Bombesin can rescue the enteric ganglia from FK506 neurotoxicity on small bowel transplantation

Background/Purpose

FK506 has been reported to have neurotoxic effects. The aim of this study was to investigate whether FK506 causes neurotoxic effects on the transplanted graft enteric ganglia (TGEG) and whether bombesin (BBS) can prevent such atrophy.

Methods

Thirty rats heterotopically underwent small bowel transplantation and were divided into 5 groups as follows: group A, syngraft (SYN) alone; group B, SYN with FK506; group C, SYN with FK506 and BBS; group D allograft with FK506; group E, allograft with FK506 and BBS. From postoperative days 14 to 28, either BBS or normal saline was administered continuously. All recipients except for group A received FK506 daily. The ganglionic count was obtained by counting the number of protein gene product 9.5 immunohistochemically stained ganglia in the cross sections of each graft.

Results

The number of TGEG in groups A, B, and C was 69.7 ± 6.0, 51.5 ± 7.7, and 84.8 ± 10.2 ganglia per cross section, respectively. There was a significant difference between each group (P < .001). The number of TGEG in groups D and E was 44.6 ± 7.5 and 65.1 ± 9.5 ganglia per cross section, respectively. There was a significant difference between the 2 groups (P < .001).

Conclusions

FK506 causes severe neurotoxicity in transplanted grafts, and BBS protects graft enteric ganglia against the neurotoxic effects of FK506.     

Antigen sampling on the Peyer's patches in a murine small bowel transplantation model

Aim

This study investigated changes in the mucosal barrier of transplanted intestines with particular emphasis on antigen sampling by Peyer's patches (PPs).

Methods

Heterotopic small bowel transplantation (SBTx) was performed as described previously. C57BL/6 mice were used as donors and BALB/c (allogeneic) or C57BL/6 mice (syngeneic) as recipients. Tacrolimus (FK506) or saline control was administered to the recipients for 2 weeks. Four groups included in this study were: syngeneic with or without immunosuppression (SYN and SYN + FK506, respectively) and allogeneic with or without immunosuppression (ALLO and ALLO + FK506, respectively). Animals were sacrificed weekly after SBTx to evaluate microfold (M) cells within PPs and for routine histology. By the third postoperative week, recipients were subjected to an intestine loop model to examine the uptake of microbeads by M cells as well as expression of Toll-like receptor 2 (TLR2) protein in the PPs with or without a TLR2 agonist challenge. We also measured occludin expression on follicle-associated epithelium (FAE) of PPs in the grafts.

Results

Transportation of microbeads through the PPs of the grafts increased in the ALLO + FK506 group compared with that in the SYN or SYN + FK506 group. This finding was accompanied by increased expression of TLR2 in the PPs and a gradually increased number of M cells following SBTx. However, occludin expression patterns on the FAE of the PPs in the grafts were similar among SYN, SYN + FK506, and ALLO + FK506 groups. Nevertheless, as transportation of microbeads and TLR2 expression in the PPs of the grafts was enhanced once exposed to Pam3Cys-SKKKK, similar results were not seen in the ALLO + FK506 group.

Conclusions

Our study revealed that the mucosal barrier of intestinal grafts is altered under alloreactivity as evidenced by enhanced antigen sampling. Such a change may provide a pathway for translocation of microorganisms in the lumen.     

Preoperative bombesin administration can protect the rat small bowel allograft from ischemic reperfusion injury

Background/Purpose

Ischemic reperfusion injury (IR/I) should be minimum for the success of small bowel transplantation (SBTx). This study investigated whether preoperative administration of neuropeptide bombesin (BBS) had a protective effect against IR/I and subsequent acute rejection.

Methods

Allogenic SBTx was performed heterotopically in rats (n = 18). All rats were administered FK506 (0.32 mg/kg per day) everyday. The rats were divided into 3 groups of 6 rats each: group 1, BBS(−)5: warm ischemic time (WIT), 5 minutes without BBS; group 2, BBS(−)15: WIT, 15 minutes without BBS; group 3, BBS(+)15: WIT, 15 minutes with BBS. The specimens were obtained from the stoma site at 1 hour after reperfusion and on postoperative day (POD) 1 and 7. The graft mucosal state and degree of acute rejection were evaluated by H&E staining. The apoptotic cells in the crypt lesion was evaluated using terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling immunohistochemistry. Apoptotic index (AI) was calculated for quantitative analysis.

