Intercellular adhesion molecule 1 (ICAM-1) induction on hepatocytes is an early marker of acute liver allograft rejection

Intercellular adhesion molecule 1 (ICAM-1) induction on hepatocytes was investigated in relation to immune activation of acute liver allograft rejection. Twelve liver recipients undergoing an episode of acute rejection were monitored by frequent fine needle aspiration biopsy (FNAB) study. All episodes were reversible, and the lymphocyte and lymphoid blast predominated with a high peak of inflammation (6.9 +/- 4.0 corrected increment units). The rejections were treated with a high dose of steroids, and the inflammation subsided within 1 week. ICAM-1 was demonstrated from FNAB preparations by a monoclonal antibody and immunoperoxidase staining. ICAM-1 was not detected on the hepatocytes immediately after transplantation but was always seen during rejection. ICAM-1 appeared 1-5 days before the onset of inflammation in the FNAB. The intensity of ICAM-1 expression increased towards the peak of inflammation and subsided thereafter. ICAM-1 induction on hepatocytes appears to be linked with a very early phase of immune activation and can be considered an early marker for acute liver allograft rejection in the FNAB.

Diet and breast cancer

It is a general opinion that the Western diet plays a significant role in increasing the risk of breast cancer in the Western World. Recently some likely mechanisms involved in increasing the risk have been disclosed. It has been found that a Western-type diet elevates plasma levels of sex hormones and decreases the sex hormone binding globulin concentration, increasing the availability of these steroids for peripheral tissues. The same diet results in low formation by intestinal bacteria of mammalian lignans and isoflavonoid phyotestrogens from plant precursors. These diphenolic compounds seem to affect hormone metabolism and production and cancer cell growth by many different mechanisms making them strong candidates for a role as cancer protective substances. The sex hormone pattern found in connection with a Western-type diet combined with low lignan and isoflavonoid excretion was found particularly in postmenopausal breast cancer patients and omnivores living in high-risk areas, and to a lesser degree in areas with less risk. However, the pattern observed was not entirely due to diet.

Cholestasis and kidney dysfunction in liver transplant patients reduces cyclosporine metabolite excretion

Cyclosporin A (CsA) is metabolized principally by the hepatic cytochrome P 450-dependent microsomal enzyme system and eliminated virtually entirely as metabolites, mainly in the bile. Only less than 1% of the oral dose is excreted unmetabolized in the urine or bile. Metabolites account for 50-70% of the total CsA in whole blood. Some of the metabolites have been shown to possess an immunosuppressive and even toxic effect but the role of this effect remains uncertain. In order to evaluate the effect of liver and kidney failure on the metabolism of CsA, we studied twelve patients who had undergone liver transplantation. The samples were collected during the first 4 postoperative weeks. The aim of the study was threefold: to evaluate (1) whether an impairment of liver function, as measured by standard biochemical liver function tests, decreased the metabolism or excretion of CsA; (2) whether an induction of either the CsA metabolites or the parent compound took place in the first postoperative period; and (3) whether kidney failure, as measured by serum creatinine, correlated with blood levels of CsA or its metabolites.

The association of HLA-DR antigens with acute steroid-resistant rejection and poor kidney graft survival

The association of an early steroid-resistant rejection (SRR) with HLA-DR antigens was analyzed in 410 kidney transplantations. A severe SRR leading to a poor (45%) 1-year graft survival (GS) occurred in 22 transplantations (5%). An acute reversible rejection (ARR) with a GS of 94% was found in 80 transplantations (20%). For the 308 (75%) transplantations with no early rejection episodes the GS was 91%. HLA-DR5 and -DR8 present in the donor as incompatible antigens were strongly associated with SRR. Further, a mismatched DR1 from the kidney donor predicted a rejection, either reversible or irreversible. These findings may have practical implications for an early diagnosis of SRR and for considering of rescue therapy whenever transplantation with disparities in these loci has been performed.

