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Fung JJ. William Hunter Harridge lecture: The changing face of short-gut syndrome management. Am J Surg 2017; 213:448-451. [PMID: 28159115 DOI: 10.1016/j.amjsurg.2017.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/10/2017] [Indexed: 02/06/2023]
Abstract
The evolution of managing short gut syndrome optimizes management and decision making of intestinal failure by way of a multidisciplinary team utilizing the latest advances in therapeutic options. Only the minority of patients referred for small bowel transplantation will actually need a transplant. Many of these patients can be rehabilitated without the need for transplant, by way of early referral, and thus the likelihood of medical therapy increases. On the other hand, in those patients with little likelihood of success with medical therapy, early referral decreases the morbidity and mortality associated with long-term total parenteral nutrition and associated complications and will improve their overall survival outcomes.
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Firl DJ, Hashimoto K, O'Rourke C, Diago-Uso T, Fujiki M, Aucejo FN, Quintini C, Kelly DM, Miller CM, Fung JJ, Eghtesad B. Role of donor hemodynamic trajectory in determining graft survival in liver transplantation from donation after circulatory death donors. Liver Transpl 2016; 22:1469-1481. [PMID: 27600806 DOI: 10.1002/lt.24633] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/20/2016] [Indexed: 02/07/2023]
Abstract
Donation after circulatory death (DCD) donors show heterogeneous hemodynamic trajectories following withdrawal of life support. Impact of hemodynamics in DCD liver transplant is unclear, and objective measures of graft viability would ease transplant surgeon decision making and inform safe expansion of the donor organ pool. This retrospective study tested whether hemodynamic trajectories were associated with transplant outcomes in DCD liver transplantation (n = 87). Using longitudinal clustering statistical techniques, we phenotyped DCD donors based on hemodynamic trajectory for both mean arterial pressure (MAP) and peripheral oxygen saturation (SpO2 ) following withdrawal of life support. Donors were categorized into 3 clusters: those who gradually decline after withdrawal of life support (cluster 1), those who maintain stable hemodynamics followed by rapid decline (cluster 2), and those who decline rapidly (cluster 3). Clustering outputs were used to compare characteristics and transplant outcomes. Cox proportional hazards modeling revealed hepatocellular carcinoma (hazard ratio [HR] = 2.53; P = 0.047), cold ischemia time (HR = 1.50 per hour; P = 0.027), and MAP cluster 1 were associated with increased risk of graft loss (HR = 3.13; P = 0.021), but not SpO2 cluster (P = 0.172) or donor warm ischemia time (DWIT; P = 0.154). Despite longer DWIT, MAP and SpO2 clusters 2 showed similar graft survival to MAP and SpO2 clusters 3, respectively. In conclusion, despite heterogeneity in hemodynamic trajectories, DCD donors can be categorized into 3 clinically meaningful subgroups that help predict graft prognosis. Further studies should confirm the utility of liver grafts from cluster 2. Liver Transplantation 22 1469-1481 2016 AASLD.
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Moris D, Vernadakis S, Papalampros A, Petrou A, Dimitroulis D, Spartalis E, Felekouras E, Fung JJ. The effect of Guidelines in surgical decision making: The paradigm of hepatocellular carcinoma. JOURNAL OF B.U.ON. : OFFICIAL JOURNAL OF THE BALKAN UNION OF ONCOLOGY 2016; 21:1332-1336. [PMID: 28039690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
It is not inconceivable to envision surgeons, offering extended liver resection in patients beyond the Barcelona Clinic Liver Cancer (BCLC) staging system criteria with intermediate/advanced hepatocellular carcinoma (HCC), to be found negligent since extensive liver resection is correlated with increased morbidity compared to conservative or palliative treatment. Given that no other classification system than BCLC has been adopted widely for HCC staging and treatment, a revision of the BCLC algorithm and clinical guidelines should be tailored using new molecular and clinical treatment algorithms, as well as including patient's preferences.