Results

H&E staining revealed that the mucosal villi on POD 1 remained shortened in the BBS(−)15 group than in the other two groups. One hour after reperfusion, the AI in the BBS(−)15 group was 145.0‰ ± 37.2‰, which was significantly higher (P < .05) than in the BBS(−)5 group (32.6‰ ± 5.0‰) or the BBS(+)15 group (32.0‰ ± 3.0‰). On POD 7, the AI in the BBS(−)15 group was 63.7‰ ± 5.03‰, which was significantly higher (P < .05) than in the BBS(−)5 (17.3‰ ± 4.6‰) or the BBS(+)15 group (12.3‰ ± 3.06‰).

Conclusions

Even a short WIT of 15 minutes induced considerable allograft mucosal damage, which also worsened acute rejection. Exogenous BBS could prevent mucosal damage by IR/I and was also beneficial for the prevention of acute rejection.     

Effects of intrauterine treatment on interstitial cells of Cajal in gastroschisis

Aim

An experimental study was performed to investigate the effects of amnio-allantoic fluid exchange and intrauterine bicarbonate treatment on intestinal damage and interstitial cells of Cajal (ICC) in gastroschisis.

Materials and Methods

Thirteen-day-old fertilized chick eggs were randomly allocated into 4 groups as control, gastroschisis, gastroschisis + amnio-allantoic fluid exchange, and gastroschisis + bicarbonate treatment groups. In the treatment groups, amnio-allantoic exchange and bicarbonate treatments were performed for 3 days, after creating gastroschisis. Specimens were processed for hematoxylin-eosin and c-kit immunohistochemistry on the 18th day of incubation, after macroscopic examination. The intestines were evaluated with light microscopy for the presence of mucosal congestion and muscular and serosal edema. Mean muscular thickness and density of ICC were measured.

Results

Mean muscular thickness significantly increased in the gastroschisis group when compared with control and treatment groups. Labeling intensity, morphology, and localization of the ICC were similar in all groups. Mean ICC density significantly decreased in the gastroschisis group when compared with the control group (P < .01), and it significantly increased after amnio-allantoic fluid exchange treatment (P < .01).

Conclusions

The decrease in ICC density encountered in damaged intestinal loops in gastroschisis was prevented with intrauterine treatment. The beneficial effects of amniotic exchange on intestinal motility may depend on both prevention of intestinal damage and preservation of ICC density and function. The density of ICC might be a reliable numeric parameter both to predict intestinal motility disorders in gastroschisis and to compare the effectiveness of intrauterine treatment methods.     

Colonic dysmotility in postsurgical patients with Hirschsprung's disease. Potential significance of abnormalities in the interstitial cells of Cajal and the enteric nervous system

Purpose

Normal gut muscular function depends on the coordinated activity of both the enteric nervous system (ENS) and the interstitial cells of Cajal (ICC). Hirschsprung's disease (HD) has long been considered a purely neuronal deficit but recent data point to abnormalities in ICC in the proximal ganglionated HD colon. We examined the labeling of ICC and neuronal cells in the proximal ganglionated colon in patients with HD to determine whether abnormalities of ICC and ENS might be associated with a poor clinical outcome.

Methods

Tissue from 11 patients with HD was studied using immunohistochemistry for ICC and neuronal identification in comparison to control tissue from patients without HD. Image data were evaluated quantitatively and interpreted relative to clinical outcome.

Results

Interstitial cells of Cajal in the ganglionated colon of the HD group did not differ from the control group, but nerve cells/fibers were decreased 40%. Paired decreases in both nerve fibers and ICC in individual patients were associated with normal bowel function. Poor postoperative outcome was observed in a patient with normal innervation but with a profound decrease in ICC in the ganglionated colon.

Conclusions

Nerve fibers are decreased in the proximal ganglionated colon in patients with HD without associated gut dysmotility. Poor clinical outcome was noted only in a patient with normal innervation and markedly decreased ICC. Collection of data from a much larger number of patients with poor clinical outcome will be necessary to determine the significance of this imbalance of ICC and innervation.     