Fine-needle aspiration biopsy in the monitoring of liver allografts

The diagnosis of acute liver allograft rejection is difficult, as clinical signs or liver function tests are too unspecific. The diagnosis is mainly based on biopsy histology. However, the liver core biopsy may be associated with complications. The fine-needle aspiration biopsy (FNAB) method, originally developed for the monitoring of renal transplants, is a reliable and atraumatic technique to diagnose acute cellular rejection of liver allografts. FNAB makes it possible to quantity the inflammation associated with rejection, and to monitor the response to anti-rejection therapy. Additional information is received from changes in liver parenchymal cells indicating tissue damage and/or possible hepatotoxic effects of the drugs used. In addition, FNAB may be helpful in differential diagnosis of infections, cholestasis or other complications. A good correlation between FNAB findings of acute liver rejection and histology has been reported. However, histological examination is needed to diagnose chronic rejection. Several liver transplant centres now use FNAB technology as a routine diagnostic tool.

High cholestanol and low campesterol-to-sitosterol ratio in serum of patients with primary biliary cirrhosis before liver transplantation

Serum levels of cholesterol precursors (squalene, delta 8-cholestanol, desmosterol and lathosterol), plant sterols (campesterol and sitosterol), cholestanol and cholestanol/noncholesterol sterol ratios were related to liver damage and liver transplantation indications in healthy controls (n = 26) and in 31 patients with primary biliary cirrhosis divided into group I (S-bilirubin less than 21 mumol/L; n = 14), group II (S-bilirubin 21 to 108 mumol/L; n = 7) and group III (elected for liver transplantation; S-bilirubin 109 to 520 mumol/L; n = 10). The mean serum respective lathosterol levels in controls and in group I were three and two times higher than those in groups II and III, respectively. The plant sterol contents were higher in group II than in groups I and III and the campesterol/sitosterol ratios were lowest in group III. The serum cholestanol levels were high even in group I (i.e., in patients without icterus) and increased progressively to group III, up to 6 and 13 times those in group I and the control group, respectively. The cholestanol/noncholesterol sterol ratios increased progressively from the controls to groups I, II and III. The serum cholestanol levels were positively related to serum bilirubin levels in all primary biliary cirrhosis patients (n = 31, r = 0.906) and to the plant sterol levels in the control group and group I, but significantly negatively in group III. The cholestanol vs. precursor sterol correlations were negative in most cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Peptic ulcer surgery during the H2-receptor antagonist era: a population-based epidemiological study of ulcer surgery in Helsinki from 1972 to 1987

To evaluate the effects of improvements in medical therapy on the incidence of, indications for and operative methods used in peptic ulcer surgery, all cases of primary peptic ulcer surgery among adults in the city of Helsinki in the years 1972, 1977, 1982 and 1987 were analysed. There was a total of 565 such cases in a population which consisted of 5.2 X 10(5) individuals in 1972 and 4.8 X 10(5) individuals in 1987. The introduction of H2-receptor antagonists in 1979 was associated with a fall in the annual incidence of elective duodenal ulcer operations, from 15.5 to 6.7 per 10(5) individuals, and a fall in the annual incidence of elective gastric ulcer operations, from 9.4 to 3.1 per 10(5) individuals (P less than 0.05). The decrease was greatest among males with duodenal ulcer. In contrast, the annual incidence of emergency surgery for ulcer haemorrhage and perforation (all types of ulcers) remained relatively stable, varying from 7.2 to 10.2 per 10(5) inhabitants over the observation period (n.s.). The mean age of patients undergoing elective surgery remained essentially unchanged. The mean age of patients undergoing emergency surgery increased. The decrease in the annual incidence of elective duodenal ulcer surgery occurred mainly in relation to proximal gastric vagotomy. There was a concomitant relative increase in the incidence of gastric resection. The types of operative procedures used in cases of pyloric, prepyloric and gastric ulcer remained unchanged over the years 1972 to 1987.

Changes in plasma complement C4 and factor B allotypes after liver transplantation

Plasma complement allotypes for C4 and factor B were determined in 21 patients before and after liver transplantation together with donor typing. In 17 transplantations allelic differences between the patient and the donor could be shown. In all cases the patient's C4 and factor-B types converted to that of the donor, showing that the liver is the major source of plasma complement C4 and factor B.