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Zhang L, Bell BA, Li Y, Zhang X, Fung JJ, Caspi RR, Lin F. The lectin but not classical pathway of activation is important for complement to regulate the development of experimental autoimmune uveitis. Immunobiology 2016. [DOI: 10.1016/j.imbio.2016.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Li Y, Clow F, Fung JJ, Fraser JD, Lin F. Therapeutic potential of staphylococcal superantigen-like protein 7 for acute complement activation-mediated diseases. Immunobiology 2016. [DOI: 10.1016/j.imbio.2016.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Demetris AJ, Bellamy C, Hübscher SG, O'Leary J, Randhawa PS, Feng S, Neil D, Colvin RB, McCaughan G, Fung JJ, Del Bello A, Reinholt FP, Haga H, Adeyi O, Czaja AJ, Schiano T, Fiel MI, Smith ML, Sebagh M, Tanigawa RY, Yilmaz F, Alexander G, Baiocchi L, Balasubramanian M, Batal I, Bhan AK, Bucuvalas J, Cerski CTS, Charlotte F, de Vera ME, ElMonayeri M, Fontes P, Furth EE, Gouw ASH, Hafezi-Bakhtiari S, Hart J, Honsova E, Ismail W, Itoh T, Jhala NC, Khettry U, Klintmalm GB, Knechtle S, Koshiba T, Kozlowski T, Lassman CR, Lerut J, Levitsky J, Licini L, Liotta R, Mazariegos G, Minervini MI, Misdraji J, Mohanakumar T, Mölne J, Nasser I, Neuberger J, O'Neil M, Pappo O, Petrovic L, Ruiz P, Sağol Ö, Sanchez Fueyo A, Sasatomi E, Shaked A, Shiller M, Shimizu T, Sis B, Sonzogni A, Stevenson HL, Thung SN, Tisone G, Tsamandas AC, Wernerson A, Wu T, Zeevi A, Zen Y. 2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection. Am J Transplant 2016; 16:2816-2835. [PMID: 27273869 DOI: 10.1111/ajt.13909] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 06/01/2016] [Accepted: 05/25/2016] [Indexed: 02/06/2023]
Abstract
The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.
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Hashimoto K, Fujiki M, Quintini C, Aucejo FN, Uso TD, Kelly DM, Eghtesad B, Fung JJ, Miller CM. Split liver transplantation in adults. World J Gastroenterol 2016; 22:7500-7506. [PMID: 27672272 PMCID: PMC5011665 DOI: 10.3748/wjg.v22.i33.7500] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/30/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
Split liver transplantation (SLT), while widely accepted in pediatrics, remains underutilized in adults. Advancements in surgical techniques and donor-recipient matching, however, have allowed expansion of SLT from utilization of the right trisegment graft to now include use of the hemiliver graft as well. Despite less favorable outcomes in the early experience, better outcomes have been reported by experienced centers and have further validated the feasibility of SLT. Importantly, more than two decades of experience have identified key requirements for successful SLT in adults. When these requirements are met, SLT can achieve outcomes equivalent to those achieved with other types of liver transplantation for adults. However, substantial challenges, such as surgical techniques, logistics, and ethics, persist as ongoing barriers to further expansion of this highly complex procedure. This review outlines the current state of SLT in adults, focusing on donor and recipient selection based on physiology, surgical techniques, surgical outcomes, and ethical issues.
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Karagkounis G, Akyuz M, Guerron AD, Yazici P, Aucejo FN, Quintini C, Miller CM, Vogt DP, Fung JJ, Berber E. Perioperative and oncologic outcomes of minimally invasive liver resection for colorectal metastases: A case-control study of 130 patients. Surgery 2016; 160:1097-1103. [PMID: 27486002 DOI: 10.1016/j.surg.2016.04.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/14/2016] [Accepted: 04/16/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Our aim was to compare the perioperative and oncologic outcomes of open liver resection and minimally invasive liver resection in the management of colorectal liver metastases. METHODS Patients who underwent minimally invasive liver resection for colorectal liver metastases between January 2006 and June 2015 at a single center were identified and matched by extent of resection to consecutive open liver resection patients from the same period. Clinicopathologic characteristics, perioperative data, recurrence, and survival outcomes were collected and analyzed based on intention-to-treat. RESULTS Sixty-five patients underwent minimally invasive liver resection during this period and were matched to 65 consecutive open liver resection patients, with similar baseline demographic, tumor, and chemotherapy parameters. Conversion to open occurred in 5 (7.7%) minimally invasive liver resection patients. R0 resection rates and operative times were comparable, but the estimated blood loss was less in the minimally invasive liver resection group (median 200 mL vs 400 mL, P < .001), as were perioperative transfusion rates (4.6% vs 15.4%, P = .04). The duration of stay was shorter after minimally invasive liver resection (median 4 days vs 6 days, P < .001), while major and minor complication rates were similar and no perioperative mortality was recorded. At a median follow-up of 28 months, there was no difference regarding disease-free (P = .90) or overall survival (P = .37). CONCLUSION In selected patients with colorectal liver metastases, minimally invasive liver resection resulted in similar oncologic outcomes, with decreased blood loss and shorter duration of stay compared to patients who underwent open liver resection.
