576
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Matas AJ, Simmons RL, Kjellstrand CM, Fryd DS, Najarian JS. When should the third renal transplant rejection episode be treated? Ann Surg 1977; 186:104-10. [PMID: 327950 PMCID: PMC1396191 DOI: 10.1097/00000658-197707000-00015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recent reports cite better survival when repeatedly rejecting renal allografts are removed and patients returned to hemodialysis. However, the criteria for graft removal remain undefined; although some reports recommend removing all kidneys undergoing a third rejection. In our series (1968-1973) of 316 patients with technically successful first grafts followed 2(1/2)-8 years, graft survival was inversely related to the number of rejection episodes. One hundred per cent of kidneys without rejection are currently functioning or functioned at the time of death compared to 90% with one rejection, 67.4% with two and 21% with three. However, 40% of kidneys having three rejection episodes functioned longer than one year after treatment of the third rejection episode. In an attempt to determine the predictability of one year graft survival or failure following treatment of the third rejection, a formula was developed that correctly predicted in 33 of 38 (87%) patients. The formula was based on information available prior to treatment of the third rejection episode, and represents an index of baseline renal function (serum creatinine after second rejection episode) and two indices of the severity of rejection episodes (serum creatinine change between the first and second rejection episodes; rapidity of sequential rejection).Following its derivation, the formula was applied to a second group (1974) of 19 patients having had three rejection episodes. The formula correctly predicted one year allograft survival or failure following treatment of the third rejection episode in 68% of these patients. A striking finding of our review was a significant difference in current patient survival between those having no rejection episodes (89%) and those having one or more rejection episodes (65%) (p < .00001). There was no significantly greater long-term curtailment in survival if more than one rejection eipsode was treated. Patients having one rejection eipsode seemed to die from varying causes and at varying time periods. Patients dying after two or more rejection episodes had an increased incidence of deaths due to bacterial infection.
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577
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Matas AJ, Simmons RL, Kjellstrand CM, Najarian JS. Pseudorejection: factors mimicking rejection in renal allograft recipients. Ann Surg 1977; 186:51-9. [PMID: 327954 PMCID: PMC1396197 DOI: 10.1097/00000658-197707000-00008] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Serum creatinine level is used as a major measure of post-transplant renal function at most centers. A significant elevation of creatinine level suggests allograft rejection. However, other factors affect renal function in the transplant recipient and each may cause an elevation in serum creatinine level, suggesting a rejection episode. It is important to make the correct diagnosis and not treat these episodes with anti-rejection therapy. We reviewed the course of patients transplanted between 1969 and 1974 to determine the pathogenesis of creatinine elevations retrospectively found to be due to causes other than rejection. Six distinct causes were found: hyperglycemia, ureteral obstruction, infection, lymphocele, arterial stenosis, and recurrence of the original disease. Each of these is discussed individually. In order to make the diagnosis of pseudorejection, a high index of suspicion is necessary.
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578
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Kretschmer GJ, Sutherland DE, Matas AJ, Cain TL, Najarian JS. Autotransplantation of pancreatic islets without separation of exocrine and endocrine tissue in totally pancreatectomized dogs. Surgery 1977; 82:74-81. [PMID: 195358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aims of this study were to determine whether diabetes could be ameliorated in dogs by autotransplantation of pancreatic fragments to the spleen and to determine the optimal time of collagenase digestion for pancreatic tissue dispersal. Forty-eight dogs were made diabetic by total pancreatectomy. Fifteen dogs not further treated survived 7.0+/-1.1 (SE) days with a mean plasma glucose of 401+/-5 (SE) mg/100 ml 2 days after pancreatectomy. The pancreases of 33 dogs were distended with Hanks' solution, minced, digested with collagenase (600 microns/ml of tissue), for 0 to 25 minutes, and autotransplanted to the splenic pulp. The incidence of permanent normoglycemia (fasting plasma glucose less than 150 mg/100 ml) and the K value of glucose tolerance tests (GTT) performed 2 and 10 weeks after transplant were determined in experimental groups divided according to the length of collagenase digestion. All five dogs receiving undigested tissue remained hyperglycemic. One of seven dogs receiving tissue digested for 10 minutes became normoglycemic. In contrast, seven of eight, seven of seven, and six of six dogs receiving tissue digested for 15, 20, and 25 minutes, respectively, became normoglycemic (followed for 6 months). K values at 2 weeks were 1.20+/-1.19 (SE)% 1.60+/-0.25 (SE)%, and 0.78+/-0.08 (SE)% in the normolgycemic dogs of the 15, 20, and 25 minute digestion groups, respectively. The K value of normal dogs was 3.30+/-0.27 (SE)%. The glucose tolerance curves of the 20 minute group at 2 and 10 weeks most nearly approximated the curves of normal dogs. K values improved in all recipient dogs. Diabetes recurred immediately and death occurred at a mean of 4.8+/-1.5 days in 12 recipient dogs following splenectomy. We conclude that pancreatic fragments can be successfully autotransplanted to the spleen without separation of endocrine and exocrine tissue and that 20 minutes is the optimal period of collagenase digestion for tissue preparation.