Alterations of Cajal cells in patients with small bowel atresia

Purpose

Interstitial cells of Cajal (ICC) are regarded as the pacemaker cells of the gastrointestinal tract. There are some well-designed studies investigating the structure and function of ICC subsequent to experimentally induced intestinal obstructions. However, it remains unclear whether reduction of number of ICC primarily leads to mechanical obstruction of the bowel such as seen in intestinal atresia. We aimed to investigate the number of ICC in proximal and distal parts of the atresias of patients with small bowel atresia.

Patients and Methods

Twenty-one patients (13 male and 8 female; median age, 3 days; median gestation age, 38 weeks) with jejunal or ileal atresia underwent primary repair between 2001 and 2009. The demographic data were reviewed. The specimen of the distal and proximal parts of the atretic segments was investigated according to presence and number of ICC in the myenteric plexus using immunohistochemical methods. The jejunum segments of 14 newborns who died from causes other than bowel disease were examined as a control. Scoring and count systems were developed for the evaluation of ICC. A continuous layer of CD-117 immunoreactive Cajal cells around the myenteric plexus was scored as 3, whereas discontinuous and diminished Cajal cells were scored as 2. Few and sparse Cajal cells around the myenteric ganglia and in the muscle layer were scored as 1. If there was no Cajal cell at all, it was scored as zero. In addition, the number of ICC per field was counted. The scores and the numbers of ICC per field were compared in patients with small bowel atresia and control group.

Results

All patients but one survived. One patient was lost because of congenital cardiac anomalies. The median score of control subjects was 3 (range, 1-3). Both the proximal and distal segments of the atretic bowel had a median score of 1 in patients with atresia. Twenty patients' score of proximal (95%) and 19 patients' score of distal bowel segment (90%) had an ICC score of 2 or less. Only 1 control subject (7%) had an ICC score of less than 2. Results were statistically significant in controls and patients. The mean number of ICC in the control group was 5.36 ± 2.36; in distal segments of patients with atresia, it was 1.03 ± 1.4; and in proximal s\egments, it was 0.82 ± 1.56. The difference between the control group and the patients was statistically significant (P < .05).

Conclusion

We demonstrated a remarkable decrease of ICC in small bowel wall of patients with intestinal atresia; but we could not show whether the reduction of ICC is a primary event, which also participates in the pathogenesis of intestinal atresia, or whether the mechanical obstruction caused by any unknown etiology (eg, ischemia) leads to decrease in number of ICC.     

Dyslipidemia in human kidney transplant recipients receiving cyclosporine and tacrolimus is associated with different expression of CD36 on peripheral blood monocytes

Purpose

We studied the mechanisms by which immunosuppressants result, in dyslipidemia among human kidney transplant recipients.

Methods

Seventy-five living donor kidney transplant recipients were enrolled in our study with informed consent and the approval of out Institutional Ethics Committee. Each donor-recipient pair were relatives, there were no prisoners. The serum lipid profile, the expression of CD36 on peripheral blood monocytes, and the whole blood concentrations of cyclosporine (CsA) or tacrolimus (FK506) were determined at various times after transplantation.

Results

CsA significantly increased serum lipid concentrations. The CsA concentration correlated positively with low-density lipoprotein cholesterol (LDL) levels, whereas FK506 showed no significant effect on serum lipid level. There was a positive correlation between the CsA concentrations and the expression of CD36; FK507 showed no significant effect on CD36 expression.

Conclusions

Hyperlipidemia in kidney transplant recipients treated with CsA was associated with overexpression of CD36 on peripheral blood monocytes.     

A 39-month follow-up study to evaluate the safety and efficacy in kidney transplant recipients treated with modified-release tacrolimus (FK506E)-based immunosuppression regimen

Background

We initially performed a study to evaluate the safety and efficacy of modified-release tacrolimus (FK506E) in a phase 3, 2-arm, 6-month, randomized, open-label, multicenter trial in Korean living donor de novo kidney transplant recipients. We then performed an extended study to evaluate the long-term safety and efficacy of a FK506E-based regimen up to 45 months posttransplantation in recipients already treated with FK506E.

Methods

Initial study was designed as a randomized, open-label, comparative, multicenter study in de novo living donor kidney transplant recipients. The patients were randomized to an FK506E versus a control (FK506) group (1:1). Recipients who completed a 6-month FK506E treatment study were enrolled in the 39-month follow-up study. Primary end-points were patient and graft survivals at posttransplantation 45 months. Secondary end-point was the incidence of a clinical or biopsy-proven acute rejection episode between 6 and 45 months posttransplantation.