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Li Y, Lu L, Qian S, Fung JJ, Lin F. Hepatic Stellate Cells Directly Inhibit B Cells via Programmed Death-Ligand 1. THE JOURNAL OF IMMUNOLOGY 2016. [DOI: 10.4049/jimmunol.196.supp.195.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
We previously demonstrated that mouse hepatic stellate cells (HSCs) suppress T cells via programmed death-ligand 1 (PD-L1), but whether HSCs exert any effects on B cells, the other component of the adaptive immune system, remains unknown. In this study, we found that mouse HSCs directly inhibited B cells and that PD-L1 was also integrally involved. We found that (a) HSCs inhibited the upregulation of activation markers on activated B cells; (b) HSCs inhibited the proliferation of activated B cells and their cytokine/immunoglobulin production in vitro; and (c) pharmaceutically or genetically blocking the interaction of PD-L1 with programmed death-1 (PD-1) impaired the ability of HSCs to inhibit B cells. To test the newly discovered B-cell-inhibitory activity of HSCs in vivo, we developed a protocol of intrasplenic artery injection to directly deliver HSCs into the spleen. We found that local delivery of wild-type HSCs into the spleens of mice that had been immunized with 4-hydroxy-3-nitrophenylacetyl-Ficoll, a T-cell-independent antigen, significantly suppressed antigen-specific IgM and IgG production in vivo, whereas splenic artery delivery of PD-L1-deficient HSCs failed to do so. In conclusion, in addition to inhibiting T cells, mouse HSCs concurrently inhibit B cells via PD-L1. This direct B-cell-inhibitory activity of HSCs should contribute to the mechanism by which HSCs maintain the liver’s immune homeostasis.
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Li Y, Lu L, Qian S, Fung JJ, Lin F. Hepatic Stellate Cells Directly Inhibit B Cells via Programmed Death-Ligand 1. THE JOURNAL OF IMMUNOLOGY 2016; 196:1617-25. [PMID: 26755818 DOI: 10.4049/jimmunol.1501737] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 12/06/2015] [Indexed: 12/24/2022]
Abstract
We demonstrated previously that mouse hepatic stellate cells (HSCs) suppress T cells via programmed death-ligand 1 (PD-L1), but it remains unknown whether they exert any effects on B cells, the other component of the adaptive immune system. In this study, we found that mouse HSCs directly inhibited B cells and that PD-L1 was also integrally involved. We found that HSCs inhibited the upregulation of activation markers on activated B cells, as well as the proliferation of activated B cells and their cytokine/Ig production in vitro, and that pharmaceutically or genetically blocking the interaction of PD-L1 with programmed cell death protein 1 impaired the ability of HSCs to inhibit B cells. To test the newly discovered B cell-inhibitory activity of HSCs in vivo, we developed a protocol of intrasplenic artery injection to directly deliver HSCs into the spleen. We found that local delivery of wild-type HSCs into the spleens of mice that had been immunized with 4-hydroxy-3-nitrophenylacetyl-Ficoll, a T cell-independent Ag, significantly suppressed Ag-specific IgM and IgG production in vivo, whereas splenic artery delivery of PD-L1-deficient HSCs failed to do so. In conclusion, in addition to inhibiting T cells, mouse HSCs concurrently inhibit B cells via PD-L1. This direct B cell-inhibitory activity of HSCs should contribute to the mechanism by which HSCs maintain the liver's immune homeostasis.
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Firl DJ, Hashimoto K, O'Rourke C, Diago-Uso T, Fujiki M, Aucejo FN, Quintini C, Kelly DM, Miller CM, Fung JJ, Eghtesad B. Impact of donor age in liver transplantation from donation after circulatory death donors: A decade of experience at Cleveland Clinic. Liver Transpl 2015; 21:1494-503. [PMID: 26334196 DOI: 10.1002/lt.24316] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/23/2015] [Accepted: 08/12/2015] [Indexed: 12/12/2022]
Abstract
The use of liver grafts from donation after circulatory death (DCD) donors remains controversial, particularly with donors of advanced age. This retrospective study investigated the impact of donor age in DCD liver transplantation. We examined 92 recipients who received DCD grafts and 92 matched recipients who received donation after brain death (DBD) grafts at Cleveland Clinic from January 2005 to June 2014. DCD grafts met stringent criteria to minimize risk factors in both donors and recipients. The 1-, 3-, and 5-year graft survival in DCD recipients was significantly inferior to that in DBD recipients (82%, 71%, 66% versus 92%, 87%, 85%, respectively; P = 0.03). Six DCD recipients (7%), but no DBD recipients, experienced ischemic-type biliary stricture (P = 0.01). However, the incidence of biliary stricture was not associated with donor age (P = 0.57). Interestingly, recipients receiving DCD grafts from donors who were <45 years of age (n = 55) showed similar graft survival rates compared to those receiving DCD grafts from donors who were ≥45 years of age (n = 37; 80%, 69%, 66% versus 83%, 72%, 66%, respectively; P = 0.67). Cox proportional hazards modeling in all study populations (n = 184) revealed advanced donor age (P = 0.05) and the use of a DCD graft (P = 0.03) as unfavorable factors for graft survival. Logistic regression analysis showed that the risk of DBD graft failure increased with increasing age, but the risk of DCD graft failure did not increase with increasing age (P = 0.13). In conclusion, these data suggest that stringent donor and recipient selection may ameliorate the negative impact of donor age in DCD liver transplantation. DCD grafts should not be discarded because of donor age, per se, and could help expand the donor pool for liver transplantation.