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579
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Sutherland DE, Numata M, Matas AJ, Simmons RL, Najarian JS. Hepatocellular transplantation in acute liver failure. Surgery 1977; 82:124-32. [PMID: 327598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute liver failure carries a high rate of mortality, but if metabolic support can be maintained for a critical period, liver healing and recovery are possible. Current techniques of temporary hepatic support are cumbersome and inconsistently effective. We studied the ability of dispersed hepatocytes to provide metabolic support when transplanted to rats with liver failure induced by dimethylnitrosamine (DMNA), a rapidly metabolized agent that is selectively toxic to liver cells. DMNA (20 mg/kg) was administered intravenously to 92 Lewis rats. Animals were divided into four groups receiving the following treatments 24 hours after DMNA administration: group I-intraperitoneal transplantation of hepatocytes prepared from 2.0 gm of normal isologous rat liver; group II-infusion into the portal vein of hepatocytes prepared from 1.5 gm of liver; group III-infusion of saline into the portal vein; group IV-no further treatment. The percentages surviving in each group 3 weeks after DMNA administration were 63%, 71%, 17%, and 6%, respectively. Mean serum glutamic oxaloacetic transaminase (SGOT) levels 3 days after DMNA administration were similar in the four groups, indicating that the degree of liver damage was equivalent. A significantly higher proportion of hepatocyte treated rats survived. Liver histology after DMNA administration showed hemorrhagic central lobular necrosis. A return to near-normal architecture occurred by 3 weeks in surviving animals. In group II hepatocytes were seen in portal venules, sinusoids, and central veins. We conclude that dispersed hepatocytes, transplanted either intraperitoneally or via the portal vein, can provide sufficient metabolic support to allow for recovery from drug-induced hepatic necrosis.
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580
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Matas AJ, Payne WD, Simmons RL, Buselmeier TJ, Kjellstrand CM. Acute renal failure following blunt civilian trauma. Ann Surg 1977; 185:301-6. [PMID: 843128 PMCID: PMC1396622 DOI: 10.1097/00000658-197703000-00009] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Renal failure developed in 20 patients following blunt civilian trauma. Ten recovered normal renal function; 8 currently survive. Survivors and nonsurvivors did not differ in age, time from trauma to anuria, mean blood urea nitrogen or creatinine level prior to the first or to subsequent dialyses. However, there was an increased incidence of sepsis and liver failure in those who died. When outcome was related to site of injury, patients with closed head injury and/or intra-abdominal injury had a worse prognosis than those with thoracic or extremity injury only. Only 2 patients with perforated bowel survived; both had peritoneal dialysis combined with peritoneal lavage with antibiotic solutions. Mortality in patients with posttraumatic renal failure remains high; however, death is usually a result of associated complications rather than a result of the renal failure. Aggressive management of other complications of the trauma, especially sepsis or potential sepsis, is necessary. We recommend peritoneal dialysis combined with peritoneal antibiotic lavage where there is a potential for posttraumatic intra-abdominal sepsis associated with renal failure.