The value of repeated renal retransplantations

The outcome of 64 repeated renal retransplantations (50 third, 13 fourth, and 1 fifth) during a period of 25 years was retrospectively evaluated. The prognosis of third and subsequent grafting was greatly improved if cyclosporine was included in the induction immunosuppressive regimen (one-year graft survival 79.9%, compared with 32.4% if CsA was not used). The onset of graft function was not delayed by CsA and the proportion of never functioning grafts was significantly lower (5.3%) in patients treated with CsA than in those treated without it (43.2%). Survival of the previous grafts for longer than one year favorably influenced the outcome of the subsequent grafts.

Fine-needle aspiration biopsy in the monitoring of liver allografts. Different cellular findings during rejection and cytomegalovirus infection

Fine-needle aspiration biopsies were used for clinical monitoring of liver allografts; 21 patients with an inflammatory episode of acute rejection (12.0 +/- 3.3 CIU at the peak) were studied; all episodes were reversible. The inflammatory infiltrate consisted mainly of lymphoid cells, including lymphoid blasts, with increased numbers of class II and IL-2-receptor expressing lymphocytes. No lymphoid activation was seen in corresponding blood specimens. A rapid response to antirejection therapy with high-dose steroids was recorded by FNAB. Another group of 7 recipients without rejection developed a severe CMV disease. The CMV disease was associated with mild inflammation in the FNAB (3.2 +/- 0.9 CIU at the peak), but fewer blast cells and activated cell types were recorded in the graft, and blast cells and lymphocyte activation were seen in the blood specimens, as well. The inflammation disappeared from the FNABs during successful antiviral treatment. The cellular findings of rejection and CMV infection were significantly different, and the presence or absence of rejection could be firmly established by FNAB.

Peroperative fluid management of the brain-dead multiorgan donor

Brain-dead organ donors are often dehydrated and have serum electrolyte disorders. This study was designed to analyse the haemodynamic condition and serum electrolyte balance of liver donors. Two different fluid management plans for the harvesting operation were studied. Sixteen consecutive organ donors were included. They were randomly infused either with a combination of colloid (hydroxy ethyl starch) and electrolyte solution (group COL) or with crystalloid fluid alone (group CR). Arterial pressures, heart rate, central venous pressure and oesophageal temperature were monitored and serum electrolytes were analysed before the beginning of the operation and during harvesting. The amount of fluid needed in the COL group was significantly less (P less than 0.01) than in the CR group. There were no statistical differences between the groups in the haemodynamic parameters during the study period. The oesophageal temperature was maintained in both groups. All donors were initially hypernatraemic, but the serum sodium values returned towards normal during surgery in both groups. Immediate function was seen in all livers. In conclusion, the haemodynamic stability is maintained with a smaller infused volume if hydroxyethyl starch is combined with crystalloid fluids. The formation of interstitial oedema will be less when colloids are used, but its significance in organ donation needs further evaluation.

Renal allograft immunosuppression. II. A randomized trial of withdrawal of one drug in triple drug immunosuppression

A prospective randomized study was conducted to evaluate the impact of four different conversion protocols on graft outcome in long-term follow-up. Between January 1986 and May 1987, 128 patients with first cadaveric kidney allografts were randomized at the time of transplantation to four treatment groups of 32 patients each, to be assigned 10 weeks post-transplantation. During the first 10 weeks, all patients received triple therapy with low-dose azathioprine (Aza), cyclosporin (CyA), and methylprednisolone (MP). After 10 weeks, one group continued with triple therapy (group A) while the three other groups received different combinations of two drugs, namely, Aza and CyA (group B), Aza and MP (group C), or CyA and MP (group D). Withdrawal of MP (group B) or especially of CyA (group C) was associated with 4/29 (14%) and 10/28 (36%) acute rejection episodes, respectively, for 60 days after conversion. All rejections were mild and reversible. There were no rejections after Aza withdrawal or in the group that continued on triple therapy during the corresponding time period. The most common reason for dropping out after withdrawal, for those patients who could not continue on the originally randomized medication, was azathioprine intolerance (n = 12). Five patients were switched back to triple therapy after CyA withdrawal due to rejection. Steroid intolerance was rare and CyA in low doses was very well tolerated. At 1 year there were no statistically significant differences in graft survival between groups A, B, C, and D--81%, 88%, 88%, and 88%, respectively--or in patient survival--88%, 88%, 88%, and 97%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)