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Woodside KJ, Goldfarb DA, Rabets JC, Sanchez EQ, Lebovitz DJ, Schulak JA, Fung JJ, Eghtesad B. Enhancing kidney function with thrombolytic therapy following donation after cardiac death: a multicenter quasi-blinded prospective randomized trial. Clin Transplant 2015; 29:1173-80. [PMID: 26448622 DOI: 10.1111/ctr.12647] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2015] [Indexed: 12/21/2022]
Abstract
Kidneys from donors after cardiac death (DCD) are at risk for inferior outcomes, possibly due to microthrombi and additional warm ischemia. We describe an organ procurement organization-wide trial utilizing thrombolytic tissue plasminogen activator (tPA) during machine pulsatile perfusion (MPP). A kidney from each recovered kidney pair was prospectively randomized to receive tPA (50 mg Alteplase) or no tPA (control) in the MPP perfusate. From 2011 to 2013, 24 kidneys were placed with enrolled recipients from 19 DCD kidney donors. There were no significant differences for absolute values of flow or resistance while undergoing MPP between the groups, nor rates of achieving discrete flow and resistance targets. While there was a trend toward lower creatinine and higher glomerular filtration rates in the tPA group at 3, 6, 9, and 12 months, these differences were not significant. Delayed graft function (DGF) rates were 41.7% in the tPA group vs. 58.4% in the control group (OR 0.51, 95%CI 0.10-2.59, p = 0.68). Death-censored graft survival was similar between the groups. In this pilot study, encouraging trends are seen in kidney allograft function independent of MPP parameters following DCD kidney transplantation for those kidneys receiving thrombolytic tPA and MPP, compared with standard MPP.
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Duquesnoy RJ, Gebel HM, Woodle ES, Nickerson P, Baxter-Lowe LA, Bray RA, Claas FHJ, Eckels DD, Friedewald JJ, Fuggle SV, Gerlach JA, Fung JJ, Kamoun M, Middleton D, Shapiro R, Tambur AR, Taylor CJ, Tinckam K, Zeevi A. High-Resolution HLA Typing for Sensitized Patients: Advances in Medicine and Science Require Us to Challenge Existing Paradigms. Am J Transplant 2015; 15:2780-1. [PMID: 26177785 DOI: 10.1111/ajt.13376] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 04/26/2015] [Accepted: 04/26/2015] [Indexed: 01/25/2023]
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Morita M, Joyce D, Miller C, Fung JJ, Lu L, Qian S. Rejection triggers liver transplant tolerance: Involvement of mesenchyme-mediated immune control mechanisms in mice. Hepatology 2015; 62:915-31. [PMID: 25998530 PMCID: PMC4549241 DOI: 10.1002/hep.27909] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 05/19/2015] [Indexed: 12/31/2022]
Abstract
UNLABELLED Liver tolerance was initially recognized by the spontaneous acceptance of liver allografts in many species. The underlying mechanisms are not completely understood. However, liver transplant (LT) tolerance absolutely requires interferon (IFN)-γ, a rejection-associated inflammatory cytokine. In this study, we investigated the rejection of liver allografts deficient in the IFN-γ receptor and reveal that the liver graft is equipped with machineries capable of counterattacking the host immune response through a mesenchyme-mediated immune control (MMIC) mechanism. MMIC is triggered by T effector (Tef) cell-derived IFN-γ that drives expression of B7-H1 on graft mesenchymal cells leading to Tef cell apoptosis. We describe the negative feedback loop between graft mesenchymal and Tef cells that ultimately results in LT tolerance. Comparable elevations of T-regulatory cells and myeloid-derived suppressor cells were observed in both rejection and tolerance groups and were not dependent on IFN-γ stimulation, suggesting a critical role of Tef cell elimination in tolerance induction. We identify potent MMIC activity in hepatic stellate cells and liver sinusoidal endothelial cells. MMIC is unlikely exclusive to the liver, given that spontaneous acceptance of kidney allografts has been reported, although less commonly, probably reflecting variance in MMIC activity. CONCLUSION MMIC may represent an important homeostatic mechanism that supports peripheral tolerance and could be a target for the prevention and treatment of transplant rejection. This study highlights that the graft is an active participant in the equipoise between tolerance and rejection and warrants more attention in the search for tolerance biomarkers.