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581
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Matas AJ, Sutherland DE, Kretschmer G, Steffes MW, Najarian JS. Pancreatic tissue culture: depletion of exocrine enzymes and purification of islets for transplantation. Transplant Proc 1977; 9:337-9. [PMID: 405775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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582
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Najarian JS, Sutherland DE, Matas AJ, Steffes MW, Simmons RL, Goetz FC. Human islet transplantation: a preliminary report. Transplant Proc 1977; 9:233-6. [PMID: 405770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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583
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Sutherland DE, Matas AJ, Steffes MW, Simmons RL, Najarian JS. Transplantation of liver cells in an animal model of congenital enzyme deficiency disease: the Gunn rat. Transplant Proc 1977; 9:317-9. [PMID: 405773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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584
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585
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Matas AJ, Sutherland DE, Payne WD, Kretschmer GJ, Steffes MW, Najarian JS. Islet transplantation. The critical period of donor ischemia in neonatal rats. Transplantation 1977; 23:295-8. [PMID: 140483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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586
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Matas AJ, Simmons RL, Najarian JS. Complex pathogenesis of cancer in transplant recipients. COMPREHENSIVE THERAPY 1977; 3:49-53. [PMID: 65239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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587
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Sutherland DE, Kretschmer GJ, Matas AJ, Najarian JS. Experience with auto- and allotransplantation of pancreatic fragments to the spleen of totally pancreatectomized dogs. TRANSACTIONS - AMERICAN SOCIETY FOR ARTIFICIAL INTERNAL ORGANS 1977; 23:723-5. [PMID: 410138 DOI: 10.1097/00002480-197700230-00196] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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588
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Matas AJ, Sutherland DE, Payne WD, Grotting J, Steffes MW, Kretschmer GJ, Najarian JS. Successful transplantation of neonatal rat islet tissue preserved for up to 63 hours. ASAIO J 1977; 23:347-51. [PMID: 143746 DOI: 10.1097/00002480-197700230-00087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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589
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Sutherland DE, Matas AJ, Steffes MW, Najarian JS. Infant human pancreas. A potential source of islet tissue for transplantation. Diabetes 1976; 25:1123-8. [PMID: 186347 DOI: 10.2337/diab.25.12.1123] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Twelve pancreases from human infants one year old or less were analyzed for tissue insulin and amylase content before and after dispersal of pancreatic fragments by mincing and collagenase digestion. Tissue insulin and amylase content provide an index of pancreatic islet mass and exocrine digestive enzyme content, respectively. The results were compared with similar anaylses performed on juvenile and adult human pancreases before and after islet isolation and on intact and dispersed neonatal rat and adult rat pancreas. Infant human pancreas has an average tissue insulin concentration of 1,128 mug./gm. of tissue and a total insulin content of 1,718 mug/pancreas, as against values of 140 mug./gm. of tissue and 7,209 mug./pancreas for adult human pancreas. Average tissue amylase concentration is 0.24 mg./gm. of tissue in infant human pancreas and 3.0 mg./gm. of tissue in adult human pancreas. The insulin/amylase ratio in infant pancreas is 4,800, as against 46 in the adult pancreas. Neonatal rat pancreas, which can be dissociated and transplanted without separation of islet and exocrine components, has a similarly high tissue insulin and low tissue amylase content when compared with adult rat pancreases. Infant human pancreas has a total islet mass 24 per cent that of an adult human pancreas, and neonatal rat pancreas has a total islet mass 11 per cent of that of an adult rat pancreas. One neonatal rat pancreas prepared by minimal collagenase digestion can cure diabetes when transplanted via the portal vein to a rat. Following dispersal of infant human pancreas by collagenase digestion, the islet content and the insulin/amylase ratio of the recovered tissue equals or exceeds that which usually can be isolated from adult cadaver pancreases. Infant human pancreas is a rich source of islet tissue that is relatively uncontaminated by exocrine digestive enzymes. After dispersal, infant human pancreas may be ideal for transplantation to selected diabetic patients.
