Regulation of natural killer cell-mediated swine endothelial cell lysis through genetic remodeling of a glycoantigen

The effect of remodeling of a glycoantigen such as the alpha-Gal epitope, Galalpha1,3Galbeta1,4GlcNAc-R, by the introduction of glycosyltransferase genes on natural killer (NK) cell-mediated direct cytotoxicity was investigated using human peripheral blood mononuclear cells (PBMC) or an NK-like cell line, YT cells, as an effector, and swine endothelial cells (SEC) as a target. Several SEC transfectants were established by transfection with the genes for beta1,4-N-acetylglucosaminyltransferase III, alpha2, 3-sialyltransferase and alpha1,2-fucosyltransferase. These transfections led to dramatic reductions in both direct and indirect NK cell-mediated cytotoxicity, by 72-94% in the case of PBMC and 27-72% in that of YT cells, in addition to an effective reduction in xenoantigenicity, which is substantially caused by the alpha-Gal epitope, to human natural antibodies. The NK cell-mediated direct cytotoxicity was remarkably blocked by an anti-alpha-Gal epitope monoclonal antibody or GSI lectin which preferentially binds to the epitope. Furthermore, treatment of the parental cells with alpha-galactosidase resulted in a significant reduction in cytotoxicity. These results suggest that the alpha-Gal epitope is involved not only in hyperacute rejection and acute vascular rejection, but also in NK cell-mediated direct cytotoxicity. Thus, the genetic remodeling of the alpha-Gal epitope and probably other glycoantigens as well can be expected to represent a new approach for overcoming not only indirect but also direct immunity to xenografts.

Function of human factor H and I on xenosurface

The cell membrane-bound forms of mini-factor H with 1-4 short consensus repeats (fH-PI) and factor I (fI-PI) were constructed. Swine endothelial cell (SEC) lines and Chinese hamster ovary (CHO) cell expressing fH-PI or fI-PI were established and confirmed by flow cytometry. The cell lysate of the SEC line expressing fH-PI showed strong cofactor activity for the cleavage of C3b, and fI-PI demonstrated the protease activity for C4b and C3b not only in the fluid phase but also on the cell membrane. In addition, fH-PI blocked human complement-mediated cell lysis by approximately 30-40%. An SEC line with a low expression of fI-PI showed a weak inhibition of cell lysis in human serum, whereas a CHO cell transfectant with a high expression of fI-PI showed over a 60% inhibition of cell lysis. The results suggest that fH-PI and fI-PI have potential for use in clinical xenotransplantation.

Masking and reduction of the Galactose-alpha1,3-Galactose (alpha-Gal) epitope, the major xenoantigen in swine, by the glycosyltransferase gene transfection

The alpha-Gal epitope (Gal-alpha1-3Gal-beta1-4-GlcNAc-R), which is biosynthesized by the UDP-Gal:alpha1-3-galactosyltransferase (alpha1, 3GT), is highly associated with hyperacute rejection in swine to human xenotransplantation. A variety of strategies have been pursued to reduce or eliminate this epitope from swine tissues. Since swine ES cells are not available at present, the targeted knock out of the alpha1,3GT is restricted. Other strategies, such as enzyme competition of the alpha1,3GT with other glycosyltransferases and/or control of sugar processing by the glycosyltransferases, provide a new insight into the downregulation of the alpha-Gal epitope. This review will focus on this type of strategy, which involves a gene transfection of variety of glycosyltransferases as competitors against alpha1,3GT.

Cisplatin-5-fluorouracil therapy with remarkable effect and 5-year survival for paraaortic lymph node metastases of rectal carcinoma in females: a case report

A 68-year-old woman was admitted because of a rectal carcinoma with huge paraaortic lymph node metastases. Low anterior resection with regional lymph node dissection was performed, leaving the paraaortic mass. After the operation, cisplatin-5-fluorouracil therapy was used as supplemental chemotherapy. The metastatic lymph nodes shrank remarkably in response to anticancer drugs. We evaluated the effect of chemotherapy as a partial response. The physical condition of the patient was well controlled for more than 4 years until she was admitted again because of cardiac failure accompanied by relapse of abdominal lymph node swelling. She died of cardiac failure 5 years and 3 days after the operation.