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Kelly DM, London DA, Siperstein A, Fung JJ, Walsh MR. A Structured Educational Curriculum Including Online Training Positively Impacts American Board of Surgery In-Training Examination Scores. JOURNAL OF SURGICAL EDUCATION 2015; 72:811-817. [PMID: 26160131 DOI: 10.1016/j.jsurg.2015.04.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 02/02/2015] [Accepted: 04/16/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To assess the effect of a structured postgraduate year 1 educational curriculum, including online surgical training, on American Board of Surgery In-Training Examination (ABSITE) scores. DESIGN This was a retrospective cohort study. SETTING The study was performed in an academic surgical residency program in a tertiary care hospital, Cleveland Clinic Foundation, Cleveland, Ohio. PARTICIPANTS The participants were 140 surgical postgraduate year 1 residents from 2000 to 2009. Interns from 2000 to 2004 were grouped together and completed a self-directed learning curriculum. Interns from 2005 to 2009 participated in a structured educational curriculum that included lectures and the use of an online program. Lectures were based on the American College of Surgeons curriculum. The online program consisted of 8 to 12 hours of assigned tutorials and quizzes that corresponded to the lectures and 3 multiple-choice (MC) examinations. RESULTS Use of a structured educational curriculum led to improved ABSITE scores (66 ± 9%) compared with that of those who had no curriculum (55 ± 10%, p < 0.001). Several variables positively correlated with the ABSITE score: United States Medical Licensing Examination step 1 score (p < 0.001), monthly quiz scores (p = 0.003), average MC examination scores (p = 0.005), lecture attendance (p = 0.02), and time spent online (p = 0.04). Multivariable analysis demonstrated that the step 1 United States Medical Licensing Examination score, time spent online, and MC examination score are predictive of total the ABSITE score. When ABSITE subscores (basic science and clinical science) were compared, the online curriculum had a greater effect on basic science subscores, whereas lectures had a greater effect on clinical science subscores. CONCLUSIONS Providing surgery residents a structured curriculum with lectures and an online component positively impacts ABSITE scores.
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Li Y, Kim BG, Qian S, Letterio JJ, Fung JJ, Lu L, Lin F. Hepatic Stellate Cells Inhibit T Cells through Active TGF-β1 from a Cell Surface-Bound Latent TGF-β1/GARP Complex. THE JOURNAL OF IMMUNOLOGY 2015; 195:2648-56. [PMID: 26246140 DOI: 10.4049/jimmunol.1500139] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 07/16/2015] [Indexed: 01/03/2023]
Abstract
Hepatic stellate cells (HSCs) inhibit T cells, a process that could help the liver to maintain its immunoprivileged status. HSCs secrete latent TGF-β1, but the detailed mechanisms by which latent TGF-β1 is activated and whether it plays any role in HSC-mediated T cell suppression remain unclear. Glycoprotein A repetitions predominant (GARP) is a surface marker of activated regulatory T cells. GARP binds latent TGF-β1 for its activation, which is critical for regulatory T cells to suppress effector T cells; however, it is still unclear whether GARP is present on HSCs and whether it has any impact on HSC function. In this study, we found that TGF-β1(+/-) HSCs, which produce reduced levels of TGF-β1, showed decreased potency in inhibiting T cells. We also found that pharmaceutical or genetic inhibition of the TGF-β1 signaling pathway reduced the T cell-inhibiting activity of HSCs. Additionally, using isolated primary HSCs, we demonstrated that GARP was constitutively expressed on HSCs. Blocking GARP function or knocking down GARP expression significantly impaired the potency of HSCs to suppress the proliferation of and IFN-γ production from activated T cells, suggesting that GARP is important for HSCs to inhibit T cells. These results demonstrate the unexpected presence of GARP on HSCs and its significance in regard to the ability of HSCs to activate latent TGF-β1 and thereby inhibit T cells. Our study reveals a new mechanism for HSC-mediated immune regulation and potentially for other conditions, such as liver fibrosis, that involve HSC-secreted TGF-β1.