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590
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Matas AJ, Hertel BF, Rosai J, Simmoms RL, Najarian JS. Post-transplant malignant lymphoma. Distinctive morphologic features related to its pathogenesis. Am J Med 1976; 61:716-20. [PMID: 790955 DOI: 10.1016/0002-9343(76)90151-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Malignant lymphoma developed in two patients after renal transplantation. In both, the central nervous system was involved. Histologic study of the tumors showed that they were composed of a monomorphous proliferation of cells characterized by a large vesicular nucleus, prominent basophilic nucleolus and strongly pyroninophilic cytoplasm. The tumors thus would be classified as "diffuse large lymphoid lymphomas with pyroninophilia" or "immunoblastic sarcomas" as described in the literature. Tumor cells resembled cells observed in the paracortex of antigenically stimulated lymph nodes, cells from malignant lymphomas in mice that were antigenically stimulated and from malignant lymphomas in patients with immunodeficiency diseases or autoimmune disorders. The distinctive morphologic features of the tumors in the transplant recipients described provide further evidence that long-term antigenic stimulation may be important in their pathogenesis.
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591
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Sutherland DE, Kjellstrand CM, Simmons RL, Mauer SM, Buselmeier TJ, Goetz FC, Matas AJ, Haymond M, Howard RJ, Buls J, Najarian JS. Renal transplantation in the diabetic. MINNESOTA MEDICINE 1976; 59:766-71. [PMID: 794681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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592
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Matas AJ, Scheinman JI, Rattazzi LC, Mozes MF, Simmons RL, Najarian JS. Immunopathological studies of the ruptured human renal allograft. Transplantation 1976; 22:420-6. [PMID: 63167 DOI: 10.1097/00007890-197611000-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The immunopathology of five cases of spontaneous allograft rupture has been studied. All kidneys were edematous on exploration and routine histological sections showed interstitial edema and mononuclear cell infiltration characteristic of acute rejection. Immunofluorescence revealed, at most, scattered vascular deposition of IgM and mild mesangial C3 deposition. These findings are compared with findings in normal kidneys and kidneys which had been hyperacutely rejected. The normal kidney showed focal afferent arteriolar and proximal mesangial stalk deposition of C3 without IgM. The kidneys of patients with hyperacute rejection showed brilliant staining for fibrin and IgM in all arterial and arteriolar walls with lesser amounts of C3 and IgG; IgM and C3 were prominent in the glomerulus. These findings suggest that mechanisms other than circulating preformed antibodies are responsible for the pathogenesis of spontaneous allograft rupture.
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593
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594
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Najarian JS, Simmons RL, Condie RM, Thompson EJ, Fryd DS, Howard RJ, Matas AJ, Sutherland DE, Ferguson RM, Schmidtke JR. Seven years' experience with antilymphoblast globulin for renal transplantation from cadaver donors. Ann Surg 1976; 184:352-68. [PMID: 786192 PMCID: PMC1344397 DOI: 10.1097/00000658-197609000-00013] [Citation(s) in RCA: 77] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Antibody of the IgGab type can be isolated from horses immunized with cultured human lymphoblasts plus complete Freund's adjuvant. The essential steps for the production of a safe, potent anti-human lymphoblast globulin (ALG) are: A) the use of early bleedings after immunization to reduce the titer of antibodies which react with red blood cells and platelets; B) careful absorption with human red blood cell stroma and platelets; C) stabilization with non-crystalline silica dioxide; D) chromatography through QAE sephadex to remove pyrogens, microaggregates and possible inhibitors of ALG activity; E) careful safety testing in animals for toxicity and pyrogenicity; and F) testing in vitro for sterility. Such a purified horse ALG (IgGab) can be administered safely intravenously to patients to supplement a standardized immunosuppressive regimen incorporating azathioprine and prednisone. Under these circumstances, allergic reactions are very rare, antibodies to horse IgG do not develop, skin tests to horse IgG remain negative, and immune elimination of circulating horse IgG from the human circulation cannot be demonstrated. The overall results of ALG patient survival and transplant function after 184 consecutive first cadaver transplants at the University of Minnesota demonstrate a statistically significant improvement in both parameters accompanying increases in ALG dose while rigidly utilizing standardized doses of azathioprine and prednisone. There is a significant reduction in the number of grafts lost to rejection; significant reduction in the number of rejection episodes; significant delay in the onset of rejection episodes; but there is no increase in septic loss of patients or kidneys. These efforts could be seen in the gross data or when subgroups controlling for patient age, tissue typing were analyzed. Excluding patients at high risk did not alter the results. The beneficial effects of ALG were particularly striking in good matches. In the highest doses, ALG may be dangerous for older patients with poor matches who develop an increased incidence of septic loss of kidney and/or life. Thus, ALG appears to be a useful adjunct in the early management of cadaver transplants by reducing the incidence and frequency of rejection episodes. The dose should probably be reduced in the older patients who receive kidneys from badly mismatched donors. One cannot conclude from this study that ALG manufactured in other centers by this or other techniques, will accomplish the same results since the multiplicity of factors involved in the success and failure of transplants must be controlled so that the influence of intravening variables in the assessment of ALG effectiveness can be assessed.