Results

In the initial 6-month de novo study 124 enrolled patients were randomized into either the FK506E (n = 62) or the control group (n = 62). The incidence of an acute rejection episode was 19.4% (n = 12) in the FK506E versus 16.1% (n = 10) in the control group (P = .638). There was no mortality or graft failure among the 44 recipients enrolled in this additional 39-month follow-up study. There was 1 patient with biopsy-proven acute cellular rejection episode (2.3%) who underwent steroid pulse therapy with renal function recovery. At the time of study completion 40/44 recipients (90.9%) maintained FK506E treatment.

Conclusion

This 39-month study following the initial 6-month FK506E study period showed an FK506E-based immunosuppressive regimen in living donor kidney transplantation recipients to be safe and effective.     

FK506 induces the atrophy of enteric ganglia in small bowel transplantation, which can be prevented by the neuropeptide bombesin

PURPOSE: FK506, which is widely used for immunosuppression, is reported to have neurotoxicity. However, its neurotoxicity for transplanted graft enteric ganglia (TGEG) has never been reported. The aim of this study was to investigate whether FK506 has a neurotoxic effect on TGEG, and whether bombesin (BBS) prevents such atrophy. METHODS: Eighteen rats that underwent syngertic heterotopic small bowel transplantation (SBTx) using a cuff method were divided into three groups of six rats each; A: SBTx alone, B: SBTx with FK506, C: SBTx with FK506/BBS. Either BBS (10 mg/kg/d) or normal saline was infused continuously from day 14 to 28. Rats in groups B and C were administered FK506 (0.32 mg/kg/day, intramuscularly) daily. Analysis of TGEG was performed using immunohistochemistry with protein gene product (PGP) 9.5. The ganglionic number was obtained by counting PGP9.5-positive ganglia in each graft. RESULTS: The number of TGEG were reduced significantly in group B (51.5 +/- 7.7 ganglia per cross section (G/CS)) compared with group A (69.7 +/- 6.0 G/CS), but were well preserved in group C (84.8 +/- 10.2 G/CS). There were significant differences between groups B and C (P < .001) and also between groups A and C (P < .001). CONCLUSION: FK506 showed severe neurotoxicity on transplanted grafts, and bombesin could rescue TGEG against FK506 neurotoxicity.     

Demographic of short gut syndrome: increasing demand is not followed by referral of potential candidates for small bowel transplantation

Background

Despite improvements in small bowel transplantation (SBTx), early referral of patients with irreversible intestinal failure (IF) remains a major obstacle. In this study we evaluated the demand for SBTx among seven surgical pediatric centers located at least 200 km from our center.

Methods

From 1997 to 2001, 640 patients have been treated for neonatal diseases, including 248 who underwent a minor or major intestinal resection. Twenty-four patients with major resections presented with short gut syndrome, requiring total parenteral nutrition (TPN). The greatest demand was in postsurgical neonates with necrotizing enterocolitis, gastroschiesis, onphalocoeles, or midgut volvulus, and in three adults with postradiotherapy arteritis (n = 2) and mesenteric vein thromboses (n = 1). The median length of residual bowel after resection was 20 to 30 cm, without an ileocecal valve. Four patients were referred for SBTx evaluation; three died while awaiting a donor; 20 were not referred, among whom 14 died of TPN complications.

Results

Approximately 62 children per year require nutritional support for IF, most of whom develop complications related to TPN. Because many patients who are TPN-dependent develop complications, we believe that early referral would reduce mortality.

Conclusions

Greater medical awareness about the feasibility of SBTx procedures and earlier referral may improve results and quality of life after transplant.     

Transfusion of endothelial cells with lentivirus-mediated expression of fas ligand prolonged survival of rat liver allograft

Background

Immunologically privileged sites have been shown to express Fas ligand (FasL) and may protect themselves by inducing apoptosis of infiltrating inflammatory cells. We asked whether the Fas/FasL interaction could be used to protect liver allograft from acute rejection. We proposed that endothelial cells that are resistant to Fas-mediated killing could be considered as a vehicle for expression of recombinant FasL.