HLA-DRB1 polymorphisms and autoimmune responses to desmogleins in Japanese patients with pemphigus

Pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are caused by autoantibodies against keratinocyte adhesion molecules desmoglein 3 (Dsg3) and desmoglein 1 (Dsg1), respectively. To determine possible major histocompatibility complex (MHC) class II associations with autoantibody responses to desmogleins, haplotype and allele distributions, along with molecular polymorphisms of HLA-DR and -DQ genes were analyzed based on the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) results in 85 Japanese patients with pemphigus. Each of 55 PV patients carried at least one allele of HLA-DRB1*04 and DRB1*14 subtypes, with significant increases of HLA-DRB1*0406/DQA1*0301/DQB1*0302, DRB1*14/DQA1*0104/DQB1*05 and DRB1*1406/DQA1*0503/ DQB1*0301 haplotypes compared to normal controls. The HLA-DRB1*04 and DRB*14 alleles carried by PV patients shared hydrophobic amino acid residues Phe26, Leu67 and Val86, as well as hydrophilic amino acid residues at positions 70 and 71 on the DRB1 beta chain. HLA-DR/DQ distributions did not differ among PV patients according to the presence or absence of anti-Dsg1 co-existing with anti-Dsg3. Thirty PF patients, all producing autoantibodies only to Dsg1, showed more diverse HLA-DR/DQ distributions, sharing hydrophobic amino acid residues at positions 26 and 67, as well as hydrophilic amino acid residues at positions 70 and 71, of the DRB1 chain. These findings suggest that autoantibody responses to desmogleins might be regulated by amino acid residues at positions 26, 67, 70, 71 and 86 at peptide binding sites of HLA-DRB1 molecules, and that autoimmune responses to Dsg3 might be more strictly regulated by specific amino acid residues at these positions on the HLA-DRB1 chain than responses to Dsg1.

[A case of systemic lupus erythematosus discovered from left heart failure due to lupus induced mitral regurgitation]

A 50-year-old female was admitted to a local hospital because of dyspnea, and diagnosed as having left heart failure secondary to mitral regurgitation. After the improvement of congestive heart failure, polyarthralgia, fever, and positive anti-nuclear antibody were pointed out. She was referred to our hospital for the further evaluation. Serological test showed anti-double stranded DNA antibodies, anti-SS-A antibodies, anti-beta 2-GPI antibodies and biological false positive for syphilis. The diagnosis of SLE has been made from the clinical signs and the serology. Therefore mitral valvular lesion of this patient was considered to be one of the symptoms of SLE. We reported a rare case in which left heart failure was a initial clinical manifestation of SLE.

Living-related donor liver transplantation in adults: experience at Shinshu University Hospital

Several considerations and improved techniques for performing LRLT in adults have been discussed. Taking into account the worldwide shortage of cadaveric organ grafts, the significance of LRLT for adult patients will probably never diminish. Further study is needed to clarify the factors governing the outcome of adult-to-adult LRLT.

Prognostic significance of anatomical resection and des-gamma-carboxy prothrombin in patients with hepatocellular carcinoma

BACKGROUND

Portal venous tumour extension and intrahepatic metastasis result in a poor prognosis following hepatectomy for hepatocellular carcinoma (HCC). Anatomical resection is, in theory, preferable for eradicating these types of invasion. Des-gamma-carboxy prothrombin (DCP) has been reported to be associated with adverse pathological variables. This study investigated the significance of anatomical resection and DCP as predictive factors for postoperative recurrence of HCC.

METHODS

A retrospective cohort study was carried out in 138 consecutive patients who underwent hepatectomy for HCC smaller than 5 cm using the Cox proportional hazards model.