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595
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Matas AJ, Sutherland DE, Steffes MW, Najarian JS. Short-term culture of adult pancreatic fragments for purification and transplantation of islets of Langerhans. Surgery 1976; 80:183-91. [PMID: 133470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Minced adult human, rat, and dog pancreatic fragments were cultured under various conditions in an attempt to selectively purify pancreatic islet tissue from exocrine digestive enzymes. Islet purification was assessed by measuring tissue insulin and amylase concentrations, proportional to islet beta cell mass and exocrine enzyme content, respectively. Tissue amylase content decreased rapidly over a 24 hour culture period under all conditions. By addition of pilocarpine, cobalt chloride, and aprotinin to the culture medium, pancreatic tissue insulin levels stabilized. Under these conditions the tissue insulin: amylase ratio increased rapidly and a high ratio was maintained, indicating that islet tissue decontaminated of exocrine digestive enzymes was preserved in short-term culture. Fifteen dogs rendered diabetic with streptozotocin immediately following a partial pancreatectomy received an autotransplant of pancreatic tissue fragments maintained in culture for 24 hours. Seven dogs were rendered normoglycemic. Six of these dogs have survived for longer than 30 days. Only one of 14 control pancreatectomized dogs injected with streptozotocin and not transplanted survived and was normoglycemic. Viable islet tissue free of exocrine enzymes can be obtained by short-term culture of pancreatic fragments, and separation of islet and exocrine components of adult pancreas is not essential for successful islet transplantation.
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596
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Matas AJ, Sutherland DE, Steffes MW, Najarian JS. Minimal collagenase digestion: amelioration of diabetes in the rat with transplantation of one dispersed neonatal pancreas. Transplantation 1976; 22:71-3. [PMID: 180636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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597
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Matas AJ, Sutherland DE, Steffes MW, Mauer SM, Sowe A, Simmons RL, Najarian JS. Hepatocellular transplantation for metabolic deficiencies: decrease of plasms bilirubin in Gunn rats. Science 1976; 192:892-4. [PMID: 818706 DOI: 10.1126/science.818706] [Citation(s) in RCA: 236] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A sustained decrease of plasma bilirubin concentrations occurred in homozygous recessive Gunn rats lacking the enzyme uridine diphosphate glucuronyltransferase following infusion into the portal vein of hepatocytes from heterozygous nonjaundiced Gunn rats possessing the enzyme. Transplantation of cells capable of continuous enzyme production could be an effective mode of therapy for congenital enzyme deficiency diseases.
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598
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Matas AJ, Sutherland DE, Steffes MW, Najarian JS. Islet transplantation using neonatal rat pancreata: quantitative studies. J Surg Res 1976; 20:143-7. [PMID: 817084 DOI: 10.1016/0022-4804(76)90132-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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599
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Matas AJ, Mauer SM, Sutherland DE, Spanos PK, Simmons RL, Najarian JS. Polar infarct of a kidney transplant simulating appendicitis. Am J Surg 1976; 131:383-5. [PMID: 769587 DOI: 10.1016/0002-9610(76)90133-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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600
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Matas AJ, Simmons RL, Kjellstrand CM, Buselmeier TJ, Najarian JS. Transplantation of the aging kidney. Transplantation 1976; 21:160-1. [PMID: 766333 DOI: 10.1097/00007890-197602000-00013] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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