfusion for 90 minutes. Blood samples collected before ischemia and after reperfusion were analyzed for alanine transaminase (ALT), lactic dehydrogenase (LDH), hydroxyl radical, and nitric oxide (NO) levels. Pharmacologic interventions included administration of ascorbic acid (100 mg/kg, i.p., 1 hour before I/R) or LB, an extract of Gogi berries: 600 mg in 100 mL of drinking water for 2 weeks prior to experimentation.Results: This protocol resulted in elevation of blood concentrations of NO, hydroxyl radical, ALT, and LDH (P < .001) in the I/R-induced liver injury group. Ascorbic acid significantly attenuated the reperfusion liver injury by attenuating hydroxyl radical (P < .01) and NO (P < .05) release. The LB aggravated I/R-induced liver injury by increasing hydroxyl radical release with no effect on NO release.Discussion and conclusions: This I/R protocol resulted in oxidative and nitrosative stress and liver injury. Ascorbic acid showed significant protective effects on reperfusion liver injury by attenuating hydroxyl radical and NO release. In contrast, LB aggravated liver injury by increasing hydroxyl radical release.

Brain Death and Its Influence on the Lungs of the Donor: How Is It Prevented?

K. Faropoulos, E. Apostolakis — 2009-12-01

Abstract: The need for lung grafts is currently greater than ever. Unfortunately, the availability of grafts is insufficient for this demand. So we are forced to request organs for transplantation in the “waste bin.” One possible solution to this problem may be the use of grafts from brain-dead patients. Sadly brain death is followed by devastating hemodynamic, inflammatory, and neurohumoral reactions in the potential donor which not only inflict direct damage, but also induce activation of the immune system which can cause rejection or even graft failure. Therefore, various groups have examined measures to prevent this outcome. In this review, we attempt to reconstruct the events that follow brain death, suggesting an algorithm to prevent a brain-dead patient's lungs from further damage. Finally, we are proposing potential measures of graft's protection of further investigation.

Essential Role for Nuclear Factor κB in Ischemic Preconditioning for Cold Ischemia-Reperfusion Injury of Intestinal Transplantation

Z. Wei, L. Fan, C. Xiangming — 2009-12-01

Abstract: Objective: The present study was designed to examine whether ischemic preconditioning could play a protective role on cold ischemia and reperfusion injury associated with intestinal transplantation in rats.Methods: The 48 male Sprague Dawley (SD) rats were randomly assigned to 2 groups. Ischemic preconditioning was performed in experimental but not control rats by preserving the self donor small bowel in Ringer lactate solution at 4 °C for 3 hours (n = 6), 6 hours (n = 6), 12 hours (n = 6), or 18 hours (n = 6). One hour reperfusion was performed for every rat after orthotopic transplantation of donor small bowel. Small bowel samples were obtained for histological examination and immunohistochemistry analysis of nuclear factor κB (NF-κB) expression.Result: The small intestinal villus was arranged more regularly in experimental compared with control rats. Ischemia preconditioning also decreased edema in the muscule layer and increased Chiu score in experimental rats. Immunohistochemistry analysis revealed that ischemic preconditioning down-regulated the expression of NF-κB in the epithelia of experimental rats.Conclusion: Ischemic preconditioning improved intestinal transplantation in rats from cold ischemia and reperfusion injury by down-regulating the expression of NF-κB.

Effect of Donor Ethnicity on Kidney Survival in Different Recipient Pairs: An Analysis of the OPTN/UNOS Database

C.O. Callender, W.S. Cherikh, P. Traverso, A. Hernandez, T. Oyetunji, D. Chang — 2009-12-01

Abstract: Background: Previous multivariate analysis performed between April 1, 1994, and December 31, 2000 from the Organ Procurement Transplant Network/United Network for Organ Sharing (OPTN/UNOS) database has shown that kidneys from black donors were associated with lower graft survival. We compared graft and patient survival of different kidney donor-to-recipient ethnic combinations to see if this result still holds on a recent cohort of US kidney transplants.Methods: We included 72,495 recipients of deceased and living donor kidney alone transplants from 2001 to 2005. A multivariate Cox regression method was used to analyze the effect of donor–recipient ethnicity on graft and patient survival within 5 years of transplant, and to adjust for the effect of other donor, recipient, and transplant characteristics. Results are presented as hazard ratios (HR) with the 95% confidence limit (CL) and P values.Results: Adjusted HRs of donor–recipient patient survival were: white to white (1); and white to black (1.22; P = .001). Graft survival HRs were black to black (1.40; P <.001); black to white (1.35; P <.001); black to Hispanic (0.87; P = .18); and black to Asian (0.69; P =.05).Summary: Black donor kidneys are associated with significantly lower graft survival when transplanted into whites or blacks and are only associated with lower patient survival when these kidneys are transplanted into white recipients. The graft and patient survival rates for Asian and Latino/Hispanic recipients, however, were not affected by donor ethnicity. This analysis underscores the need for research to better understand the reasons for these disparities and how to improve the posttransplant graft survival rates of black kidney recipients.

Potential Differences in Kidney Allograft Outcomes Between Ethnicities When Converting to Sirolimus Base Immunosuppression

2009-12-01

Abstract: Objective: The aim of this study was to determine whether ethnicity impacts graft outcomes in kidney transplant patients converted to sirolimus (SRL) and maintained on either calcineurin inhibitors (CI) or mycophenolate mofetil (MMF) with steroids.Methods: This study analyzed kidney transplants converted to SRL and transplanted between July 1991 and April 2007. Patients were divided into 4 groups: group 1: African-Americans converted to SRL + CI; group 2: non-African-Americans converted to SRL + CI; group 3: African-Americans converted to SRL + MMF; group 4: non-African-Americans converted to SRL + MMF.Results: A total of 242 patients was included. Demographics, baseline immunosuppression, and reason for SRL conversion were similar among groups. Patients converted to SRL + CI regimens had significantly higher rates of acute rejection before SRL conversion, but equal rates after conversion. Development of proteinuria was similar across groups. African-American patients converted to SRL + MMF tended to have poorer outcomes compared with African-American patients converted to SRL + CI. Non-African-American patients converted to SRL + MMF tended to have better graft outcomes compared with non-African-American patients converted to SRL + CI.Conclusions: African-Americans converted to SRL may benefit from continued CI, whereas non-African-Americans converted to SRL seem to have better outcomes with MMF. Further prospective studies are warranted to confirm these findings.

Renal Function Outcomes in Kidney Transplant Recipients After Conversion to Everolimus-Based Immunosuppression Regimen with CNI Reduction or Elimination

A. Cataneo-Dávila, J. Zúñiga-Varga, R. Correa-Rotter, J. Alberú — 2009-12-01

Abstract: Background: Chronic allograft nephropathy (CAN) is a major cause of progressive renal failure in kidney transplant recipients. Its etiology is multifactorial and can be due to immunologic or nonimmunologic conditions including calcineurin inhibitor (CNI) toxicity.Objective: To evaluate the effect of conversion from CNIs to everolimus in kidney transplant recipients with CAN.Patients and Methods: In this 12-month pilot study in renal transplant recipients with biopsy-proved CAN, therapy was changed to an everolimus-based immunosuppression regimen. Cyclosporine or tacrolimus dosage was reduced by 80% (group 1, n = 10) or discontinued (group 2, n = 10). Mycophenolate mofetil or azathioprine were withdrawn in group 1, whereas both agents were maintained in group 2. All patients received prednisone.Results: Twenty renal allograft recipients switched to an everolimus-based regimen, and patients were followed up for a mean (SD) of 12 (0.1) months. Baseline and end-of-study data were as follows: serum creatinine concentration, 1.27 (0.35) mg/dL vs 1.24 (0.4) mg/dL in group 1, and 1.27 mg/dL (0.36) vs 1.25 (0.3) mg/dL in group 2 (difference not significant); and estimated glomerular filtration rate, 72.4 (19.86) mL/min vs 76.26 (22.69) mL/min in group 1 (not significant), and 66.2 (12.95) mL/min vs 66.2 (13.73) mL/min in group 2 (not significant). One patient in group 1 experienced an acute rejection episode (Banff grade Ib), and 2 patients in group 1 and 1 patient in group 2 demonstrated borderline changes, all associated with everolimus blood concentration less than 3 ng/mL.Conclusions: Reduction or withdrawal of CNI and introduction of everolimus may be useful to slow the rate of loss of renal function in patients with CAN.

Distinct Cytokine Patterns in Different States of Kidney Allograft Function

2009-12-01

Abstract: Cytokines are crucial inflammatory mediators involved in the development of immune response leading to allograft rejection. We investigated the cytokine patterns in patients sera from cases of acute rejection episodes (ARE), chronic rejection (CR), and long-term stable courses (STABLE). The project included 20 patients with ARE, 20 with CR, and 15 with at least a 5-year stable course. Serum samples collected at the time of rejection diagnosis were cytometrically tested for concentrations of interleukin (IL) 2, IL-4, IL-6, IL-10, interferon (IFN) γ, and tumor necrosis factor α. No significant differences between investigated groups were observed before transplantation (P > .05). Significant differences were observed among the groups in serum levels of IFN-γ, IL-4, IL-6, and IL-10. Our data suggested that distinct serum cytokine patterns were present among various states of kidney allograft function. ARE was characterized by a mixed cytokine pattern with elevated IL-10 and IFN-γ compared with the STABLE patients. The cytokine pattern in CR patients, in turn, was characterized by elevated levels of IL-4, IL-6, and IL-10 and decreased levels of IFN- γ compared with both STABLE and ARE subjects. Our results suggested that the TH2 response may contribute to the initiation and/or maintenance of CR, because IL-4, IL-6, and IL-10 serve as growth and differentiation factors for B cells to increase antibody production. We also observed up-regulated production of IFN-γ and down-regulation of TH2 cytokines among patients with stable long- term graft function.

Late Acute Kidney Transplant Rejection: Clinicopathological Correlates and Response to Corticosteroid Therapy

R. Nair, N. Agrawal, M. Lebaeau, S. Tuteja, P.K.G. Chandran, M. Suneja — 2009-12-01

Abstract: Acute rejection is a major cause of kidney allograft dysfunction. It is important to distinguish between cellular and antibody-mediated rejection to guide the treatment strategy. The management of acute antibody-mediated rejection includes aggressive therapy with plasmapheresis and intravenous immunoglobulin. C4d staining of peritubular capillaries has emerged as a valuable tool in identifying antibody-mediated rejection. Late acute rejection has a worse prognosis than early acute rejection. The clinical and pathological features of late acute kidney allograft rejection are not fully understood. We studied the clinicopathological correlates of late acute rejection in our patient population. During an 8-year period, all patients who had late acute rejection (6 months posttransplant) were identified. Patients with severe chronic changes and transplant glomerulopathy were excluded. Patients were divided into C4d− and C4d− groups. Histopathological features and treatment response were evaluated. Nine patients met inclusion criteria (4 C4d+, 5 C4d−). Maintenance therapy consisted of mycophenolate mofetil, calcineurin inhibitors, and low-dose prednisone. All patients received intravenous methlyprednisolone or high-dose oral prednisone as antirejection therapy. Seventy-five percent of patients in the C4d+ group and 80% of patients in the C4d− group had a clinical response to antirejection therapy. The majority of C4d+ patients with late acute rejection who were treated with corticosteroids alone responded to treatment. The study raises the possibility that a subset of C4d+ patients with acute rejection who do not have severe chronic changes might respond to corticosteroid therapy alone.

Clinicopathological Study of Expression of Lymphatic Vessels in Renal Allograft Biopsy After Treatment for Acute Rejection

2009-12-01

Abstract: Background: Lymph vessel expression is related to inflammatory cell infiltration, around renal tubules in acute rejection episodes (ARE) of transplanted kidneys. However, there is little information on the lymph vessels after treatment of an ARE, particularly in relation to renal function and histological findings.Patients and Methods: We investigated 13 cases of ARE diagnosed by kidney transplant biopsy performed from 1997 to 2005 within 3 years of transplantation. Treatment of the ARE lead to an improved serum creatinine level in all cases. There was neither an ABO-incompatible nor an acute humoral rejection case. Lymphatic vessels in re-biopsies were examined using immunohistochemical staining with D2-40 antibody that detected lymphatic endothelium. Re-biopsy cases in which the baseline creatinine had increased by more than 20% despite treatment were considered the severe group; the others, as the stable group. The relation between lymphatic vessel density (LVD) and renal function was examined using Banff scores.Results: LVD was significantly higher in the severe than the stable group. The expression of lymph vessels versus the Banff score showed a direct relation: greater Banff scores showed higher expressions of lymph vessels.Conclusions: The expression of lymph vessels in renal allograft specimens after treatment of an ARE was related to deterioration of renal function and inflammatory cell invasion. We plan a further examination of the relationship between the expression of lymph vessels and long-term prognosis.