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Chen B, Wang W, Tam MD, Quintini C, Fung JJ, Li X. Transjugular intrahepatic portosystemic shunt in liver transplant recipients: indications, feasibility, and outcomes. Hepatol Int 2015; 9:391-8. [DOI: 10.1007/s12072-015-9632-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/06/2015] [Indexed: 12/11/2022]
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Duquesnoy RJ, Kamoun M, Baxter-Lowe LA, Woodle ES, Bray RA, Claas FHJ, Eckels DD, Friedewald JJ, Fuggle SV, Gebel HM, Gerlach JA, Fung JJ, Middleton D, Nickerson P, Shapiro R, Tambur AR, Taylor CJ, Tinckam K, Zeevi A. Should HLA mismatch acceptability for sensitized transplant candidates be determined at the high-resolution rather than the antigen level? Am J Transplant 2015; 15:923-30. [PMID: 25778447 DOI: 10.1111/ajt.13167] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 10/19/2014] [Accepted: 11/11/2014] [Indexed: 01/25/2023]
Abstract
Defining HLA mismatch acceptability of organ transplant donors for sensitized recipients has traditionally been based on serologically defined HLA antigens. Now, however, it is well accepted that HLA antibodies specifically recognize a wide range of epitopes present on HLA antigens and that molecularly defined high resolution alleles corresponding to the same low resolution antigen can possess different epitope repertoires. Hence, determination of HLA compatibility at the allele level represents a more accurate approach to identify suitable donors for sensitized patients. This approach would offer opportunities for increased transplant rates and improved long term graft survivals.
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Hashimoto K, Quintini C, Aucejo FN, Fujiki M, Diago T, Watson MJ, Kelly DM, Winans CG, Eghtesad B, Fung JJ, Miller CM. Split liver transplantation using Hemiliver graft in the MELD era: a single center experience in the United States. Am J Transplant 2014; 14:2072-80. [PMID: 25040819 DOI: 10.1111/ajt.12791] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 04/08/2014] [Accepted: 04/17/2014] [Indexed: 01/25/2023]
Abstract
Under the "sickest first" Model for End-Stage Liver Disease (MELD) allocation, livers amenable to splitting are most often allocated to patients unsuitable for split liver transplantation (SLT). Our experience with SLT using hemilivers was reviewed. From April 2004 to June 2012, we used 25 lobar grafts (10 left lobes and 15 right lobes) for adult-sized recipients. Twelve recipients were transplanted with primary offers, and 13 were transplanted with leftover grafts. Six grafts were shared with other centers. The data were compared with matched whole liver grafts (n = 121). In 92% of donors, the livers were split in situ. Hemiliver recipients with severe portal hypertension had a greater graft-to-recipient weight ratio than those without severe portal hypertension (1.96% vs. 1.40%, p < 0.05). Hemiliver recipients experienced biliary complications more frequently (32.0% vs. 10.7%, p = 0.01); however, the 5-year graft survival for hemilivers was comparable to whole livers (80.0% vs. 81.5%, p = 0.43). The secondary recipients with leftover grafts did not have increased incidences of graft failure (p = 0.99) or surgical complications (p = 0.43) compared to the primary recipients. In conclusion, while routine application is still controversial due to various challenges, hemiliver SLT can achieve excellent outcomes under the MELD allocation.
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Li Y, Tu Z, Qian S, Fung JJ, Markowitz SD, Kusner LL, Kaminski HJ, Lu L, Lin F. Myeloid-derived suppressor cells as a potential therapy for experimental autoimmune myasthenia gravis. THE JOURNAL OF IMMUNOLOGY 2014; 193:2127-34. [PMID: 25057008 DOI: 10.4049/jimmunol.1400857] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
We recently demonstrated that hepatic stellate cells induce the differentiation of myeloid-derived suppressor cells (MDSCs) from myeloid progenitors. In this study, we found that adoptive transfer of these MDSCs effectively reversed disease progression in experimental autoimmune myasthenia gravis (EAMG), a T cell-dependent and B cell-mediated model for myasthenia gravis. In addition to ameliorated disease severity, MDSC-treated EAMG mice showed suppressed acetylcholine receptor (AChR)-specific T cell responses, decreased levels of serum anti-AChR IgGs, and reduced complement activation at the neuromuscular junctions. Incubating MDSCs with B cells activated by anti-IgM or anti-CD40 Abs inhibited the proliferation of these in vitro-activated B cells. Administering MDSCs into mice immunized with a T cell-independent Ag inhibited the Ag-specific Ab production in vivo. MDSCs directly inhibit B cells through multiple mechanisms, including PGE2, inducible NO synthase, and arginase. Interestingly, MDSC treatment in EAMG mice does not appear to significantly inhibit their immune response to a nonrelevant Ag, OVA. These results demonstrated that hepatic stellate cell-induced MDSCs concurrently suppress both T and B cell autoimmunity, leading to effective treatment of established EAMG, and that the MDSCs inhibit AChR-specific immune responses at least partially in an Ag-specific manner. These data suggest that MDSCs could be further developed as a novel approach to treating myasthenia gravis and, even more broadly, other diseases in which T and B cells are involved in pathogenesis.