Methods

Based on the lenti-rFasl/puro expression system, constructs were designed that allowed endothelial cell-specific and continual expression of FasL. Endothelial cells with expression of FasL or viruses recombinant with FasL gene were transfused into portal vein of recipient rats during liver transplant surgery. Comparing groups of rats after liver transplant surgery using regular dose of FK506 and with no other treatment, we observed the aspartate aminotransferase and BIL value and survival of four groups of rat recipients.

Results

Values of AST and BIL in the cell and virus transfusion groups were between FK506 and contrast groups. The survival of cell and virus transfusion groups were longer than contrast group and shorter than FK506 group.

Conclusion

This in vitro model shows that endothelial cells with expression of FasL or viruses recombinant with FasL gene transfusion can preserve liver function and prolong the survival time of liver allografts.     

Gastroschisis in the rat model is associated with a delayed maturation of intestinal pacemaker cells and smooth muscle cells

Background

A pacemaker system is required for peristalsis generation. The interstitial cells of Cajal (ICC) are considered the intestinal pacemaker, and are identified by expression of the c-kit gene—encoded protein. Gastroschisis is characterized by a severe gastrointestinal dysmotility in newborns. In spite of this clinical picture, few studies have focused on smooth muscle cells (SMC) morphology and none on ICC. Therefore, their morphology has been studied in fetuses at term in the rat model of gastroschisis.

Methods

At 18.5 day’s gestation (E18.5), 10 rat fetuses were killed, 10 underwent surgical creation of gastroschisis, and 10 underwent manipulation only. The small intestine of the latter 2 groups was harvested at E21.5. Specimens were processed for H&E, c-kit and actin (alpha smooth muscle antibody [α-SMA]) immunohistochemistry, and trasmission electron microscopy (TEM).

Results

In the controls, SMC were c-kit+ and α-SMA+, with labeling intensity increasing by age. At E21.5, some cells around the Auerbach’s plexus were more intensely c-kit+, and differentiating ICC were seen under TEM at this level. Gastroschisis fetuses had no c-kit+ cells referable to ICC. In the more damaged loops, SMC were very faintly c-kit+ and α-SMA+. Under TEM, there were few differentiated SMC and no presumptive ICC. In the less-damaged loops, SMC were faintly c-kit+ and α-SMA+ and had ultrastructural features intermediate between those of E18.5 and E21.5 controls; ICC were very immature.

Conclusions

ICC and SMC differentiation is delayed in gastroschisis with the most damaged loops showing the most incomplete picture. These findings might help in understanding the delayed onset of peristalsis and the variable time-course of the recover seen in babies affected by gastroschisis.     

Tracheostomy--a 10-year experience from a UK pediatric surgical center

Background/Purpose

Tracheostomy in the pediatric population is associated with significant morbidity and mortality compared to adult practice. This study highlights evolving experience from a UK children's hospital.

Patients and Methods

All children undergoing tracheostomy between 1995 and 2004 were identified. Indications, complications, and outcomes were evaluated.

Results

Complete case records were reviewed for 112 children (age range, newborn-18 years). Indications included congenital birth defects—craniofacial disorders, esophageal atresia, laryngeal cleft, cystic hygroma, vascular malformations. Acquired upper airway pathology (15.5%) and malacia (12.1%) were additional criteria. Tracheostomy was also required for long-term ventilation in patients with neuromuscular disorders (12.1%) or ventilator dependency (26.7 %).Fifty-eight (50%) tracheostomies were created in infants <1 year. One hundred and nine were elective procedures with only 7 (6%) for emergency airway management. Morbidity included wound problems (14, 14.4%), tube displacement or obstruction (14, 14.4%), tracheocutaneous fistula (6, 6.2%), and pneumothorax (4, 4.1%). There were no acute hemorrhagic complications. Two children died after accidental tube displacement/obstruction.

Conclusion

Tracheostomy at this UK center is largely undertaken as an elective procedure. Children less than 1 year form an increasing patient group. Complications may be minimized by meticulous surgical technique and ensuring a comprehensive tracheostomy care program.     