Enteric-Coated Mycophenolate Sodium Reduces Gastrointestinal Symptoms in Renal Transplant Patients

M. Burg, M.D. Säemann, C. Wieser, S. Kramer, W. Fischer, K. Lhotta — 2009-12-01

Abstract: A main cause for gastrointestinal (GI) complications in graft recipients is the routinely administered inosine monophosphate dehydrogenase inhibitor mycophenolic acid (MPA). MPA is available in two formulations, the prodrug mycophenolate mofetil (MMF) and the enteric-coated sodium salt (EC-MPS). Clinical results point to a better GI tolerability of EC-MPS as compared to MMF. We performed an open surveillance study in 397 organ graft recipients to investigate the clinical tolerability of EC-MPS in renal graft recipients who were converted from MMF to EC-MPS (maintenance) or who received EC-MPS as a new component of their immunsuppressive regimen (de novo). Physicians recorded GI symptoms (nausea, emesis, anorexia, diarrhea, abdominal cramps) at the start of EC-MPS treatment (visit 1) and at the next two visits in the clinic (visits 2 and 3); general tolerability (very good/good/moderate/poor) was assessed at visit 2 and 3. Two hundred seventy-five patients were on maintenance treatment with MMF and were converted to equimolar doses of EC-MPS, and 122 patients received EC-MPS de novo. The mean time since transplantation was 4.2 ± 4.4 years. Median time until visit 2 was 28 days and until visit 3, 65 days. In 63.0% of patients, tolerability was rated as very good at visit 2 and in 64.7% at visit 3. Most patients who had suffered from GI complications during preceding MMF treatment reported improvement or total disappearance of their symptoms after conversion to EC-MPS. In conclusion, EC-MPS is a useful means to reduce GI complications in MPA-treated patients.

Low-Dose Dopamine in Kidney Transplantation

M. Ciapetti, S. di Valvasone, A. di Filippo, A. Cecchi, M. Bonizzoli, A. Peris — 2009-12-01

Abstract: Background: The use of low-dose dopamine (LDD; 0.5–2.5 μg/kg/min) in kidney transplant recipients seeks to increase urine output, prevent arterial vasospasm, and reduce the incidence of acute tubular necrosis. The aim of this study was to evaluate the effect of LDD in the early postoperative period (12 hours) among kidney transplant recipients.Methods: We studied all kidney transplant recipients admitted to the Intensive Care Unit (ICU) in the early postoperative period from January 2004 to December 2008. A total of 105 patients were retrospectively assigned to two groups: group A (n = 57) was treated with LDD and group B (n = 48), not treated with LDD. All patients otherwise received the same therapy. Blood sample analysis and kidney function were recorded at 0, 6, and 12 hours after admission. For each patient, we collected the following data: donor and transplant kidney features, recipient demographics, intraoperative events, hemodynamic and kidney function parameters in the ICU, and outcomes. Patients were followed for 6 months after ICU discharge.Results: Hourly diuresis and kidney function parameters showed no significant difference between the groups. Significant differences between group A and group B were observed in heart rate (92.63 ± 14.18 vs 82.87 ± 13.5, respectively), hours of ICU length of stay (29.0 ± 17.42 vs 20.43 ± 7.35, respectively), and 6-month mortality rate (8.8% vs 0%, respectively; P < .05).Conclusion: LDD prescription in kidney transplantation neither improved kidney function during the postoperative period nor short-term outcomes, but was associated with an increased heart rate, ICU length of stay and 6-month mortality.

Characteristics of Long-Term Immunosuppressive Therapy in Chinese Pediatric Renal Transplant Patients: A Single-Center Experience

S. Yang, Z. Wu, W. Wu, W. Lin, T. Xu, J. Cai, Q. Wang, L. Liao, J. Tan — 2009-12-01

Abstract: We performed this study to investigate the trend and characteristics of various immunosuppressive regimens as well as their efficacy and safety for long-term survival of Chinese pediatric renal allograft recipients.Methods: Thirty-four patients who underwent kidney transplantation between January 1985 and July 2002 had ≥5 years follow up. We retrospectively reviewed the baseline characteristics, patient and kidney survival rates, renal function, immunosuppressive regimens, drug levels, and adverse effects of immunosuppressive medications.Results: The 1-, 3-, and 5-year recipient versus graft survival rates were 100% and 97.1%; 91.2% and 88.2%; 85.3% and 82.4%, respectively. The proportions of patients treated with cyclosporine- or tacrolimus-based immunosuppressive regimen at these times were 48.5%/51.5%; 60.0%/40.0%; and 53.6/46.4%. There were no significant differences in the dosages and drug levels after 1 year (P > .05). The proportions of azathioprine versus mycophenolate mofetil adjunctive therapy were 21.3/78.8%; 23.3%/70%; and 32.1%/60.7%, respectively. Forty percent of the surviving recipients developed complications, including hypertension, hyperlipidemia, gingival hyperplasia, hirsutism, liver dysfunction, herpes zoster, diabetes mellitus or cataracts.Conclusions: Cyclosporine or tacrolimus, plus mycophenolate mofetil or azathioprine, and prednisone triple therapies showed promising long-term results with similar efficacy and safety in pediatric renal recipients. Periodic drug level monitoring is required to facilitate individualization of immunosuppressive regimens. Drug doses and levels differed markedly from non-Chinese patients because of the ethnic discrepancy.

Pilot Study: Association of Traditional and Genetic Risk Factors and New-Onset Diabetes Mellitus Following Kidney Transplantation

2009-12-01

Abstract: Introduction: New-onset diabetes mellitus, which occurs after kidney transplant and type 2 diabetes mellitus (T2DM), shares common risk factors and antecedents in impaired insulin secretion and action. Several genetic polymorphisms have been shown to be associated with T2DM. We hypothesized that transplant recipients who carry risk alleles for T2DM are “tipped over” to develop diabetes mellitus in the posttransplant milieu.Methods: We investigated the association of genetic and traditional risk factors present before transplantation and the development of new-onset diabetes mellitus after kidney transplantation (NODAT). Markers in 8 known T2DM-linked genes were genotyped using either the iPLEX assay or allelic discrimination (AD)-PCR in the study cohort testing for association with NODAT. We used univariate and multivariate logistic regression models for the association of pretransplant nongenetic and genetic variables with the development of NODAT.Results: The study cohort included 91 kidney transplant recipients with at least 1 year posttransplant follow-up, including 22 who developed NODAT. We observed that increased age, family history of T2DM, pretransplant obesity, and triglyceridemia were associated with NODAT development. In addition, we observed positive trends, although statistically not significant, for association between T2DM-associated genes and NODAT.Conclusions: These findings demonstrated an increased NODAT risk among patient with a positive family history for T2DM, which, in conjunction with the observed positive predictive trends of known T2DM-associated genetic polymorphisms with NODAT, was suggestive of a genetic predisposition to NODAT.

Statin Therapy Ameliorates Renal Allograft Function

S.P. Hariparshad, N.D. Madala, A.G.H. Assounga — 2009-12-01

Abstract: Background: Statins have proven ability as antilipidemic agents and benefit cardiovascular survival in transplant recipients. The pleiotropic effects of statins on renal function in renal allograft recipients are still undetermined.Methods: Statin therapy was initiated according to guidelines for cardiovascular protection. Serum creatinine concentration and estimated glomerular filtration rate (eGFR) were analyzed before and after introduction of statins. The 73 patients who were retrospectively studied included those who were dialysis-dependent. Mean changes in eGFR and lipid profile were compared before and after commencing statins using χ2 tests.Results: Mean serum creatinine concentration 18 months before starting statin therapy was 160.13 μmol/L, and 24 months after starting statin therapy was 172.22 μmol/L. Mean eGFR was 53.40 mL/min 18 months before starting statin therapy, and decreased to 49.43 mL/min after starting statin therapy. This represented a decline in renal function of 0.22 mL/min/mo over 18 months. The eGFR at 12 months after beginning statin therapy was 52.67 mL/min, and at 24 months was 49.06 mL/min. The rate of decline of eGFR after starting statin therapy was significantly lower: 0.02 mL/min/mo over 24 months (P < .001). Total cholesterol and low-density lipoprotein cholesterol concentrations were significantly decreased after starting statin therapy (P < .001). Four of 73 patients developed graft failure within 24 months.Conclusion: Statin therapy in our setting was associated with a lower rate of decline in renal function in renal allograft recipients within 2 years of starting treatment.

Effects of Cyclosporine-Tacrolimus Switching in Posttransplantation Hyperlipidemia on High-Density Lipoprotein 2/3, Lipoprotein A1/B, and Other Lipid Parameters

P. Seymen, M. Yildiz, M.F. Türkmen, M.İ. Titiz, H.O. Seymen — 2009-12-01

Abstract: Objective: In renal transplant recipients, cyclosporine treatment appears to cause more frequent hyperlipidemia than tacrolimus usage. In this study, hyperlipidemic renal transplant recipients who use cyclosporine were investigated for changes in high-density lipoprotein (HDL)-2/3, apolipoprotein (Apo) A1/B, other lipid and biochemical parameters, and body mass index after prospective cyclosporine to tacrolimus switching.Materials and Methods: Fifteen patients, including 9 females of overall mean age of 33.2 ± 10.7 years and posttransplantation time of 78.06 ± 42.93 months with a mean body mass index of 23.77 ± 3.34 kg/m2, were included if they were nondiabetic, hyperlipidemic, and had undergone renal transplantation between 1992 and 2000, using cyclosporine and candidates for a switch to tacrolimus due to hyperlipidemia. Before switching to tacrolimus and at 12 months of tacrolimus use we studied fasting blood samples for creatinine, uric acid, glucose, triglyceride, Apo A1, Apo B, low-density lipoprotein (LDL), HDL2, HDL3, and total cholesterol.Results: There were no significant differences in creatinine, uric acid, glucose levels, or body mass index before tacrolimus versus 12 months thereafter. It was observed that tacrolimus significantly decreased triglyceride, Apo A1, Apo B, LDL, HDL, and total cholesterol levels (P < .001; P = .006; P = .01; P < .001; P = .03; P ≤ .001, respectively), but had no effect on homocysteine, Apo A1/B, HDL 2, HDL 3, or HDL 2/3 levels (P > .05).Conclusion: Switching from cyclosporine to tacrolimus was associated with a more favorable cardiovascular risk profile by improving hyperlipidemia.

Improved 24-Hour Blood Pressure Control With Sirolimus Versus Calcineurin Inhibitor Based Immunosuppression in Renal Transplant Recipients

2009-12-01

Abstract: Introduction: Calcineurin inhibitors (CNI) have brought dramatic improvements in early renal allograft survival. However, CNI are associated with posttransplant hypertension (PTHTN), a risk factor for mortality from cardiovascular disease and graft failure. Sirolimus (SRL) is emerging as an alternative to CNI. SRL effects on blood pressure (BP) in humans are unclear. We compared the prevalence of PTHTN among patients receiving SRL as maintenance immunosuppression with a group receiving CNI by using 24-hour ambulatory BP (AMBP). AMBP has been shown to predict cardiovascular events and progression of kidney disease better than casual office BP measurements in chronic kidney disease (CKD) patients.Methods: Renal transplant recipients with office hypertension (defined as BP > 130/80 or on antihypertensive medications), receiving stable immunosuppression and displaying consistent serum creatinine values for ≥6 months were eligible. We enrolled the first 40 patients to consent. Office BP was measured twice using a BP-Tru machine. AMBP was then analyzed for systolic BP (SBP), diastolic BP (DBP), and nocturnal blood pressure fall (NF; “dipping”). Patients were placed in the SRL group (n = 18) and the CNI group (n = 20) based on their maintenance immunosuppressive protocol. Two patients were excluded because of incomplete data. All patients received mycophenolate mofetil, and 14/38, maintenance steroids. We collected, demographics as well as type and date of renal allograft, medications, comorbidities, CKD stage, proteinuria, and plasma creatinine at the time of study enrollment.Results: Patients in the SRL group displayed lower 24-hour SBP than the CNI group (128.0 ± 10.8 vs 137.7 ± 14; P = .029). Nightime MAP, nightime SBP, and nighttime DBP were all lower in the SRL group. NF did not reach significance between the SRL and CNI groups (44% vs 15%; P = .074). Patient demographics and number of antihypertensive medications did not differ.Conclusion: The lower 24-hour SBP seen in the SRL group by AMBP may lead to improved cardiovascular and renal outcomes over time. Long-term patient follow-up will be needed to clarify the effect of the lower 24-hour SBP.