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Shiba H, Zhu X, Arakawa Y, Irefin S, Wang B, Trenti L, Fung JJ, Kelly DM. Oxygen consumption predicts outcome in porcine partial liver grafts. J Surg Res 2014; 189:335-9. [DOI: 10.1016/j.jss.2014.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 02/06/2014] [Accepted: 02/11/2014] [Indexed: 11/24/2022]
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Bhatt S, Qin J, Bennett C, Qian S, Fung JJ, Hamilton TA, Lu L. All-trans retinoic acid induces arginase-1 and inducible nitric oxide synthase-producing dendritic cells with T cell inhibitory function. THE JOURNAL OF IMMUNOLOGY 2014; 192:5098-108. [PMID: 24790153 DOI: 10.4049/jimmunol.1303073] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hepatic stellate cells (HSC) are a major source of the immunoregulatory metabolite all-trans retinoic acid (ATRA), which may contribute to the generation of tolerogenic dendritic cells (DCs) in the liver. The present study seeks to clarify the mechanism(s) through which ATRA promotes the development of tolerogenic DCs. Although bone marrow-derived ATRA-treated DCs (RA-DCs) and conventional DCs had comparable surface phenotype, RA-DCs had diminished stimulatory capacity and could directly inhibit the expansion of DC/OVA-stimulated OT-II T cells. Arginase-1 (Arg-1) was found promote suppression because 1) ATRA was a potent inducer of Arg-1 protein and activity, 2) the Arg-1 inhibitor N(w)-hydroxy nor-l-arginine partially reversed suppression, and 3) the suppressive function of RA-DCs was partially compromised using OT-II T cells from GCN2(-/-) mice, which are insensitive to Arg-1. Inducible NO synthase (iNOS), however, was found to be a more significant contributor to RA-DC function because 1) ATRA potentiated the expression of IFN-γ-induced iNOS, 2) suppressive function in RA-DCs was blocked by the iNOS inhibitor N(G)-monomethyl-l-arginine, monoacetate salt, and 3) RA-DCs derived from iNOS(-/-) mice exhibited near complete loss of tolerogenic function, despite sustained Arg-1 activity. The expression of iNOS and the suppressive function of RA-DCs were dependent on both IFN-γ and ATRA. Furthermore, the in vivo behavior of RA-DCs proved to be consistent with their in vitro behavior. Thus, we conclude that ATRA enhances both Arg-1 and iNOS expression in IFN-γ-treated DCs, resulting in a tolerogenic phenotype. These findings elucidate mechanisms through which ATRA may contribute to liver immune tolerance.
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Asrani SK, Wiesner RH, Trotter JF, Klintmalm G, Katz E, Maller E, Roberts J, Kneteman N, Teperman L, Fung JJ, Millis JM. De novo sirolimus and reduced-dose tacrolimus versus standard-dose tacrolimus after liver transplantation: the 2000-2003 phase II prospective randomized trial. Am J Transplant 2014; 14:356-66. [PMID: 24456026 DOI: 10.1111/ajt.12543] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 09/20/2013] [Accepted: 09/20/2013] [Indexed: 01/25/2023]
Abstract
We studied whether the use of sirolimus with reduced-dose tacrolimus, as compared to standard-dose tacrolimus, after liver transplantation is safe, tolerated and efficacious. In an international multicenter, open-label, active-controlled randomized trial (2000-2003), adult primary liver transplant recipients (n=222) were randomly assigned immediately after transplantation to conventional-dose tacrolimus (trough: 7-15 ng/mL) or sirolimus (loading dose: 15 mg, initial dose: 5 mg titrated to a trough of 4-11 ng/mL) and reduced-dose tacrolimus (trough: 3-7 ng/mL). The study was terminated after 21 months due to imbalance in adverse events. The 24-month cumulative incidence of graft loss (26.4% vs. 12.5%, p=0.009) and patient death (20% vs. 8%, p=0.010) was higher in subjects receiving sirolimus. A numerically higher rate of hepatic artery thrombosis/portal vein thrombosis was observed in the sirolimus arm (8% vs. 3%, p=0.065). The incidence of sepsis was higher in the sirolimus arm (20.4% vs. 7.2%, p=0.006). Rates of acute cellular rejection were similar between the two groups. Early use of sirolimus using a loading dose followed by maintenance doses and reduced-dose tacrolimus in de novo liver transplant recipients is associated with higher rates of graft loss, death and sepsis when compared to the use of conventional-dose tacrolimus alone.