Biologics and donor bone marrow cells for targeted immunomodulation in vascularized composite allotransplantation: a translational trial in swine

Introduction

Bone marrow (BM) infusion following organ transplantation is a prerequisite for potential donor-antigen-specific tolerance induction. We developed a preclinical swine model to determine the optimal dose of BM cells to achieve microchimerism. Furthermore, induction therapy was optimized by augmenting the BM infusion with biologics in the form of costimulatory blockade: cytotoxic T-lymphocyte antigen 4 immunoglobulin (CTLA4-Ig).

Materials and Methods

Yucatan miniature swine (n = 12) underwent total body and thymic irradiation for cytodepletion. Animal groups received 15, 30, or 60 million cells per kilogram of whole unmodified BM. The optimal dose of BM cell infusion (BMT) was then applied to subsequent experiments evaluating the addition of CTLA4lg. Group 1 (control) received no treatment. Group 2 received FK506 only; group 3 received irradiation, BMT, and FK506; group 4 received FK506 and CTLA4-lg.

Results

Microchimerism was established in all animals after BM cell infusion; at postoperative day 9, it was significantly increased for 60 million cells per kilogram (P = .0001). Transplanted animals in group 1 rejected the allograft 5 to 8 days after transplantation. Group 2 rejected the allograft (skin and muscle) 30 to 32 days after transplantation (2 days after cessation of immunosuppression). Group 3 rejected the skin portion of the allograft at 50, 52, and 53 days posttransplant. Remaining allograft components (muscle, bone, nerve, vessel) survived indefinitely. Group 4 animals demonstrated significantly prolonged muscle survival beyond 150 days posttransplant; the skin component survived past 150 days in two of three animals. Skin and muscle histology in all long-term surviving animals were normal.

Conclusions

BM cell infusion with 60 million cells per kilogram results in stable levels of microchimerism. The addition of costimulatory blockade (CTLA4lg) prolonged allograft skin survival and overall graft survival. Such targeted immunomodulatory protocols might facilitate immune tolerance and eliminate the need for multidrug immunosuppression to maintain graft survival after vascularized composite allotransplantation.     

Reliability of subjective wound assessment

Introduction

Assessment of the take of split-skin graft and the rate of epithelialisation are important parameters in burn surgery. Such parameters are normally estimated by the clinician in a bedside procedure. This study investigates whether this subjective assessment is reliable for graft take and wound epithelialisation.

Methods

Observers involved in the field of burns (experienced, medium-experienced and inexperienced observers), and dermatologists specialized in the field of wound healing evaluated the percentage graft take and epithelialisation in 50 photographic skin-grafted burn wounds. Reliability was tested using the intraclass correlation coefficient (ICC).

Results

Intra- and interobserver reliability of parameter graft take was highest within the experienced observers (ICC average > 0.91), followed by medium- and inexperienced observers (ICC average > 0.80 and ICC average > 0.68). Parameter epithelialisation showed the same pattern of intra- and interobserver ICC scores (experienced > medium > inexperienced). Interobserver ICC single scores of the experienced group were reasonable to good. Interobserver reliability of the dermatologists was similar to medium-experienced observers.

Conclusions

Our data show that one experienced observer can obtain adequate reliable results by means of a single assessment of graft take and epithelialisation. Furthermore, experience of the observer results in an increase of reliability.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Sirolimus-Based Immunosuppression Therapy in Liver Transplantation for Patients With Hepatocellular Carcinoma Exceeding the Milan Criteria

Aim

Sirolimus (SRL) acts as a primary immunosuppressant or antitumor agent. The aim of the present study was to evaluate the influence of SRL on the recurrence rate and survival of patients after orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC) exceeding the Milan criteria.

Materials and Methods

We retrospectively examined 73 consecutive patients who underwent OLT for HCC exceeding the Milan criteria from March 2004 through December 2005. Among them, 27 patients were treated with SRL-based immunosuppressive protocols after OLT, and 46 patients by an FK506-based protocol. Statistical analysis was based on the intent-to-treat method.

Results

The 2 groups were comparable in all clinicopathologic parameters. The mean overall survival was 594 ± 35 days in the SRL group and 480 ± 42 days in the FK506 group (P = .011); the mean disease-free survival period was 519 ± 43 days in the SRL group and 477 ± 48 days in the FK506 group (P = .234). Multivariate analysis revealed Child's status (P = .004) and immunosuppressive protocol (P = .015) were the significant factors affecting overall survival. Only microvascular invasion (P = .004) was significantly associated with disease-free survival. Among 24 surviving patient in the SRL group, 2 patients had SRL discontinued for toxicity; 10 had SRL monotherapy immunosuppression.