Foxp3 Staining in BK Virus Allograft Nephropathy and Comparison With Acute Cellular Rejection

D.C. Miller, Y. Qazi, M. Smogorzewski, C.G. Azen, T. Shah, M.N. Koss — 2009-12-01

Abstract: Background: Foxp3+CD4+CD25+ regulatory T cells are involved in maintaining immunologic self-tolerance. These cells have been investigated in acute cellular rejection (ACR) of renal allografts. In this retrospective pathological study, we evaluated Foxp3+ immunostaining in BK virus nephropathy (BKVN). In some circumstances, BKVN may be difficult to distinguish histologically from ACR.Methods: Sequential sections were made of 30 allograft core biopsies and stained for hematorylin and eosin (H&E), C4d, cytomegalovirus (all negative), SV40, CD3, CD20, and Foxp3. Twelve biopsies were from diagnosed BKVN cases, 12 were from diagnosed ACR cases, and six showed neither BKVN nor ACR (controls). The 100× field of maximum cellular inflammation was located and marked on the H&E stain. The same area on the CD3, CD20, and Foxp3 slides was marked. Staining lymphocytes were counted under 400× magnification. Degree of BKVN was assessed according to the Drachenberg scale; degree of ACR was assessed by the Banff criteria.Results: The range of Foxp3+ staining (cells/mm2) was much larger in BKVN (0–270) compared to ACR (0–35). The mean difference did not reach statistical significance owing to a large degree of overlap between the two groups. In BKVN, the Foxp3+ infiltrate correlated with the degree of CD3+ infiltrate (P = .012), and median Foxp3+ infiltrate increased with Drachenberg grade of BKVN. CD3+ cell levels were not significantly different in BKVN versus ACR.Conclusions: BKVN cases with high levels of Foxp3+ graft infiltrates may be manifesting an immune response different from that of ACR. Positive Foxp3 correlation with Drachenberg grade suggests a down-regulatory response.

Preventing Graft Thrombosis After Renal Transplantation: A Multicenter Survey of Clinical Practice

T. Ripert, J. Menard, Y. Schoepen, P. Nguyen, P. Rieu, F. Staerman — 2009-12-01

Abstract: Background: Renal allograft vascular thrombosis is a complication that often results in graft loss. Since there are no guidelines on immediate postoperative thromboprophylaxis, we performed a telephone survey of clinical practice in all renal transplantation centers in France.Methods: Each center considered 4 cases relating to renal transplant candidates on dialysis with an increasing risk of thrombosis: Case 1: patient with no identified risk factors; Case 2: patient with an earlier incidence of deep vein thrombosis; Case 3: patient with ischemic heart disease on antiplatelet therapy; Case 4: patient with atrial fibrillation taking a vitamin K antagonist (VKA) with lupus nephritis syndrome.Results: The treatments proposed by the centers (%) were: Case 1: No anticoagulation therapy (57.1%), calcium heparin at prophylactic doses (P-dose) (40%), or unfractionated heparin (UFH); (P-dose; 2.9%). Case 2: No anticoagulation therapy (34.3%), calcium heparin (P-dose; 51.4%), or UFH (P-dose; 5.7%). Case 3: (A) Interruption of aspirin (65.7%), and either no anticoagulation therapy (21.7%) or substitution of aspirin by calcium heparin (P-dose; 56.6%) or by UFH (P-dose; 8.7%). (B) No interruption of aspirin (34.3%), and either no additional prophylaxis (58.3%) or calcium heparin (P-dose; 33.3%). Case 4: Interruption of VKA (100%), and UFH at a curative dose (68.6%), UFH (P-dose; 14.3%), or calcium heparin (P-dose; 11.4%).Conclusions: Practices varied widely in the absence of studies of sufficiently high power. There is a need for a preoperative classification of thrombotic and hemorrhagic risk among renal transplant candidates and for consensus guidelines.

Renal Cell Carcinoma of Native Kidney After Renal Transplantation: Clinical Relevance of Early Detection

2009-12-01

Abstract: Background: Life expectancy after transplantation has improved, and cancer may soon be the leading cause of late death after transplantation. The guidelines of the American and European societies of nephrology and urology have not yet established the optimal frequency for screening for renal cell carcinoma (RCC) of native kidneys in patients who have undergone renal transplantation.Objective: To evaluate the prevalence, prognosis, and risk factors of RCC in a series of patients followed up for 16 years in our transplantation unit.Materials and Methods: Our study is a follow-up observational cohort study conducted in 694 consecutive renal transplant recipients admitted to our institution from July 1991 through July 2007. At our institution, ultrasound studies of the native kidneys were performed every 6 months after renal transplantation.Results: In the patient cohort studied, 10 patients developed a renal tumor (1.6% incidence). Three patients died of causes other than recurrence of RCC. Seven patients are alive with no evidence of RCC recurrence or metastatic disease after a mean (range) follow-up of 41 (12–96) months. Acquired cystic kidney disease and dialysis duration were positively associated with development of RCC.Conclusions: The incidence of RCC in the literature varies between 0.3% and 4.8%. The variability depends on the timing of follow-up, with a higher incidence in prospective studies with strict follow-up. We advise ultrasound studies performed by specialized physicians every 6 months after transplantation. More detailed guidelines designed by the major international transplantation societies are necessary.

Postimplantation Syndrome in a Kidney Trasplant Patient: Fever Is Not Always Synonimous With Infection

2009-12-01

Abstract: Fever in an immunocompromised patient like the transplanted subject is usually due to an overt or occult infection. Clinicians must make important decisions to find the cause of fever, and also concerning the timing and adequacy of empiric antibiotic therapy. However, occasionally, fever is not due to an infectious cause. A correct identification of its causes may avoid a needlessly prolonged course of antibiotics. Herein we have reported a kidney transplant patient with a febrile syndrome, which appeared after endovascular aortoiliac stent-graft placement, that was finally attributed to a noninfectious cause like postimplantation syndrome.

Nucleosome Serum Levels in Acute Hepatic Failure and MARS Treatment

G.A. Roth, B.A. Lubsczyk, J. Pilz, P. Faybik, H. Hetz, C.G. Krenn — 2009-12-01

Abstract: Serum nucleosomes have been suggested to be markers for cell death and apoptosis. Increased hepatocyte apoptosis can be demonstrated in acute liver failure (ALF) as well as acute-on-chronic liver failure (ACLF). We investigated the relevance of nucleosomes in the setting of acute hepatic failure. Further, we studied the effects of the molecular adsorbent recirculating system (MARS) on this marker of cell death. We measured serum nucleosome concentrations with ELISA in 12 patients with ACLF and 7 patients suffering from ALF, with 14 patients experiencing stable chronic hepatic failure (CHF) as controls. In a subset of 8 ACLF and ALF patients treated with MARS, nucleosomes were determined immediately before and after the first MARS session. Baseline nucleosome serum concentrations were significantly increased in ACLF and ALF patients as compared with CHF patients (P = .0161 and P = .0037, respectively). There was no significant difference between the ALF and ACLF groups. Moreover, serum nucleosome levels did not change significantly during MARS treatment in ALF and ACLF patients. Serum nucleosome levels therefore may be useful to discern acute from chronic hepatic failure or to monitor the course and the severity of the disease. Our results, however, warrant further larger clinical studies regarding the clearance of nucleosome in artificial liver-assist devices and to assess their role in acute hepatic failure.

Vascular Immunohistochemical Markers: Contributions to Hepatocellular Nodule Diagnosis in Explanted Livers

C. Nascimento, A. Caroli-Bottino, J. Paschoal, V.L. Pannain — 2009-12-01

Abstract: Introduction: The process of hepatic carcinogenesis involves a progression including large regenerative nodules, to dysplastic nodules, and finally to hepatocellular carcinoma. Angiogenesis is fundamental to the development of malignant tumors. Changes in sinusoidal capillarization and isolated arteries occur early in hepatic carcinogenesis. However, sometimes differentiation of hepatocellular nodules can be difficult for the general pathologist. The aim of this study was to evaluate angiogenesis by immunohistochemistry using CD34 and HHF35 antibodies for differential diagnosis of large regenerative nodules versus dysplastic nodules versus hepatocellular carcinoma using explanted cirrhotic livers.Methods: Seventy-nine nodules obtained from 29 explanted cirrhotic livers were classified according to the International Working Party as follows: 17 large regenerative, 23 low-grade dysplastic, 23 high-grade dysplastic, and 16 hepatocellular carcinomas. These nodules were submitted to immunohistochemistry with antibodies to CD34 and HHF35 to analyze sinusoidal capillarization and arterialization, respectively.Results: Semiquantitative analysis revealed that CD34 expression was >30% in dysplastic nodules and hepatocellular carcinoma; the staining in 93.8% of cases was diffuse, almost involving the entire sinusoidal lining in hepatocellular carcinoma. The number of isolated arteries was high in hepatocellular carcinoma (average, 4.369), which positively correlated with the other nodules (P < .005).Conclusion: Quantification of sinusoidal capillarization and isolated arteries in hepatocellular nodules, as detected with CD34 and HHF35 antibodies, respectively provided an important tool to differentiate dysplastic nodules from hepatocellular carcinoma.

Living Donor Liver Transplantation for Congenital Absence of the Portal Vein

2009-12-01

Abstract: The congenital absence of the portal vein (CAPV) is a rare venous malformation in which mesenteric venous blood drains directly into the systemic circulation. Liver transplantation (OLT) may be indicated for patients with symptomatic CAPV refractory to medical treatment, especially due to hyperammonemia, portosystemic encephalopathy, hepatopulmonary syndrome, or hepatic tumors. Because portal hypertension and collateral circulation do not occur with CAPV, significant splanchnic congestion may occur when the portocaval shunt is totally clamped during portal vein (PV) reconstruction in OLT. This phenomenon results in severe bowel edema and hemodynamic instability, which negatively impact the patient's condition and postoperative recovery. We have successfully reconstructed the PV in living donor liver transplantation (LDLT) using a venous interposition graft, which was anastomosed end-to-side to the portocaval shunt by a partial side-clamp, using a patent round ligament of the liver, which was anastomosed end-to-end to the graft PV with preservation of both the portal and caval blood flows. Owing to the differences in anatomy among patients, at LDLT for CAPV liver transplant surgeons should seek to preserve both portal and caval blood flows.

Comparison of Stroke Volume Variations Derived From Radial and Femoral Arterial Pressure Waveforms During Liver Transplantation

Y.K. Kim, W.J. Shin, J.G. Song, I.G. Jun, H.Y. Kim, S.H. Seong, G.S. Hwang — 2009-12-01

Abstract: Background: Stroke volume variation (SVV) is being increasingly used to predict fluid responsiveness. Since radial arterial pressure (RAP) and femoral arterial pressure (FAP) frequently showing discrepancies during liver transplantation (LT), we sought to investigate the effect of differing arterial waveforms on SVV and cardiac output (CO) derived from the Vigileo device, by comparing SVV and CO values derived from RAP (SVVRAP, CORAP) and FAP (SVVFAP, COFAP) during LT.Methods: The linear associations and agreements between SVVRAP and SVVFAP and between CORAP and COFAP were assessed during LT. Hemodynamic variables were measured at nine predefined time points in all 32 recipients, resulting in 288 data pairs.Results: Correlations were observed between SVVRAP and SVVFAP (r = .961) and between CORAP and COFAP (r = .848) at all time points. These correlations between SVVRAP and SVVFAP (r = .923) and between CORAP and COFAP (r = .902) existed even during the period when mean RAP and FAP values differed (10 minutes after reperfusion). Bland-Altman analysis for SVVRAP versus SVVFAP and for CORAP versus COFAP showed weak biases (−0.2% and −0.5 L/min) and reasonable limits of agreement (−2.2 to 1.8% and −1.9 to 0.9 L/min). The percentage errors for SVV and CO values were 27.0% and 22.2%.Conclusions: There was no significant difference between SVVRAP and SVVFAP when measured using the Vigileo device during LT. This finding indicated that SVV obtained using the Vigileo device offered relatively consistent information regardless of the catheterization site.