RESULTS

Eight factors were univariately related to poor prognosis (in decreasing order of hazard ratio): intrahepatic metastasis, multiple tumours, alpha-fetoprotein 32 ng/ml or more; DCP greater than 0.1 arbitrary units (AU), tumour-exposed surgical margin, vascular invasion, non-anatomical resection and tumour 2.5 cm or more. Three variables (DCP, vascular invasion and tumour-exposed surgical margin) were excluded by a stepwise procedure in multivariate analysis. Although DCP was not an independent prognostic factor, a model replacing intrahepatic metastasis with DCP showed similar predictive accuracy in a receiver-operating characteristic curve.

CONCLUSION

Anatomical resection appeared to have a beneficial effect on recurrence-free survival after hepatectomy for HCC. DCP measurement was effective in predicting HCC recurrence and had the advantage that it can be assessed before operation.

Low-dose intravenous immunoglobulin therapy for intractable dermatomyositis skin lesions

We report a 45-year-old female patient with dermatomyositis whose corticosteroid-resistant cutaneous manifestations improved with low-dose (0.1 g/kg body weight/day for 5 days weekly for 2 weeks) intravenous immunoglobulin (IVIG) therapy.

Neonatal lupus erythematosus: results of maternal corticosteroid therapy

OBJECTIVE

To assess the possibility of preventing cardiac or cutaneous manifestations of neonatal lupus erythematosus or treating the fetus with congenital heart block by administering corticosteroid therapy to the mother.

METHODS

Eighty-seven offspring of 40 anti-Ro/SSA-positive mothers, followed up from 1979 to 1996, were evaluated. Autoantibodies against Ro/SSA and La/SSB antigens were detected by immunodiffusion and enzyme-linked immunosorbent assay.

RESULTS

None of 26 neonates whose mothers received corticosteroid maintenance therapy initiated before 16 weeks' gestation demonstrated congenital heart block, whereas 15 of 61 neonates whose mothers received no corticosteroids during pregnancy or began receiving steroid therapy after 16 weeks' gestation had congenital heart block. Complete congenital heart block, once developed, did not respond to corticosteroid treatment in utero. Four infants whose mothers received steroid treatment before 16 weeks' gestation had skin lesions of neonatal lupus erythematosus.

CONCLUSION

Once established, complete congenital heart block was irreversible and maternal corticosteroid therapy did not effectively prevent cutaneous lupus erythematosus. However, prenatal maintenance therapy with prednisolone or betamethasone given to the mother starting early in pregnancy (before 16 weeks' gestation) might reduce the risk of developing antibody-mediated congenital heart block in the offspring.

Proximal bile duct stricture disguised as malignant neoplasm

BACKGROUND

Discrimination of malignant proximal bile duct (PBD) stricture from a benign lesion is difficult with nonsurgical methods; indeed, 8% to 13% of PBD strictures prove to be benign after histologic examination of the surgically resected specimen.

METHODS

In a 7-year period 178 patients with PBD stricture were admitted, and 99 of them underwent radical resection for presumably malignant lesions. In 14 of these patients the stenotic lesions were proved to be benign by postoperative histologic assessment. We reviewed these patients retrospectively by collecting data from their charts.

RESULTS

Preoperative radiologic findings including cholangiography and angiography were compatible with malignancy in all 14 patients. Preoperative histologic studies suggested malignancy in 2 of 8 examined. Findings at laparotomy could not allow differentiation between malignant and benign lesions in any of the patients and strongly suggested malignancy in 3. Histologic examination of the resected specimens revealed extensive fibrosis with inflammatory cellular infiltration in all patients. There was 1 episode of significant morbidity postoperatively (transient cholangitis) but no mortality.

CONCLUSION

Benign PBD strictures, although rare, are usually indistinguishable from malignant PBD strictures by preoperative or perioperative investigation. Given the minimal morbidity, all PBD strictures should be presumed malignant and managed accordingly, even at the risk of overtreating some benign cases.