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Cywinski JB, You J, Argalious M, Irefin S, Parker BM, Fung JJ, Koch CG. Transfusion of older red blood cells is associated with decreased graft survival after orthotopic liver transplantation. Liver Transpl 2013; 19:1181-8. [PMID: 23813754 DOI: 10.1002/lt.23695] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 06/12/2013] [Indexed: 01/11/2023]
Abstract
Investigations have demonstrated conflicting results regarding the influence of the red blood cell (RBC) storage duration on outcomes. We evaluated whether graft failure or mortality after orthotopic liver transplantation (OLT) increased when recipients were transfused with older RBCs. This study included 637 patients who underwent OLT between January 2001 and June 2011. Baseline and perioperative data were obtained from our blood bank, the Unified Transplant Center database, and the United Network for Organ Sharing database. Recipients whose transfused RBCs were all stored for ≤ 15 days were grouped in a younger group, and recipients who were transfused with RBCs stored for >15 days were placed in an older group. The relationship between graft survival/mortality and the age of intraoperatively transfused RBCs was studied by Kaplan-Meier estimation with a log-rank test and multivariate Cox proportional hazards regression. Three hundred thirty-four patients and 303 patients were grouped in the younger and the older RBC groups, respectively, on the basis of the ages of intraoperatively transfused RBCs. Kaplan-Meier estimates of graft survival/mortality as a function of the posttransplant time were significantly different: the older group experienced the outcome sooner than the younger group [P = 0.02 (log-rank test)]. After covariate adjustments, the risk of graft failure/mortality was significantly different at any given time after transplantation between patients receiving intraoperative transfusions of older RBC units and patients receiving intraoperative transfusions of younger RBC units (hazard ratio = 1.65, 95% confidence interval = 1.18-2.31). In conclusion, patients who received intraoperative transfusions of RBCs with longer storage times had an increased risk of adverse outcomes.
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Bansal S, Berk M, Alkhouri N, Partrick DA, Fung JJ, Feldstein A. Stearoyl-CoA desaturase plays an important role in proliferation and chemoresistance in human hepatocellular carcinoma. J Surg Res 2013; 186:29-38. [PMID: 24135379 DOI: 10.1016/j.jss.2013.07.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 06/26/2013] [Accepted: 07/02/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is often diagnosed at an advanced stage, when it is not amenable for aggressive therapies such as surgical resection or liver transplantation. Current therapeutic options achieve clinical responses in only a small percentage of cases. As a consequence, effective approaches for prevention and treatment are greatly needed. Altered lipid metabolism has been recently linked to HCC pathogenesis. The aims of this study were to define the cellular and molecular mechanisms linking stearoyl-CoA desaturase (SCD), the rate-limiting enzyme and an essential regulator of lipid homeostasis in liver cells, to carcinogenesis in HCC. MATERIAL AND METHODS HCC and normal liver specimens were collected. Human HCC cell lines: HepG2, Hep3B, and PLC/PLF/5 were used for immunoblot, cell viability, proliferation, and apoptosis assays. Small interfering RNAs were used for genetic inhibition, and 10, 12 conjugated linoleic acid was used for pharmacologic SCD inhibition. RESULTS SCD was strongly expressed in surgically resected HCC (n = 64) and various human HCC cell lines (HepG2, Hep3B, and PLC/PLF/5). The levels of SCD negatively correlated with degree of tumor differentiation (P < 0.01). Treatment of these HCC cell lines with a panel of chemotherapeutic drugs resulted in a time-dependent, phosphatidylinositol 3 kinase- and c-Jun N-terminal kinases1/2-mediated upregulation of SCD expression, which paralleled the degree of resistance to drug-induced apoptosis. Specific genetic or pharmacologic SCD suppression resulted in inhibition of cell proliferation (P < 0.001) and significantly increased sensitivity to chemotherapy-induced apoptosis. CONCLUSIONS Our data suggest that increased SCD expression plays an important role in HCC development and resistance to chemotherapy-induced apoptosis, and this is in part mediated by phosphatidylinositol 3 kinase/c-Jun N-terminal kinases activation. Specific targeted interruption of this pathway in HCC could be a desirable approach in designing novel therapeutic strategies.
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