A Significant Expansion of CD8+ CD28− T-Suppressor Cells in Adult-to-Adult Living Donor Liver Transplant Recipients

2009-12-01

Abstract: Background: The appearance of human regulatory CD8+ CD28− T-suppressor (Ts) cells has been associated with a reduced need for maintenance immunosuppression in cadaveric heart- kidney transplant recipients and pediatric liver-intestine transplant recipients. However, few data are available in adult-to-adult living donor liver transplantation (A-A LDLT).Materials and Methods: To study the population of CD8+ CD28− Ts cells in A-A LDLT, we performed flow cytometry on whole blood specimens obtained from 20 transplant recipients, 18 end-stage liver disease patients, and 20 normal controls. Meanwhile, we measured the trough levels of immunosuppressants and monitored graft function in transplant recipients. We retrospectively reviewed the clinical data of the 20 recipients.Results: A significant expansion of CD8+ CD28− Ts cells was observed among recipients of A-A LDLT as compared with a disease control group (P = .000) or healthy individuals (P = .000). All recipients were free of acute cellular rejection episodes. During the follow-up period, no grafts were lost due to acute or chronic rejection.Conclusion: Expansion of CD8+ CD28− Ts cells in A-A LDLT seemed to be associated with a decreased occurrence of acute or chronic rejection and sustained good graft function. Based on our low dosages of immunosuppressants for recipients of A-A LDLT, we suggest that this strategy may promote expansion of CD8+ CD28− Ts cells, which can conversely maintain the low immunosuppressant dosages.

Nutrition Support With Glutamine Dipeptide in Patients Undergoing Liver Transplantation

Y. Qiu, X. Zhu, W. Wang, Q. Xu, Y. Ding — 2009-12-01

Abstract: Aim: The effect of total parenteral nutrition (TPN) support supplemented with alanyl-glutamine (Ala-Gln) dipeptide was investigated in a randomized, controlled clinical trial.Methods: Sixty-five patients with the diagnosis of end-stage liver disease or hepatic cellular carcinoma admitted for orthotopic liver transplantation were randomly divided into 3 groups: diet group (n = 21), TPN group (n = 22), and Gln group (n = 22). Patients in the TPN and Gln groups received isocaloric and isonitrogenous TPN for 7 days. Venous heparin blood samples were obtained for assay on days 2 and 9 after surgery; we performed routine pathologic tests.Results: Compared with the results on day 9 in the TPN group, there was a significant increase in the prognostic nutrition index and in prealbumin among the Gln group. Aspartate aminotransferase improved significantly by Gln treatment compared with traditional TPN support (P < .05). The pathologic results also showed Gln supplementation to reduce hepatic cell injury. A significant decrease in postoperative hospital stay was observed in the Gln group.Conclusions: Posttransplant TPN support greatly improved protein metabolism and nutritional state of patients. TPN with Ala-Gln helped to improve synthetic function and to reduce the injury to a transplanted liver.

Increase of Modified Retrograde to Antegrade Flow Ratio on Doppler Ultrasounds of the Hepatic Vein Indicating Tricuspid Regurgitation During Follow-up of Liver Transplantation: Correlation With Echocardiographic Results

2009-12-01

Abstract: The purpose of this study was to explore the best parameter of hepatic vein (HV) Doppler ultrasounds (DUS) that correlated with echocardiographic findings of and particularly the optimal cutoff value for tricuspid regurgitation (TR) following liver transplantation (LT). Thirty-six patients underwent echocardiography and DUS after LT from January 2006 to July 2007. Echocardiographic records were searched for TR grade and peak velocity of TR flow. The HV DUS parameters included peak velocity of retrograde flow (R), peak velocity of antegrade flow (A), the difference between R and A (R-A), the ratio of R to A (R/A ratio), and a modified R/A ratio, namely, the product of the R/A ratio and the R/A duration ratio. Correlation tests and receiver-operator characteristic analyses explored their interrelations and to obtained cutoff values to diagnose moderate and severe TR. TR grade best correlated with the modified R/A ratio (rho = 0.585), followed by the R/A ratio (rho = 0.503) and R (rho = 0.455). The modified R/A ratio was the most accurate parameter for the diagnosis of moderate and severe TR (Az = 0.825 and 0.895, respectively); its cutoff value was ≥0.11 for moderate TR (sensitivity and specificity both 77.78%) and 0.13 for severe TR (sensitivity, 100%; specificity, 81.2%). The modified R/A ratio best correlated with echocardiographic results of TR, although the strength of correlation was only moderate. Additionally, the modified R/A ratio was an accurate DUS parameter to diagnose moderate and severe TR among patients following LT.

Ligation of Left Renal Vein as a Salvage Procedure for Splenorenal Shunt After Living Donor Liver Transplantation: A Case Report

S.Y. Cho, S.H. Kim, K.W. Lee, S.J. Park, S.-S. Han, Y.-K. Kim — 2009-12-01

Abstract: We describe a case of recovered portal flow by ligation of the left renal vein (LRV) as a salvage procedure for a spontaneous splenorenal shunt (SRS) occurring the next day after right liver living donor transplantation (LDLT). Doppler ultrasonography showed normal graft portal venous flow immediately after LDLT, but nearly total diversion of portal flow into the existing splenorenal shunt was observed on the next day. Portal flow normalized after ligation of the LRV by relaparotomy. The patient recovered fully without complication and was discharged on the 17th postoperative day. He remains well at 14 months after the operation, returning to his previous occupation. This case was neither associated with acute rejection nor with small-for-size graft, which may increase intrahepatic vascular resistance, causing portal flow steal through shunts. Even though patients with preoperative SRS show normal portal flow immediately after transplantation, close monitoring is necessary for a possible decrease or loss of portal flow. If portal flow becomes insufficient, ligation of LRV as a salvage procedure is an important option that can be considered even after transplantation.

The Benefits of Interferon Treatment in Patients Without Sustained Viral Response After Living Donor Liver Transplantation for Hepatitis C

2009-12-01

Abstract: Although it has been recognized that interferon (IFN) treatment is crucial for recurrent hepatitis C after liver transplantation, its benefits have not been determined among patients without a sustained viral response (SVR).Methods: Eighty patients who received IFN plus ribavirin treatment after living donor liver transplantation were grouped as follows: group I (n = 18) SVR; group II (n = 25) no-SVR but viral response [VR] positive; Group III (n = 13) no-VR but biochemical response [BR] positive; and group IV (n = 24) no-VR and no-BR.Results: In groups II and III, not only the histological activity grade and fibrosis stage, but also the serum parameters including transaminases and type IV collagen were stable for 3 years after induction of IFN-based treatment. In group I, the activity grade and fibrosis stage significantly improved (P < .01). In group IV, the fibrosis stage significantly deteriorated (P < .01); the serum transaminases and type IV collagen were significantly higher than the other groups (P < .01). The mean duration of IFN treatment was significantly longer among group II (96 weeks) compared with the other cohorts (P < .05). The 5-year graft survival rate in groups II (91%) and III (100%) were comparable to those of group I (100%); group IV (62%) was significantly lower than the other groups (P < .05).Conclusion: IFN treatment was beneficial even among subjects with IFN-dependent VR or BR, although they did not achieve SVR.

Evaluation of Anti-HBs Serum Levels and Pharmacokinetic Profile After Intravenous Administration of Niuliva, a New Hepatitis B Immunoglobulin, Following Liver Transplantation

2009-12-01

Abstract: Purpose: We assessed whether trough anti–hepatitis B surface antigen (HBs) serum levels considered to be protective (>100 IU/L) were maintained in liver transplanted patients after 6 months of uninterrupted treatment with Niuliva, a new intravenous HBIg.Methods: Twenty patients, aged 18–70 years, who had undergone liver transplantation due to HBV-related liver disease at least 1 year before inclusion were enrolled in a prospective, open-label, uncontrolled, multicenter clinical study. A fixed monthly dose of 5,000 IU of study medication was administered intravenously for 6 months.Results: After the second infusion, all mean values of anti-HBs and 95% CIs were above the limit of 100 IU/L considered to be protective. The percentages of success ranged between 95% (95% CI 75.1%–99.9%) and 100% (95% CI 86.1%–100%). Mean values and 95% CI of in vivo recovery of anti-HBs at 15–30 minutes after each infusion showed overlaps between all intervals, which indicated that significant differences were not present in the recovery of post infusion anti-HBs in vivo. There were no recurrences of HBV infection during the study. There were no seroconversions in patients previously negative to hepatitis C virus or HIV. No serious adverse events related to the study medication were observed.Conclusions: Serum levels of anti-HBs after using Niuliva in patients who had undergone liver transplantation were protective in 95%–100% of cases after the study period. This new HBIg showed the expected pharmacokinetic profile and was well tolerated and safe.

The New Method of Time-Lag Ligation for Portosystemic Shunt Using Coronary Artery Bypass Graft Occluder for Adult Living Donor Liver Transplantation

2009-12-01

Abstract: We performed a living donor liver transplantation (LDLT) for a 57-year-old man who had end-stage liver failure with portal hypertension and an inferior mesenteric vein–left testicular vein (IMV-LTV) shunt. At operation, we did not clamp the shunt but encircled it with a coronary artery bypass graft (CABG) occluder (Sumitomo Bakelite K.K., Japan), which was passed outside the body through the abdominal wall to time-lag ligation (TLL). On postoperative day (POD) 5, we observed decreased portal flow. We performed TLL of the shunt using the CABG occluder without re-laparotomy. The portal flow increased, while the portal vein pressure increased slightly. In LDLT, portosystemic shunt has been reported to be a cause of portal thrombus formation or graft liver atrophy due to decreased PV flow in the mid postoperative period. However, perioperative ligation of a portosystemic shunt may prevent regeneration of the grafted liver because of excessive portal hypertension. Therefore the technique of time-lag ligation of a portosystemic shunt using a CABG occluder may be a minimally invasive, useful method to achieve physiological liver graft regeneration.

Mycophenolate Mofetil Versus Enteric-Coated Mycophenolate Sodium After Simultaneous Pancreas-Kidney Transplantation

2009-12-01

Abstract: Introduction: Adverse gastrointestinal events are frequent after mycophenolate use. The objectives of the present study were to report the incidence of acute noninfectious diarrhea, to determine the risk factors, and to compare the severity of reactions between mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS) after simultaneous pancreas kidney transplantation (SPKT).Methods: We included 165 SPKT patients from December 2000 to May 2007. Uni- and multivariate analyses were performed, using acute noninfectious diarrhea as the dependent variable. P < .05 was considered significant.Results: Mean age and duration of dialysis and of diabetes were 34.9 ± 8.2 years, 27.3 ± 18.3 months, and 21.9 ± 16.2 years, respectively. Sixty-three percent used MMF, 36.4% used EC-MPS, and 0.6% used azathioprine. Multivariate analysis showed that the duration of diabetes (P = .049, confidence interval [CI] 1.0– 1.13) and MMF use (P = .013, 95% CI 0.2–0.82) were the main determinants of acute diarrhea after SPKT. MMF dose reduction (79.2% vs 62.3%, P = .024) and severity of diarrhea associated with orthostatic hypotension were more pronounced among MMF than EC-MPS patients (42.4% vs 15.1%, P = .001). There was no difference between MMF and EC-MPS after dose reduction in relation to the occurrence of acute kidney rejection (30.8% vs 26.7%, P = .53).Conclusions: Acute noninfectious diarrhea after SPKT was related to the duration of diabetes and to prescription of MMF. Preferential use of EC-MPS was associated with a lower necessity of dose reduction and less severe episodes of acute diarrhea compared with MMF, although dose reduction was equally associated with acute episodes of kidney rejection.

One Hundred Pancreas Transplants Performed in a Brazilian Institution

J. Nicoluzzi, F. Silveira, F. Porto, M. Macri — 2009-12-01

Abstract: After decades of controversy surrounding the therapeutic validity of pancreas transplantation, the procedure has become accepted as the preferred treatment for selected patients with type 1 diabetes mellitus. Between January 2001 and January 2008, 100 patients underwent pancreatic transplantation at our center: 88 simultaneous pancreas-kidney transplantation and 12 pancreas transplantations alone. Pancreas graft management of the exocrine drainage technique involved enteric drainage in 8 (all simultaneous pancreas-kidney) and the bladder in 92 cases. The recipient systemic venous system was used for the pancreas graft venous effluent in all cases. Our overall results have shown that the number of functioning pancreatic grafts was 64 of 100. Graft losses were: rejection (n = 8), venous thrombosis (n = 9), arterial thrombosis (n = 1), or surgical complications such as anastomotic leak (n = 3), perigraft infection (n = 10), pancreatitis of the graft (n = 5). Most cases of pancreatitis (80%) had preservation times exceeding 18 hours. Despite surgical and immunosuppressive complications, our impression was that pancreas transplantation was a highly effective therapy for diabetes mellitus. After 7 years of the program and 100 transplantations, we believe that there is a major role for transplantation in diabetes management.