Isolated pancreatic tuberculosis

We present a case of tuberculosis of the pancreas in a 65 year-old man diagnosed by detection of Mycobacterium tuberculosis DNA in a resection specimen using a highly specific polymerase chain reaction-based assay. Almost all pre-operative and intra-operative findings except for helical computed tomography were highly suggestive of malignant pancreatic tumor. However, the histopathology of the pancreas revealed caseating granulomatous inflammation of possible tuberculous etiology, although special staining and culture of these tissues gave negative results. Only detection of Mycobacterium tuberculosis DNA using the polymerase chain reaction-based assay gave a positive result which allowed antituberculosis treatment to be started. The patient's post-operative recovery has been uneventful without complications. If an early accurate diagnosis can be made in such cases, antituberculosis treatment can be started rapidly.

Preoperative portal vein embolization: an audit of 84 patients

Preoperative portal vein embolization (PVE) was performed in 84 patients before extensive liver resection for various diseases. By the criteria of liver volumetric determination, some patients were candidates for PVE, whereas others were not, even though the same surgical procedure, such as extended right lobectomy (ERL), was scheduled. PVE using gelatin sponge powder induced hypertrophy in the nonembolized lobe (0%-171%; median, 30%) and proportional atrophy in the embolized lobe in 2 weeks without eliciting any major inflammatory or necrotic reaction, as evidenced histologically and by the minimal elevations in the serum aspartate transaminase (AST) and alanine transaminase (ALT) values. Alterations in the total bilirubin level and prothrombin time were also insignificant and transient, indicating that hepatocyte functions were not impaired by PVE. Not all patients who undergo PVE proceed with the scheduled hepatic resection procedure, so it is a great advantage that gelatin sponge causes minimal damage compared with other embolizing materials such as cyanoacrylate and absolute ethanol, which have been reported to induce an inflammatory reaction or histological alteration. Our multiple regression analysis showed that three factors, diabetes mellitus, a high total bilirubin level at the time of PVE, and being male, each reduced the extent of hypertrophy in the nonembolized lobe (r2 =.30). By contrast, cholestasis appeared to accelerate the process of atrophy in the embolized lobe (r2 =.16). In conclusion, PVE by gelatin sponge powder is a safe and effective preoperative maneuver that induces hypertrophy of the section of the liver that will remain after partial hepatectomy.

Liver regeneration after extended right hemihepatectomy in patients with hilar or diffuse bile duct carcinoma

BACKGROUND/AIMS

The degree to which liver size can be restored and the factors that determine liver regeneration after major hepatectomy are not well understood.

METHODOLOGY

Liver volumes (LV) were estimated from computed tomography scans in 16 patients who survived with no evidence of cancer recurrence more than 1 year after extended right hemihepatectomy.

RESULTS

The mean percentage of LV at 1 year was 75.7 +/- 9.5% and LV did not change significantly beyond 1 year after surgery. A significant correlation was observed between LV at 1 year and body surface area (r = 0.79, p < 0.001). A significant inverse correlation was observed between LV at 1 year and the plasma retention rate of indocyanine green at 15 min (the ICG 15 value) (r = -0.72, p < 0.01).

CONCLUSIONS

In adults, the liver does not always regain its pre-operative size after hepatectomy. Patients' body size and intrinsic liver function or liver blood flow, represented by the ICG 15 value, may be related to regenerated liver size.

Neonatal lupus erythematosus: maternal IgG antibodies bind to a recombinant NH2-terminal fusion protein encoded by human alpha-fodrin cDNA

IgG antibodies to a cleavage product of alpha-fodrin (120 kDa alpha-fodrin) have recently been identified as organ-specific autoantibodies in primary Sjögren's syndrome. In this study, we examined seroreactivity of mothers and infants with neonatal lupus erythematosus (NLE) to a recombinant NH2-terminal protein (120 kDa alpha-fodrin) of human alpha-fodrin. Serum samples were collected during the perinatal period in seven pregnancies of five mothers delivering offspring with NLE. Anti-120 kDa alpha-fodrin antibodies were identified by immunoblotting in six of seven perinatal maternal sera of offspring with NLE: one of two congenital heart block offspring and all five offspring with cutaneous NLE. These antibodies were placentally transmitted to infants. One of the five mothers had primary Sjögren's syndrome, and four were asymptomatic. One asymptomatic mother did not demonstrate anti-120 kDa alpha-fodrin activity at the time of the first delivery of a congenital heart block infant, but was found to be positive at the time of subsequent delivery of a second child with cutaneous NLE. We propose that maternal antibodies to 120 kDa alpha-fodrin may be an additional serologic marker for the risk of NLE in anti-Ro/SS-A positive women.