Conclusion

The SRL-based immunosuppressive protocol improved the overall survival of patients after OLT for HCC exceeding the Milan criteria, probably by postponing recurrence and with better tolerability.     

Graft-vs-host disease after small bowel transplantation in children

Purpose

Graft-vs-host disease (GVHD) is a rare complication of transplantation of organs rich in immunocompetent cells. The goal of this study was to report the features of GVHD after small bowel transplantation (SBTx) in children.

Methods

The study involved a retrospective review of patients undergoing SBTx between 1999 and 2009 who had GVHD.

Results

Of 46 children receiving 52 intestinal grafts (2 liver-intestine and 3 multivisceral), 5 (10%) developed GVHD. Median age at transplant was 42 (19-204) months. Baseline immunosupression consisted of tacrolimus and steroids supplemented with thymoglobulin (n = 2) or basiliximab (n = 3) for induction. Median time between transplantation and GVHD was 47 (16-333) days. All patients had generalized rash, 2 had diarrhea, and 2 had respiratory symptoms. Other symptoms were glomerulonephritis (n = 1) and conjunctivitis (n = 1). Four developed severe hematologic disorders. The diagnosis was confirmed by skin biopsy in 4 patients and supported by chimerism studies in two. Colonoscopy and opthalmoscopic findings were also suggestive in one. Treatment consisted of steroids and decrease of tacrolimus, with partial response in four. Other immunosuppressants were used in refractory or recurrent cases. Three patients died within 4 months after diagnosis.

Conclusion

Graft-vs-host disease is a devastating complication of SBTx, with high mortality probably associated with severe immunologic dysregulation.     

Establishment of an Ex Vivo Lung Perfusion Model Using Non-Heart-Beating Large Pigs

Background

Functional evaluation of potentially damaged lungs donated after cardiac death is crucial for widespread clinical transplantation. To date, the mean weight of animals used in studies of ex vivo lung perfusion (EVLP) has been 60 kg; however, in the clinical setting, donor weight may be greater.

Objective

To investigate EVLP using lungs from large pigs (mean weight, 115 kg) to simulate human adult lungs donated after cardiac death.

Materials and Methods

Five heart-lung blocks were obtained at 20 minutes after death at the slaughterhouse. The lungs were flushed and preserved on ice for 6 hours before being connected to an ex vivo lung circuit, and were perfused for at least 2 hours.

Results

In all cases, perfusion was sustained for at least 2 hours. Mean (SEM) final flow rate was 4.9 (0.1) L/min, pulmonary artery pressure was 14.8 (1.7) mm Hg, and oxygen tension/fraction of inspired oxygen was 518.0 (18.0) mm Hg. The shunt fraction was 20.5% (4.0%). Histologic analysis demonstrated no significant pulmonary edema at the end of perfusion.

Conclusion

We successfully completed EVLP using lungs from large pigs.     

The Effect of Malononitrilamides (FK778) on Phenotypic Properties of Human Peripheral Dendritic Cells

Background

FK778, a malononitrilamide analogue of lefunomide, is currently a promising immunosuppressive drug. Because the cellular and molecular mechanisms underlying the effects of FK778 are not entirely clarified. We studied its effects on human peripheral dendritic cells.

Methods

Peripheral blood mononuclear cells (PBMC) from 12 healthy volunteers were isolated by density separation over Ficoll solution. After resuspension in adaptive immunotherapy medium (AIM)-V medium, they were cultured without exogenous growth factors. The study group was treated with FK 778 (50 μg/mL) or Rapamycin (10 ng/mL). The phenotype of dendritic cell was ascertained by indirect immunoflurescence for analysis by flow cytometry.

Results

Compared with the Rapamycin-treated controls, the expressions of CD80, CD83, CD86, HLA-DA, CD54, CD62, CCR5, and CCR7 in the FK778-treated myeloid dendritic cells and the expression of CD80, CD83, CD86, HLA-DA, and CD54 in the FK778-treated plasmacytoid dendritic cells were significantly down-regulated.

Conclusion

FK778 inhibited the differentiation and maturation of dendritic cells.