Availability of Pancreatic Allograft Biopsies Via a Laparotomy

2009-12-01

Abstract: Objective: The aim of this study was to evaluate the availability of a pancreatic allograft biopsy via a laparotpmy.Patients and Methods: From September 2004 to November 2007, 17 pancreas transplantations were performed: 15 simultaneous pancreas and kidney transplantations (SPK), 1 pancreas transplant alone (PTA), and one pancreas after kidney transplantation (PAK). Thirteen pancreatic allograft biopsies were obtained via an open laparotomy. This study evaluated the complications associated with this procedure, the rate of obtaining an adequate sample, and the relationship between biopsy-proven rejections and laboratory markers. In SPK cases we evaluated the synchronization between pancreas and kidney rejection. The pancreatic samples were diagnosed according to the Drachenberg classification.Results: No complications resulted from the procedure. The rate of obtaining adequate samples was 84.6%. Pancreas rejection correlated with elevation of the laboratory markers in 71.4%. Simultaneous pancreas and kidney rejection occurred in 62.5%, only kidney in 25%, and only pancreas in 12.5%.Conclusion: A pancreas graft biopsy was absolutely imperative to improve the outcome in PTA, and even in SPK cases. A pancreatic allograft biopsy via a laparotomy was a safe, necessary and easy procedure to obtain an accurate diagnosis of rejection among pancreas transplantation patients.

Validation of Limited Sampling Strategy for Estimation of Mycophenolic Acid Exposure During the First Year After Heart Transplantation

2009-12-01

Abstract: Background: Individualization of mycophenolate mofetil (MMF) dosing based on mycophenolic acid (MPA) therapeutic drug monitoring may minimize the risk of organ transplant rejection. The MPA area under the 12-hour concentration–time curve (MPA-AUC0–12h) is a more powerful predictor of rejection than are MPA trough levels. Measurement of MPA-AUC0–12h, however, is difficult and clinically impractical. The limited sampling strategy (LLS) has been proposed to overcome this problem.Objective: To validate the predictive performance of MPA LSS algorithms previously published for heart transplant (HTx) recipients (initial group) when applied to a new independent group of 29 HTx recipients (validation group) during the first year after transplantation.Patients and Methods: In a previous study, we established 2 algorithms using a LSS in HTx recipients: (1) 5.568 + 0.902 × C1.25 + 2.022 × C2 + 4.594 × C6 and (2) 3.8 + 1.025 · C1.25 + 1.819 × C2 + 1.566 × C4 + 3.479 × C6. Agreement between abbreviated AUC and the full AUC0–12h was tested using the Bland-Altman method. The validation group was used to test and assess bias and precision.Results: The 2 LSS algorithms used predicted the corresponding MPA-AUC0–12h with a mean bias of −4.85% and −3.6% and mean precision of 15.9% and 14%, respectively.Conclusions: The MPA-AUC0–12h obtained using the LSS may be useful to guide clinical management and dosing. This study prospectively validates 2 algorithms for calculation of MPA-AUC0–12h using an LSS calculated in HTx recipients. Bias and precision values suggest that our algorithms could be used for MPA therapeutic drug monitoring predictions in HTx recipients who share the same characteristics.

Immunosuppression Using the Mammalian Target of Rapamycin (mTOR) Inhibitor Everolimus: Pilot Study Shows Significant Cognitive and Affective Improvement

U.E. Lang, J. Heger, M. Willbring, M. Domula, K. Matschke, S.M. Tugtekin — 2009-12-01

Abstract: Immunosuppression using calcineurin inhibitors (CNIs) is accompanied by neuropsychiatric side effects, which counteract longevity and quality of life benefits in 10% to 28% of patients. Following the availability of the mammalian target of rapamycin (mTOR) inhibitors, it became possible to replace CNI without increasing the risk of acute graft rejection. mTOR, a member of the phosphatidyl inositol 3′ kinase family, is a downstream target of brain-derived neurotrophic factor, which has been implicated in the pathophysiology and treatment of several psychiatric disorders. Preclinical evidence has implicated the mTOR pathway in synaptic plasticity and fear memory consolidation and reconsolidation.Methods: In the present study we prospectively evaluated the psychiatric outcomes of CNI-free immunosuppression in adult maintenance heart transplant recipients (n = 9; age: 66.1 ± 6.1) using the Wechsler Memory Scale-Revised (WMS-R), Symptom Checklist-90-Revised (SCL-90-R), Beck Depression Inventory (BDI), Trail Making Tests A and B, Digit Span (DS), and Hamilton Depression Scale (HAMD).Results: Four weeks after switching to CNI-free immunosuppression using everolimus, BDI (Z = −1.14; P = .048), Trail Making tests A and B (Z = −2.52; P = .012), WMS-R (Z = 2.37; P = .018), and SCL-90-R (Z = −2.37; P = .018) were all significantly improved while DS (Z = −1.18; P = .236) and HAMD (Z = −0.595; P = .552) remained unchanged.Conclusion: This report describes favorable psychiatric outcome variables using everolimus in maintenance heart transplant recipients. CNI-free immunosuppression with everolimus might provide significant improvement in memory, concentration, and overall psychiatric symptoms among heart transplant recipients.

Heart Transplantation in a Low-Organ-Donation Environment: A Single Center Experience

2009-12-01

Abstract: Objective: Heart transplantation is the “gold standard” for treating patients in end-stage heart failure who satisfy strict selection criteria. However, infrequent transplant performance, eg, less than nine per year, may be associated with suboptimal results.Methods: We reviewed our 13-year clinical experience (1996–2008) with 73 orthotopic heart transplants performed under strict selection criteria and followed closely thereafter at the only accredited center in Greece, a country with an annual rate of only seven donors per million population.Results: Low perioperative (5.47%) and long-term (7.5%) mortality rates were responsible for a 94% survival rate in the first year, 92% at five years, and 70% at ten years—similar to those reported worldwide—along with excellent functional recovery.Conclusion: Strict recipient and donor selection criteria, combined with a rigorous multidisciplinary follow-up, yield excellent results despite the existing shortage of available grafts.

Improved, Low-Cost Methods for Pancreatic Islet Purification in Rats

X.-L. Zhang, J.-K. Yang, M. Yu, G.-F. Xue — 2009-12-01

Abstract: Objective: Density gradient separation of islets from exocrine tissue is usually performed using Ficoll. However, this reagent significantly increases the cost of isolation. The aim of the present study was to investigate the effects on islet preparations of purification methods using Lymphoprep and Iodixanol (OptiPrep) density gradients.Methods: Pancreata were procured from 46 Wistar rats, loaded with collagenase V (Sigma), and mechanically dissociated using standard procedures. After the digestion phase, the islets purified by 3 methods—Ficoll, Lymphoprep, and Iodixanol (OptiPrep)—were assessed for yields, purity, morphology, and in vitro function.Result: We expressed the yields as islet equivalents (IEQ, diameter standardizing to 150 μm), showing no significant differences. Compared with the Ficoll group, the purity was significantly higher in the Lymphoprep (P = .005) and Iodixanol (OptiPrep) groups (P = .011). While the viability was >90% in all 3 groups, the viability in the Lymphoprep Group and OptiPrep groups was significantly higher than that of the Ficoll group (P < .001). In vitro islet function did not differ among the 3 experimental groups.Conclusion: Lymphoprep and Iodixanol were as effective as Ficoll in terms of islet yield and in vitro function. High-purity and high-viability islet cells were obtained using improved Lymphoprep-based or Iodixanol (OptiPrep)-based density gradient methods, potential low-cost substitutes for Ficoll.

Improved Islet Survival and Funtion With Rat Endothelial Cells In Vitro Co-Culture

2009-12-01

Abstract: Objective: Pancreatic islet transplantation is an emerging therapy for type 1 diabetes. To preserve its function, transplanted islets must be revascularized because arterial and venous connections are disrupted during islet isolation. The current paradigm is that islet revascularization originates from the transplant recipient. This study was designed to test whether the function of isolated islets can be retained by co-culture with thoracic aorta endothelial cells in vitro.Methods: Sprague-Dawley rats were used in this study. The endothelial cells (ECs) were isolated from the thoracic aorta. The viability of the isolated islets was assessed by acridine orange/propidium iodide (AO/PI) double staining. The islets were either placed in standard cultures (group A) or in co-cultures with ECs (group B). Islet viablity was assessed by an insulin release assay.Results: The islets in group B exhibited normal morphology with >90% staining positive as detected by AO/PI with 7 days. Insulin release assays showed a significantly higher simulation index (SI) in group B compared with group A (P < .05) except on the first day.Conclusion: This study suggested that co-cultrue of freshly isolated rat islets with ECs improves postculture survival and islet function in vitro.

Novel Sulfated Glucomannan-Barium-Alginate Microcapsules in Islet Transplantation: Significantly Decreased the Secretion of Monocyte Chemotactic Protein 1 and Improved the Activity of Islet in Rats

X. Chen, L. Zhang, Z. Qi, B. Guo, L. Zhong, B. Shen, Z. Yan, J. Zhang — 2009-12-01

Abstract: The sulfated glucomannan can be used to filter the heparin-binding properties of cytokines. In this study, novel sulfated glucomannan-barium-alginate (SGA) microcapsules were prepared to encapsulate islets with barium-alginate (ABa) and calcium alginate-poly-l-lysine (APA) microcapsules as controls. SD rat islets were purified as donor cells to Lewis rats that had been treated with streptozotocin. Intraperitoneal transplantation was performed with about 3000 islet equivalent (IEQ) rat. At week three after transplantation, the concentrations of monocyte chemotactic protein-1 (MCP-1), interleukin (IL)-1 β, interferon (IFN)-γ, and tumor necrosis factor (TNF)-α in intraperitoneal fluid were determined using ELISA. At week 8, the islet cell mass in the abdominal microcapsules was excised to test insulin release. The EB-FDA fluorescence staining method was used to observe the functional activity of the islet cells. Compared with ABa and APA microcapsules, SGA microcapsules showed significantly decreased MCP-1 secretion by β-cells. Also, the concentrations of cytokines IL-1β, IFN-γ, and TNF-α were decreased significantly. The activity of the transplanted islets was significantly improved in SGA microcapsules, which shielded against cytokines better than ABa or APA microcapsules and may serve as novel method.

Effect of Low-Level Laser Irradiation on In Vitro Function of Pancreatic Islets

2009-12-01

Abstract: Introduction: Although islet isolation and transplantation techniques have improved extensively in recent years, the loss of healthy functional islets is one of the major obstacles in this enterprise. A biostimulatory effect of low-level laser irradiation has been proven on proliferation of some kinds of cells. The aim of this study was to evaluate the effect of low-level laser irradiation on the function of isolated rat pancreatic islets after 24 hours of preculture.Methods: Pancreatic islets isolated from male rats (250 to 300 g) were cultured for 24 hours in RPMI 1640 media. Groups of islets then received different energy densities (1, 3, 5 joules/cm2 or silent) at 2 wavelengths (810 nm and 630 nm) using laser devices. Insulin concentrations in buffer media were measured as indices of islet function.Results: Irradiation of incubated islets with 830 nm low-level laser significantly increased insulin secretion after a glucose challenge test (P < .05). There was a significant increase in insulin secretion after irradiation with joules/cm2 630 nm energy density (P < .001).Conclusion: These findings suggest that low-level laser irradiations improved islet cell function before transplantation.

Increased T-bet to GATA-3 Ratio During Acute Allograft Rejection in the Rat Lung

W. Jungraithmayr, L. Ji, L. Yang, W. Weder, S. Korom, M. Hersberger — 2009-12-01

Abstract: Acute allograft rejection (AR) remains a major problem in solid organ transplantation. The pivotal mechanism hinges on alloantigen recognition by recipient T helper (Th) cells that differentiate into Th1 and Th2. This study investigated the association of mRNA levels of the transcription factors T-box expressed in T cells and GATA-binding protein 3 with the development of Th1/Th2-directed immune responses. We investigated the expression of T-bet and GATA-3 mRNA levels and the protein levels of their marker cytokines interleukin (IL)-2 and IL-4 in orthotopically transplanted rat lungs during AR. We observed a nonsignificant increase in T-bet expression following allografting at days 3 and 5 but there was a significant reduction in GATA-3 expression on day 5 compared with controls. The ratio of T-bet to GATA-3 expression showed a trend to increase at day 3 following allografting reaching significance at 5 days. These changes were associated with a significant increase in the expression of IL-2 over IL-4 on days 3 and 5. This study suggests that Th1 responses play a major role during AR in the rat lung, and that this differentiation can be monitored by measuring mRNA levels of T-bet and GATA-3.