[Present and future of heart transplantation in Japan and the world]

During the past 31 year, cardiac transplantation has emerged as a standard mode of therapy for patients with end-stage congestive heart failure. At present, cardiac transplantation offers dramatically improved prospects for survival and rehabilitation in properly selected patients. The shortage of donor organs is the most common problem facing organ transplantation today. Despite widespread public education programs, the number of organ donors has leveled off at approximately 5,500 per year worldwide. More than 80% of patients in need of a heart, kidney, or liver allograft fail to receive the needed organ. Extensive research on the use of porcine xenografts as alternatives to allografts has been conducted since the 1980s. In this paper, the prospects for organ transplantation are reviewed.

Staged hepatectomy after emergency transcatheter arterial embolization for ruptured hepatocellular carcinoma

BACKGROUND

Staged hepatectomy after emergency transcatheter arterial embolization (TAE) has been advocated in ruptured hepatocellular carcinoma (HCC). However, there have been no reports of clinical series of this strategy. The purpose of this study was to evaluate the protocol of this therapeutic strategy.

METHODS

Sixteen patients with suspected rupture of HCC were included in the study. After emergency TAE, tumor resectability was assessed, followed by staged hepatectomy or repeated TAE. The patients were reevaluated with regard to rupture of HCCs.

RESULTS

Primary hemostasis was achieved successfully in all patients. Eleven patients were finally judged to have experienced HCC rupture. Seven of them underwent staged hepatectomy; the other four underwent repeated TAE because their tumors were considered unresectable. Survival time tended to be longer, but not to a significant extent, in patients who underwent hepatectomy (range, 139 to 1527 days; median, 375 days) than in those treated by TAE alone (range, 43 to 1317 days; median, 158 days).

CONCLUSIONS

Staged hepatectomy after TAE is a rational treatment for patients with ruptured HCC. Although TAE is highly effective for initial hemostasis, hepatectomy appears to provide better long-term survival.

Staged hepatectomy after emergency transcatheter arterial embolization for ruptured hepatocellular carcinoma

BACKGROUND

Staged hepatectomy after emergency transcatheter arterial embolization (TAE) has been advocated in ruptured hepatocellular carcinoma (HCC). However, there have been no reports of clinical series of this strategy. The purpose of this study was to evaluate the protocol of this therapeutic strategy.

METHODS

Sixteen patients with suspected rupture of HCC were included in the study. After emergency TAE, tumor resectability was assessed, followed by staged hepatectomy or repeated TAE. The patients were reevaluated with regard to rupture of HCCs.

RESULTS

Primary hemostasis was achieved successfully in all patients. Eleven patients were finally judged to have experienced HCC rupture. Seven of them underwent staged hepatectomy; the other four underwent repeated TAE because their tumors were considered unresectable. Survival time tended to be longer, but not to a significant extent, in patients who underwent hepatectomy (range, 139 to 1527 days; median, 375 days) than in those treated by TAE alone (range, 43 to 1317 days; median, 158 days).

CONCLUSIONS

Staged hepatectomy after TAE is a rational treatment for patients with ruptured HCC. Although TAE is highly effective for initial hemostasis, hepatectomy appears to provide better long-term survival.

Concomitant caudate lobe resection as an option for donor hepatectomy in adult living related liver transplantation

In this article, we describe a successful adult living related partial liver transplantation (LRLT) using the left lobe with the left-side caudate lobe (the Spiegel lobe and the left side of the paracaval portion). The size of the donor's left lobe was 29% of the recipient's standard liver volume and did not seem to meet our criteria for adult-to-adult LRLT. However, the donor had a thick left-side caudate lobe. The estimated volume of the left lobe with the left-side caudate lobe was 32%, which met our criteria for the adult recipient. The recipient's CT scan on day 87 after transplantation showed the preserved blood flow and no biliary congestion in the left-side caudate lobe, which suggests maintenance of lobe function. This procedure may be an option for adult-to-adult LRLT in which the donor has a thick left-side caudate lobe.