Prolonged Cardiac Allograft Survival in Mouse Model After Complement Depletion with Yunnan Cobra Venom Factor

W. Wu, H.-D. Wang, X.-X. Zhu, G. Lan, K. Yang — 2009-12-01

Abstract: Background: Activation of the complement system is the leading mechanism that causes antibody-mediated acute rejection and hyperacute rejection after xenotransplantation. The major cause of acute rejection in allogeneic transplantation is the T cell–mediated specific immune response. We studied the effects of complement on acute rejection after cardiac allotransplantation using complement depletion with cobra venom factor (CVF) in the mouse.Materials and Methods: The Balb/c-C57 mouse model of heterotopic cardiac allograft was used. The mice were divided into 2 groups, a control group and a CVF-treated group. After intravenous injection of CVF, the experimental group was observed for allograft survival time. Twelve mice from the control and experimental groups were sacrificed on days 3, 5, and 7 after the operation. The pathologic grade of acute rejection, deposition of C3 in tissue, extent of infiltration by CD4+ and CD8+ T cells, and expression of MHC-II, B7-1, and B7-2 were compared between the 2 groups.Results: In the CVF-treated group, mean (SD) survival of the cardiac allograft was 26.2 (1.7) days, and in the control group was 8.4 (0.4) days (P < .01). Pathologic examination and immunohistochemistry demonstrated that the grade of acute rejection, deposition of C3 in tissue, extent of infiltration of CD4+ and CD8+ T cells, and expression of MHC-II, B7-1, and B7-2 were significantly decreased in the CVF-treated group.Conclusion: Depletion of complement in the serum with CVF inhibits acute cardiac allograft rejection in the mouse.

Antirejection Effect of Herba Asari Extract in Rats After Cardiac Allograft Implantation

L. Zhang, B. Yu, B. Yang, G. Zhang — 2009-12-01

Abstract: Objective: We studied the antirejection effect of asarinin, the extract of Herba Asari, in rats that underwent cardiac allograft implantation.Methods: Rats received either olive oil (as a placebo control) or cyclosporine, with various amounts of asarinin or a combination of asarinin and cyclosporine daily through oral administration. 102 recipient SD rats were divided randomly into 7 groups: 1) group A, treated with 8 ml/kg olive oil per day; 2) group B, treated with 2.5 mg/kg cyclosporin A (CsA) each day; 3) group C, treated with 5 mg/kg cyclosporin A (CsA) each day; 4) group D1, treated with 12.5 mg/kg asarinin each day; 5) group D2, treated with 25 mg/kg asarinin each day; 6) group D3, treated with 50 mg/kg asarinin each day; 7) group E, treated with 12.5 mg/kg asarinin and 2.5 mg/kg CsA each day. Allograft survival was observed in each group of rats. On the seventh day posttransplantation; we analyzed weights, pathological lesions, and the levels of interleukin (IL)-2, interferon (IFN)-γ, IL-4, and IL-10 in peripheral blood.Results: The survival time of donor hearts in the asarinin groups was significantly prolonged (P < .01) when compared with the control group (7.8 ± 0.7 days). The weights of rats increased in group C, group D2, group D3, and group E at 7 days after operation. Pathological lesions were significantly less severe. The levels of IL-2 and IFN-γ decreased remarkably (P < .01), while those of IL-4 and IL-10 were not affected (P > .05) in the asarinin groups (D2 and D3).Conclusions: Asarinin decreased peripheral blood concentrations of IL-2 and IFN-γ with prolongation of allograft heart survival.

Expression of NKG2D and Its Ligand in Mouse Heart Allografts May Have a Role in Acute Rejection

L. Feng, N. Ke, Z. Ye, Y. Guo, S. Li, Q. Li, Y. Li — 2009-12-01

Abstract: Background: Ligands for the natural killer cell–activating receptor NKG2D, such as retinoic acid early inducible (Rae-1), minor histocompatibility antigen H60 (mouse), and major histocompatibility complex class I chain-related (human) may be expressed by tissues in response to stress. Because NKG2D-ligand engagement may induce natural killer cell activation and provide T-cell costimulation, we examined whether this interaction between innate and adaptive immunity occurred during heart transplant rejection.Methods: Hearts from BALB/c mice were heterotopically transplanted into C57BL/6 mice without immunosupression. Grafts were harvested at 1, 3, and 5 days after transplantation. Rae-1, H60, and NKG2D mRNA were analyzed by RT-PCR, and the proteins were detected by immunohistochemistry.Results: Compared with no expression in naïve BALB/c mice hearts, Rae-1 mRNA levels in heart allografts were detected from days three to five postoperative, H60 on day five, and NKG2D on day three but prominently on day five postoperative. Immunohistochemical assay showed that compared with rare expression in syngeneic cardiac grafts, there were significant protein expressions of Rae-1 and NKG2D in heart allografts from days three to five postoperative and of H60 on day 5 postoperative.Conclusion: This study reported significant mRNA and protein expression of Rae-1, H60, and NKG2D during acute cardiac allograft rejection. The simultaneous and significant expression of NKG2D and its ligands indicated that interactions with innate immunity may promote acute rejection. The results also suggested that Rae-1 and H60 may be new targets to amelioate this immune response.

Addition of Adipose-Derived Stem Cells in Cord Blood Cultures Stimulates Their Pluripotent Differentiation

2009-12-01

Abstract: Introduction: Adipose tissue is recognized as an important source of postnatal mesenchymal stem cells for generative medicine applications. Moreover, cord blood stem cells have been shown to contain pluripotent stem cells called unrestricted somatic stem cells (USSCs). However, this population is rare and cannot be generated from every cord blood sample. In this study, we have presented a new method of co-culture of adipose-derived stem cells (ADPCs) and cord blood stem cells that results in pluripotent differentiation.Materials and Methods: ADPCs were obtained from a piece of adipose tissue after treatment with 0.075% collagenase, which was subsequently inactivated with DMEM/10% FBS. The cellular pellet of centrifugation was plated at 5–7 × 106 cells/mL in T25 culture flasks in a low-glycose DMEM with 30% FCS. Cord blood stem cells were obtained by centrifugation following double-processing in the presence of 2% HES 200/0.5 and plated at 5–7 × 106 cells/mL in the same medium. To investigate the crucial role of ADPCs in pluripotent cord blood differentiation, we added a ADPCS as (1 × 104 cells/mL) to the cord blood cultures and analyzed the contribution of ADPCs using a microscope as well as with flow cytometry.Results: After only 3 days, adherent cells (USSC colonies) of fibroblastic morphology were detected in all co-cultured samples, whereas this was observed later or not at all in the non–co-cultured samples. The greater density of colonies in the co-coltured samples was another point. Hematopoietic CD45 cells were no longer detected after the first passage. Pluripotent stem cells were obtained from all co-cultured samples that contained stem cells positive for CD29, CD44, CD49e, CD90, CD105, CD51 Stro, and C-kit antibodies but negative for CD34, CD45, CD133, and glycophorin A.Conclusion: Addition of ADPCs was crucial to generate pluripotent-derived stem cells from cord blood samples. This double culture may be a useful tool for a universal allogeneic stem cell source for tissue repair or regeneration.

Hair Stem Cells for Bladder Regeneration in Rats: Preliminary Results

T. Drewa, R. Joachimiak, A. Kaznica, V. Sarafian, M. Pokrywczynska — 2009-12-01

Abstract: Background: A variety of tissue engineering techniques are currently under development or investigation for bladder augmentation, but so far no approach is clearly superior. The aim of this study was to compare the suitability for cystoplasty augmentation in rats of in vivo implanted acellular bladder matrices (BAM) previously seeded with hair follicle stem cells and that of matrices implanted without the cells.Materials and Methods: The rat hair follicle stem cell line was positive for CD34, p63, and Ki-67. 1 × 106 cells from 34 to 40 passages seeded onto nine BAM scaffolds were cultured for one week. Nine other scaffolds were left unseeded. Scaffolds were grafted into a surgically created defect within the anterior bladder wall: nine rats with acellular matrices and nine with cell-seeded BAM. Rats observed for six months were killed in monthly intervals. We performed gross examination, X-ray cystography, and hematoxylin-eosin, cytokine (CK)-7, CK-20, myoglobin, and desmin staining of the excised bladders.Results: Minimal adhesions were observed and urinary leakage was noted in one case. Two animals died in the acellular group. Rats developed stone disease in bladders reconstructed with acellular BAM. Bladder capacity was similar, but the shape was regular and characteristically oval only in bladders grafted with cell-seeded BAM. Muscle layers in the apical parts of the reconstructed bladder walls were extremely thin in the cases of acellular grafts and thicker in bladders reconstructed with cell-seeded grafts. Muscle layer regeneration was better in the cell-seeded group. Urothelium regenerated in all animals.Conclusions: We have shown that hair follicle stem cells may be used for rat bladder wall regeneration.

Bone Marrow–Derived Mesenchymal Stem Cells Inhibit Acute Rejection of Rat Liver Allografts in Association With Regulatory T-Cell Expansion

Y. Wang, A. Zhang, Z. Ye, H. Xie, S. Zheng — 2009-12-01

Abstract: Bone marrow–derived mesenchymal stem cells (MSCs) exhibit immunosuppressive functions in vitro and in vivo. We investigated the immunoregulatory effects of rat MSCs in a model of allogeneic liver transplantation. Brown Norway rats received livers from inbred Lewis rats, and at designated intervals, infusions of MSCs derived from recipient, donor, or third-party rats. Allograft rejection and recipient survival rates were recorded. In particular, changes in circulating regulatory T cells (Tregs) were measured. After administration of MSCs derived from each of the 3 strains, allograft recipients demonstrated markedly longer survival compared with control animals. Histologic analysis revealed significant inhibition of allograft rejection. The MSCs induced generation of CD4+CD25+Foxp3+ Tregs. We concluded that MSCs inhibit acute rejection of allografts after liver transplantation, and propose that the immunoregulatory effects of MSCs are associated with expansion of Tregs.

Multipotent Progenitor Cells Derived From Human Umbilical Cord Blood Can Differentiate Into Hepatocyte-Like Cells in a Liver Injury Rat Model

2009-12-01

Abstract: Umbilical cord blood (UCB), a rich source of hematopoietic stem cells, offers practical and ethical advantages. It has been reported that various adult stem cells transplanted into a damaged liver show characteristics of a hepatic lineage. In a previous study, we reported on novel UCB-derived adult stem cells, termed umbilical cord blood-derived multipotent progenitor cells (UCB-MPCs). We demonstrated that these cells were capable of differentiating into hepatocyte- like cells in vitro. To assess the hepatic differentiation capacity of UCB-MPCs, rat models of hepatic injury were generated using carbon tetra-chloride (CCl4) with transplantation of cells into the liver. The transplanted cells successfully incorporated into the liver of the recipient animal differentiated into functional hepatocyte-like cells that expressed hepatocyte-specific markers, such as CK-18 and albumin. Moreover, human albumin was detected in the serum of the recipient rat model. These data indicated that UCB-MPCs were capable of displaying similar characteristics to those of functional hepatocytes in a recipient liver. UCB-MPCs may prove to be a useful, transplantable alternative for hepatic progenitor cells in both experimental and therapeutic applications.

Endothelial Nitric Oxide Synthase (eNOS) Gene Polymorphism in Early Term Chronic Allograft Nephropathy

E. Yılmaz, S. Mir, A. Berdeli — 2009-12-01

Abstract: Chronic allograft nephropathy (CAN) is a complex phenomenon caused by underlying kidney disease with superimposed enviromental and genetic factors. CAN development begins with progressive renal microvascular injury. Endothelial cells play key roles in the regulation of vascular tone, permeability, and remodeling. A reduction in basal nitric oxide (NO) release as a result of genetic variation in endothelial NO synthase (eNOS) function may predispose to hypertension, thrombosis, vasospasm, and atherosclerosis, all contributing to the development of CAN. We analyzed the G894T mutation at exon 7 of the eNOS gene in relationship to CAN among 81 children with renal transplantations. The 20 patients who developed CAN underwent renal biopsies for histological confirmation. Proteinuria and hypertension were observed in CAN. We selected 173 healthy reference subjects. The G894T polymorphism of the eNOS gene was determined by PCR–restriction fragment-length polymorphism analysis. The group included 33 male and 48 female subjects who received 32 living-related grafts and 49 from deceased donors (DD) donors. Donor age (y) was 32.7 ± 13.7 and the HLA A,B,DR mismatch number of the cadaveric cases was 3.5 ± 0.79. The distribution of the genotypes were ENOS GG/GT/TT 48%, 33%, 19%, respectively. G-alleles frequency was 64.8%; T-allele frequency was 35.2%. ENOS G894T gene polymorphism did not seem to influence long-term renal allograft outcome. Recipient ENOS G894T gene polymorphism did not alter the risk of chronic allograft failure. Even if NO synthesis and bioactivity are influenced by this polymorphism, many vasoactive factors may have roles to suppress the advantageous effects of NO.