Hepatic resection for hepatocellular carcinoma -- Japanese experience

In the past 20 years, thanks to the early detection of hepatocellular carcinomas (HCCs), good perioperative care, the evaluation of functional liver reserve, preoperative portal embolization and the improvement in surgical techniques such as intraoperative ultrasonography, the surgical resection of HCC has become very safe. We have performed 367 hepatectomies on 352 patients since 1990 with a surgical mortality, hospital mortality, blood transfusion rate and 5-year survival rate of 0.27, 0.82, and less than 10 and 47.4%, respectively. Our standard method for selecting surgical procedures and perioperative care resulting in low blood transfusion rates and almost no mortality are described. Since 1990, ethanol injection for HCC ablation has been extensively used in Europe and Japan, but results are poorer than with surgical intervention. Therefore, in patients with small HCCs and good liver function, the first choice treatment should not be ethanol injection, but surgical resection.

Primary Sjögren's syndrome followed by chronic myelogenous leukemia: a case report with a ten year history

We describe a female patient with primary Sjögren's syndrome who subsequently developed chronic myelogenous leukemia. The patient received a bone marrow transplant (BMT) from a genotypically HLA-identical brother after pre-transplant preparation with busulfan and cyclophosphamide. Eighteen weeks later, cutaneous and mucosal chronic graft-versus-host disease developed, followed by death 11 months after transplantation. Anti-Ro/SS-A antibodies disappeared within 6 months post-BMT, but antinuclear antibodies remained positive through the post-transplant course.

Polymorphisms of HLA class II genes in Japanese patients with pemphigus vulgaris

Pemphigus vulgaris (PV) is an autoimmune disease mediated by autoantibodies that bind to a keratinocyte adhesion molecule, desmoglein-3. The purpose of this study was to identify critical amino acid residues of PV-associated HLA class II genes. Haplotype and allele distributions, along with molecular polymorphisms, of HLA class II genes were analyzed based on the polymerase chain reaction-restriction fragment length polymorphism in 17 Japanese PV patients. Each patient had one or two alleles of DRB1*04 (*0403, *0404, *0406) or DRB1*14 (*1401, *1405, *1406) subtypes. All DRB1*04 and DRB1*14 alleles carried by PV patients with different ethnic backgrounds reported to date, including DRB1*0402, which confers strong susceptibility to PV among Jewish populations, have amino acid residues Phe26, Leu67 or Ile67, and Val86, as well as hydrophilic amino acid residues at positions 70 and 71 of the DRB1 beta chain.

Reduction of the major swine xenoantigen, the alpha-galactosyl epitope by transfection of the alpha2,3-sialyltransferase gene

alpha2,3-Sialyltransferase represents a putative enzyme that reduces the Galalpha1-3Gal beta1-4GlcNAc-R (the alpha-galactosyl epitope) by intracellular competition with alpha1,3-galactosyltransferase for a common acceptor substrate. This study demonstrates that the overexpression of the alpha2,3-sialyltransferase gene suppresses the antigenicity of swine endothelial cells to human natural antibodies by 77% relative to control cells and by 30% relative to cells transfected with alpha1,2-fucosyltransferase, and in addition, it reduces the complement-mediated cell lysis by 75% compared with control cells and by 22% compared with cells transfected with alpha1, 2-fucosyltransferase. The mechanism by which the alpha-galactosyl epitope was reduced was also studied. Suppression of alpha1, 3-galactosyltransferase activity by 30-63% was observed in the transfectants with alpha2,3-sialyltransferase, and mRNA expression of the alpha1,3-galactosyltransferase gene was reduced as well. The data suggest that the alpha2,3-sialyltransferase effectively reduced the alpha-galactosyl epitope as well as or better than the alpha1, 2-fucosyltransferase did and that the reduction of the alpha-galactosyl epitope is due not only to substrate competition but also to an overall reduction of endogenous alpha1, 3-galactosyltransferase enzyme activity.