Detection of Citrate Synthase Autoantibodies in Rats with Chronic Allograft Nephropathy

L.Y. Zhang, Y.P. Lu, L. Yang, G.H. Luo, J. Song, Y.P. Li — 2009-12-01

Abstract: Citrate synthase (CS) is the one of the key enzymes in the citric acid cycle and an important mitochondrial autoantigen. The autoimmune responses against CS have not been studied in chronic allograft nephropathy (CAN). This study investigated the role of specific CS autoantibodies in rats bearing renal allografts affected with CAN.Methods: Fisher344 rat renal grafts were orthotopically transplanted into Lewis rats following the procedure of Kamada with our modification. Lewis-to-Lewis and Fisher344-to-Fisher344 kidney transplantations were also performed as autologous control groups (each n = 9). All the allograft recipients given cyclosporine (10 mg/kg−1d−1 × 10 d) were divided into four groups (each n = 9): (1) vehicle: normal saline orally; (2) cyclosporine: 6 mg/kg−1d−1; (3)FK506: 0.15 mg/kg−1d−1; (4) mycophenolate mofetil (MMF): 20 mg/ kg−1d−1. At 4, 8, and 12 weeks posttransplantation, the animals were sacrificed to harvest sera and renal allografts. The serum creatinine (SCr) was measured and pathological changes assessed according to Banff 97 criteria. IgM and IgG isotypes of CS antibodies were detected in all recipient sera by enzyme linked immunosorbent assays.Results: Both IgM and IgG isotype CS autoantibodies were observed in the sera of all the recipients before and after transplantation, but the levels of IgM CS autoantibody were obviously higher than IgG isotype in all the blood samples. It was stable not only in autologous but also in allograft groups. In both autologous groups, the SCr and IgM and IgG isotype CS autoantibodies showed no obvious change before and after transplantation, and no typical CAN occurred. The values of IgG isotype of CS autoantibody (ΔOD) at 4, 8 and 12 weeks were stable. At 4 weeks, the values of SCr, Banff score, and IgG isotype CS autoantibody (ΔOD) were not significantly different (P > .05) among the allograft groups. At 8 and 12 weeks, with progression of CAN in vehicle, cyclosporine and FK506 groups' values of SCr, Banff score, and IgG (ΔOD) also increased dramatically (P = .005) in all three groups when compared with the baseline and 4 week values, but the differences among the three groups were not significant (P > .05). At 8 and 12 weeks, the MMF group suffered mild-to-moderate CAN, but the values of SCr and Banff score were significantly lower than those in the other three groups. MMF significantly inhibited the formation of IgG (ΔOD) when compared with the other three groups (P = .02).Conclusion: This study suggested that the IgG isotype of CS autoantibody contributes to CAN after kidney transplantation. The IgM isotype is physiological. MMF significantly inhibited the formation of IgG isotype CS autoantibody, which may be related to its effects to alleviate CAN.

Gene Profiling of Cyclosporin-Enhanced Transitional Cell Carcinoma in Rat Model

X. Zhang, L. Ren, X. Hu, W. Wang, H. Yin, H. Liu, Y. Zhang — 2009-12-01

Abstract: Objective: We sought to study the effect of cyclosporine (CsA) on development of malignancy.Materials and Methods: The observation was performed in a rat model, in which transitional cell carcinoma of urinary bladder was induced with N-butyl-N-(-4-hydroxybutyl) nitrosamine. CsA was added in the food for the rats. At the end of 30 weeks, we examined the tumor burden in the urinary bladders, and compared gene expressions between the CsA-enhanced and non–CsA-enhanced tumor groups by gene profiling.Results: CsA feeding increased tumor burden: 2.3 ± 0.9 versus 1.1 ± 0.5 g (P < .05). Gene profiling showed many variations involved in CsA enhanced malignant development. Twenty-three genes with known functions were upregulated, and 46 genes with known functions downregulated. In all, 111 genes were involved in the CsA-enhanced malignant development. The regulated genes in the present study constituted 23 pathways mostly involved in carcinogenesis.Conclusions: CsA plays an important role in tumor development through gene regulation, which may constitute pathways to malignant progression.

Tranilast Attenuates Chronic Cyclosporine Nephrotoxicity in Rats

Y. Tao, L. Hu, S. Li, Y. Bai, Q. Liu, Y. Jin, D. Wei, Z. Luo — 2009-12-01

Abstract: Our aim was to explore the effects of the anti-allergic and antifibrotic agent tranilast on chronic cyclosporine (CsA) nephrotoxicity in rats.Methods: Eighteen Sprague-Dawley rats were randomized to be given the following daily treatments by gavage for 4 weeks: (1) controls, olive oil; (2) CsA group, CsA 25 mg/kg; (3) CsA plus tranilast group, CsA 25 mg/kg and tranilast 400 mg/kg. We examined the body weights and the effects of tranilast on histopathology, macrophage (Mϕ) infiltration, and expression of osteopontin (OPN).Results: The administration of tranilast improved body weight gain by CsA-treated rats (232 ± 24 vs 203 ± 6 g; P < .05). This treatment reduced the expression of OPN protein and infiltration of macrophages (9.14 ± 2.7 vs 22.44 ± 5.68 ED-1 positive cells per high power field, P < .05). Furthermore compared with the CsA alone group, it ameliorated tubulointerstitial fibrosis scores (1.18 ± 0.08 vs 2.57 ± 0.21, P < .05).Conclusion: Tranilast attenuated tubulointerstitial fibrosis through decreased expression of OPN protein and macrophage infiltration, showing renal protective effects in rats with chronic CsA nephrotoxicity.

Hemodynamic Monitoring in Pigs Undergoing Orthotopic Abdominal Multivisceral Transplantation

J. Gu, G. Tao, B. Yi, D. Liu, Y. Guo, H. Wang, K. Lu — 2009-12-01

Abstract: Anesthesia for abdominal multivisceral transplantation (MVTx) is challenging. Surgical success depends on hemodynamic stability throughout organ removal from the donor and engraftment in recipients. The aim of the current study was to summarize our experience with anesthetic management including monitoring of hemodynamic changes in pigs during MVTx procedures.Materials and Methods: Ten male pigs were randomly divided into two groups: donors and recipients for five MVTxs. A pulmonary artery catheter (PAC), transesophageal echocardiography (TEE), and pulse indicator continuous cardiac output (PiCCO) were used intraoperatively in recipients to monitor hemodynamic changes.Results: Two recipients had cardiac arrest and died intraoperatively presumably due to hypovolemia. The data obtained by PAC and TEE from three successful cases showed huge changes in hemodynamics during the stages of organ removal and reperfusion after engraftment. Use of PiCOO in one of those three cases allowed successful fluid management, resulting in stable intraoperative hemodynamics.Conclusion: The anesthetic management for MVTx surgery was improved by PAC, TEE, and PiCOO monitoring.

A Normothermic Perfusion Bioreactor to Preserve Viability of Rat Groin Flaps Extracorporally

C. Herold, K. Reimers, C. Allmeling, H.O. Rennekampff, P.M. Vogt — 2009-12-01

Abstract: Introduction: Various attempts have been made to prolong tissue survival ex vivo. To achieve an adequate ex vivo condition for flap perfusion at normothermic temperatures in a bioreactor model, a suitable perfusion solution is necessary. The main purpose of our setting at 37°C was to produce conditions under which multilineage stem cells from adipose tissue could differentiate. This study was designed to evaluate the effect of permanent perfusion on fat flaps of the rat.Materials and Methods: We elevated an epigastric adipofascial flap based on the inferior superficial epigastric vessels bilaterally in male Lewis rats and connected it to a bioreactor. The system was run by a cable pump and filled either with Hannover or Eurocollin's solution with or without permanent perfusion for 10 days. The lactate dehydrogenase (LDH) level in each solution was analyzed every 48 hours, assuming that injured cells emit this enzyme to the extracellular space and consequently to the perfusion solution. Histological samples were analyzed at the end of each trial.Results: There was a continuous significantly greater LDH level (P < .001) in bioreactors perfused with Hannover than with Eurocollin's solution. The nonperfused bioreactors showed a similar finding with lower levels compared with their perfused equivalents. Histological examination revealed significantly better preserved (P < .001) fat tissue structures in Hannover solution–perfused specimens.Conclusion: Because LDH has a half life of 24 hours, ongoing production of this enzyme for 10 days is a marker for an injured tissue consisting of viable cells. Bioreactors run with Hannover solution showed significantly higher LDH levels. Histological analyses revealed intact cells preserved in Hannover solution. Thus, Hannover solution seemed to be superior to Eurocollin's solution to keep flaps viable under normothermic conditions. The presented model facilitated fat tissue conservation under normothermic conditions and represented a foundation for further studies on the differentiation of vascularized fat tissue.

Investigation of Porcine Endogenous Retrovirus in the Conservation Population of Ningxiang Pig

2009-12-01

Abstract: Porcine endogenous retrovirus (PERV) varies between pig breeds. Screening and analysis of PERV in putative pig breeds may provide basic parameters to evaluate the biological safety of xenotransplantation from pigs to humans. In this study, PERV was investigated among the conservation population of the Ningxiang pig. The result revealed that the genotype of PERV distribution was subtype A, 100%; subtype B, 100%; and subtype C, 100%. The env sequences of PERV-A and -B showed 11 clones detected by KpnI and MboI digestion, indicating that there existed multiple variants of PERV-A and -B in the Ningxiang pig. Reverse transcriptase polymerase chain reaction results showed that PERV had transcriptional activity in these individuals. In addition, PERV A/C recombinant was detected in most individuals of Ningxiang pig. Because PERV A/C recombinants increase the potential infectious risk, the breed may not be a proper donor for xenotransplantation.

Effects of Radiation on Protein Oxidation and Lipid Peroxidation in the Brain Tissue

O. Gulbahar, A. Aricioglu, M. Akmansu, Z. Turkozer — 2009-12-01

Abstract: Radiation produces reactive oxygen species that modify macromolecules such as protein and lipid by oxidation and act in many pathological processes, causing serious damage to the brain. This study sought to evaluate the effects of radiation and the protective effect of N-acetylcysteine (NAC) on the brain tissue of guinea pigs based on the levels of lipid peroxidation and protein oxidation. Thirty-two guinea pigs were divided into groups of eight animals each: control group (group I); radiation group (group II); NAC group (group III), and NAC administered before radiation exposure group; (group IV). Guinea pigs in groups II and IV were exposed to Co60 radiotherapy using the Source-Axis-Distance = 80 technique. The levels of protein carbonyl content and malondialdehyde (MDA), which is a marker for lipid peroxidation, were investigated by the Evans-Levine and Uchiyama-Mihara methods, respectively. The protein carbonyl and MDA levels of group II were significantly greater than those of group I (P < .01). The protein carbonyl and MDA levels of group IV were lower than those of group II. The difference between the MDA levels of group IV and group II was significant (P < .01); however, the difference in protein carbonyl levels between the two groups was not significant. The results indicated that radiation increased protein oxidation and lipid peroxidation in the brain, and NAC administration before radiation exposure may aid in the treatment by decreasing protein and lipid oxidation.

Application of a Self-Made Swivel Intravenous Transfusion Device in Constructing Allogenic Small Bowel Transplantation Rejection Model in Rats

J. Yang, M. Li, H. Zhang, L. Hong, F. Feng, F. Pan, Y. Wang, W. Wang — 2009-12-01

Abstract: Background: Lacking a long-term continuous intravenous infusion device for experimental animals is the biggest obstacle to constructing an allogenic small bowel transplantation rejection model.Objective: To establish a rat heterotopic small bowel transplantation model with the use of a swivel device for intravenous transfusion.Methods: The randomized block design of controlled observations included 90 inbred male F344/NCrl BR rats as donors and 90 LEW/Crl rats as recipients. On the basis of body weight, the rats were divided into three groups each with 30 pairs of rats. Group 1, the control group, underwent small bowel transplantation. Group 2, the transfusion group, received small bowel transplantation and continuous infusion of parenteral nutrient solution. Group 3, the tacrolimus (FK506) treatment group, received small bowel transplantation, continuous infusion of parenteral nutrient solution, and intravenous injection of FK506. The general status and survival time of transplanted rats were observed for 5 weeks.Results: The operative success rate was 100%. The survival rate was 83.3% (25/30) in the control group; and 96.7% (58/60) in groups 2 and 3 (P = .039). The mean survival time of the FK506 group was 22.1 ± 13.4 days, which was significantly higher than that in the transfusion group (10.4 ± 2.9 days, P = .023).Conclusion: The simple, practical swivel intravenous infusion device provided treatment for more than 30 days, a useful tool for heterotopic segmental small bowel transplantation.

Expression of Mesenchymal, Hematopoietic, and Biliary Cell Markers in Adult Rat Hepatocytes After Partial Hepatectomy

B. Kara, K. Daglioglu, F. Doran, H. Akkiz, M. Sandikci, I.O. Kara — 2009-12-01

Abstract: Background and Purpose: It has been suggested that liver regeneration can occur either by differentiated adult hepatocytes which retain the capability for several rounds of replication or by hepatic progenitor cells, depending on the number of hepatocytes lost. We sought to study the differentiation potential of hepatocytes following partial hepatectomy (PH) in rats.Methods: Using immunohistochemistry and confocal microscopy we studied the distribution of cytokeratin 7 (CK7), CK19, vimentin, desmin, CD34, and c-kit among adult rat liver hepatocytes after PH at various times just after hepatectomy and after 8, 16, 24, 36, 48, and 60 hour and 6 and 16 days.Results: Vimentin, c-kit, and desmin positivity were observed in regenerating hepatocytes in the early stages. Desmin and vimentin staining were also demonstrated in stellate cells. Staining enhancement in stellate cells progressed from day 3 to day 6. No liver sections were stained positive for CD34, CK19, or CK7.Conclusion: After PH, mature hepatocytes revealed their potential to regain the markers that they do not express when they are quiescent. This result supported the plasticity and differentiation potential of adult hepatocytes during regeneration.

Bortezomib Successfully Reverses Early Recurrence of Light-Chain Deposition Disease in a Renal Allograft: A Case Report

Z. Kaposztas, B.D. Kahan, S.M. Katz, C.T. Van Buren, L. Cherem — 2009-12-01

Abstract: Light-Chain Deposition Disease (LCDD) frequently recurs after renal transplantation, displaying a pernicious course. Herein we have described a 39-year-old Caucasian man with a history of immunoglobulin G-kappa multiple myeloma who failed two chemotherapy regimens, but ultimately responded to the combination of thalidomide, bortezomib, and dexamethasone followed by high-dose melphalan and autologous stem cell transplantation 3 years prior to transplantation, during which time he showed no evidence of persistent or recurrent disease. At 3 days following spousal living related renal transplantation, he displayed a rapid deterioration of renal function requiring dialysis therapy. This episode failed to respond to empiric antirejection therapy including anti-thymocyte globulin, plasmapheresis, and anti-CD20 monoclonal antibody. Increasing evidence suggested recurrence of LCDD, including positive immunofluorescence staining of basement membranes and vessels for kappa light chains as well as free kappa light chains in his urine and serum. Following suspension of sirolimus, he was initiated on and responded to bortezomib (1.3 mg/m2) with discontinuation of dialysis within 3 weeks and progressively improving renal function. His maintenance therapy, in addition to six 2-week-long cycles of bortezomib separated by 1-week rest periods, includes cyclosporine (50 mg twice daily), prednisone (10 mg daily), and curcumin (9 g daily). In sum, bortezomib rescue therapy salvaged a spousal renal transplant afflicted with recurrent LCDD.

Postexposure Prophylaxis of H1N1 With Oseltamivir in a Newly Transplanted Kidney Recipient Receiving Intense Immunosuppressive Therapy

K. Marfo, J. Chapochnick-Friedmann, E. Akalin, A. Lu — 2009-12-01

Abstract: Solid organ transplant recipients undergoing immunosuppressive therapy are considered to be at high risk for serious infectious complications. Recently in the United States, a pandemic of H1N1 flu infection has been reported with serious complications. We describe H1N1 infection in a living kidney donor and the 42-year-old kidney transplant recipient exposed to this kidney donor and undergoing intense immunosuppressive therapy. Postexposure prophylaxis with oseltamivir was effective to prevent H1N1 influenza A virus in a donor and a recipient.

Myocardial Metastasis of Cutaneous Squamous Cell Carcinoma in a Renal Transplant Recipient

K.A. Mackenzie, J.W. Simcock, J.G. Lainchbury, M.J. Currie, K.L. Lynn — 2009-12-01

Abstract: Myocardial metastasis from a cutaneous squamous cell carcinoma (SCC) is rare. Herein we have presented a case of metastasis from cutaneous SCC to the myocardium in a renal transplant recipient, which was confirmed by a cardiac fine-needle biopsy. Postmortem examination revealed disseminated metastatic disease involving myocardium, lungs, thyroid, skin, and peritoneum secondary to cutaneous SCC likely related to immunosuppression. At 46 years of age, he received a renal transplant for chronic renal failure caused by chronic glomerulonephritis. He started to develop multiple nonmelanoma skin cancers 4 years later. At least 23 invasive SCCs and 14 basal cell carcinomas were excised. His immunosuppressive regimen consisted of cyclosporine (150 mg), azathioprine (75 mg), and prednisone (10 mg daily), which was not modified despite multiple nonmelanoma skin cancers. Our case report further illustrates the potentially aggressive and fatal nature of cutaneous SCCs that can develop in organ transplant recipients. It argues for modification of the immunosuppressive regimen in such patients. The management of renal transplant patients with nonmelanoma skin cancers remains difficult and complex.

Hemorrhagic Cystitis Secondary to Adenovirus or Herpes Simplex Virus Infection Following Renal Transplantation: Four Case Reports

2009-12-01

Abstract: Viral infections are common complications following renal transplantation. However, there have been few reported cases of viral cystitis secondary to herpes simplex virus or adenovirus infection. Herein, we have reported four cases of hemorrhagic cystitis secondary to infections with herpes simplex virus and adenovirus following renal transplantation. The etiology was adenovirus in three cases and herpes simplex virus in the remaining case. In all four cases, the primary cause of the renal dysfunction was diabetic nephropathy. All four patients presented with a clinical profile characterized by dysuria, pollakiuria, macroscopic hematuria, and graft dysfunction. Three of the four patients developed these symptoms within the first 3 months after renal transplantation. In all four cases, there was an increase, albeit slight, in creatinine levels, which returned to normal or near-normal values upon resolution of the symptoms. Acute cellular rejection was observed in only one case. Although rare, hemorrhagic cystitis secondary to infection, which typically occurs early in the posttransplant period, causes pronounced symptoms. The infection appears to be self-limiting, resolving completely within 4 weeks.

Successful Kidney Transplantation from a Donation After Cardiac Death Donor With an Ileal Conduit

J.M. Bellingham, M.E. Anderson, A.M. D'Alessandro — 2009-12-01

Abstract: Kidney transplantation is the treatment of choice for those affected by end-stage renal disease. Consent for organ donation continues to be one of the greatest challenges to transplanting more patients waiting for a life-saving transplant. In an attempt to increase the donor pool for patients on kidney transplant waiting lists, transplant surgeons and physicians have expanded their acceptance criteria to include expanded criteria donors, donation after cardiac death donors, as well as those donors who present unique technical challenges to organ recovery. Here we report a successful kidney transplant from a kidney donor who died from cardiac causes and who previously underwent an ileal conduit for a neurogenic urinary bladder secondary to a spinal cord injury.

Sarcomatoid Renal Cell Carcinoma in a Renal Transplant Recipient

2009-12-01

Abstract: The incidence of transplanted kidneys derived from elderly donors is increasing because of the larger waiting lists and greater age of patients with end-stage renal failure. Compared with young donors, one of the problems is the heightened risk of neoplasm transmission. We report 2 cases of kidney recipients, both of whom developed a sarcomatoid renal cell carcinoma after receiving a kidney transplant from the same 68-year-old male donor, who did not show signs of a neoplasm on a previous abdominal ultrasound or a pretransplant biopsy.The first recipient was a 66-year-old woman who developed a kidney mass with several urologic obstructive complications, tumor dissemination, and death at 9 months after kidney transplantation. The second recipient was a 48-year-old asymptomatic man with normal renal function, who was studied after the results of the first recipient, revealing another renal tumor. Transplant nephrectomy was performed and a peritoneal implant was resected. The patient is alive without evidence of a neoplasm after 18 months.Herein we have discussed the mechanisms of neoplasm transmission in kidney transplantation and possible strategies for its prevention and treatment.

False Serologic Evidence for Acute Primary Toxoplasmosis During Liver Transplantation for Fulminant Hepatitis B: A Case Report

I. Uçkay, W. Wunderli, E. Giostra, P. Majno, G. Mentha, C. van Delden — 2009-12-01

Abstract: Acute primary Toxoplasma gondii infection is usually considered to be a contraindication for solid organ transplantation. Recent reports of acute T. gondii infection have highlighted the need to include T. gondii serology in the pretransplant screening of solid-organ transplant recipients. However such serology might be misleading. We describe the case of a 25-year-old woman who received a liver transplantation for life-threatening liver failure due to hepatitis B virus infection. The presence of high IgM titers against T. gondii, as detected by membrane immunoassay, immunofluorescence, and μ-capture ELISA tests, together with the absence of IgG antibodies in the immediate pretransplant serology screening suggested acute primary T. gondii infection at the time of transplantation. We initiated a preemptive therapy with intravenous clindamycin and cotrimoxazole. However, negative PCR and IgA capture assays, together with the absence of a sustained IgG response finally excluded the initial diagnosis of primary toxoplasmosis, leading to discontinuation of antitoxoplasmosis therapy. This case illustrates the problem that, in the context of fulminant hepatitis B, serologic markers for acute primary toxoplasmosis can be falsely positive. Confirmation by PCR and IgA antibody determinations is required to confirm this diagnosis.

Emergency Liver Transplantation After Umbilical Hernia Repair: A Case Report

2009-12-01

Abstract: We report a rare case of acute liver failure due to embolization of the liver after an umbilical hernia repair in a patient with Child B liver cirrhosis and status posttransjugular intrahepatic portosystemic shunt (TIPSS). This patient initially presented with a symptomatic umbilical hernia. His umbilical vein was open (Cruveilhier–Baumgarten syndrome). After hernia repair the patient developed thrombosis of the umbilical vein with consequent partial embolization to, and acute failure of, the liver. The patient underwent successful emergency liver transplantation. This disease needs close collaboration among surgeons, gastroenterologists, hepatologists, radiologists, nutritionists, and transplant teams to establish an effective treatment plan.

Graft-versus-Host Disease Presenting With Pancytopenia After En Bloc Multiorgan Transplantation: Case Report and Literature Review

R. Mawad, A. Hsieh, L. Damon — 2009-12-01

Abstract: Graft-versus-host disease (GVHD) is a dreaded complication of bone marrow and solid organ transplantation. Commonly affected organs include skin, liver, and the gastrointestinal tract, with bone marrow and renal involvement occurring more rarely. GVHD is less commonly seen with solid organ transplants. Fewer than 100 cases of GVHD have been reported in the literature following liver transplantation. We report a case of a 53-year-old woman who required a multiorgan transplant after a complicated postoperative course following paraduodenal hernia repair. She developed isolated pancytopenia approximately 4 months after receiving an en bloc transplant involving the liver, kidney, small bowel, and pancreas. No evidence of skin, gastrointestinal, or hepatic involvement was discovered. HLA typing of the peripheral blood revealed that 28% of patient peripheral blood was composed of donor lymphocytes. Bone marrow biopsy showed a markedly hypocellular marrow with 23% donor lymphocytes and 80% of the T-cell population from the donor as well. The patient began treatment for GVHD, including high-dose steroids, basiliximab, and rituximab. Unfortunately, she developed overwhelming sepsis and subsequently died. This case describes an instance of GVHD manifested by isolated pancytopenia after en bloc transplantation of multiple solid organs. GVHD is a rare, but serious complication of solid organ transplantation that can result in death. Although isolated bone marrow involvement is uncommon, it must be considered early to avoid a delay in diagnosis. This case also highlights an association of GVHD with multiorgan transplants, although this is incompletely characterized in the current literature.

Author Index

2009-12-01