Persistent hepatitis B virus following interferon alfa therapy and liver transplantation

A 44-year-old man with chronic hepatitis B virus infection and cirrhosis was treated with recombinant human interferon alfa for 67 days immediately before orthotopic liver transplantation and immunoprophylaxis with hyperimmune globulin to hepatitis B virus in the peritransplant period. Dot blots for hepatitis B virus DNA demonstrated marked reduction in viremia after 41 days of interferon alfa treatment. Southern analysis for hepatitis B virus in liver showed a pronounced decrement in actively replicating forms in the explant, although hepatic infection was still detectable. After liver transplantation, tests for serum hepatitis B virus DNA and hepatitis B surface antigen remained negative. The patient died 32 days after transplantation of causes unrelated to hepatitis B virus. DNA isolated from liver and other visceral organs at autopsy showed infection of the engrafted liver and the persistence of monomeric relaxed circular forms of hepatitis B virus DNA in pancreas, kidney, and spleen. Thus, graft reinfection occurred despite aggressive antiviral therapy and immunoprophylaxis combined with liver transplantation. Existing viral serological markers appear insufficiently sensitive to assess residual infectivity.

Percutaneous transhepatic portal vein angioplasty and stent placement after liver transplantation: early experience

In four patients who underwent liver transplantation, portal vein thrombosis was associated with esophageal varices and significant gastrointestinal bleeding. In a fifth liver transplant patient, portal vein stenosis was suspected when evidence of hepatic ischemia was revealed at liver biopsy. Four patients were treated with percutaneous transhepatic portal vein angioplasty. Percutaneous recanalization was precluded by technical factors in the remaining patient. Early in the series, one patient required surgical excision of what proved to be a thick cuff of fibrous tissue and lymph nodes after angioplasty failed to widen the stenosis significantly. Later, a patient with residual stenosis was treated successfully by means of intravascular stent placement. Of the four patients treated, three eventually died secondary to multiple problems unrelated to the percutaneous procedure. This early experience suggests that transhepatic portal vein interventions are feasible in patients who have received liver transplants and may prove useful at least in the early postprocedure period.

Examination of vascular anastomoses during liver transplantation by intraoperative Doppler duplex scanning

Intraoperative examination of the arterial and portal vein anastomoses was performed in 16 liver transplant patients using duplex scanning. Two major defects and three minor defects were found in 5 arterial anastomoses. Major defects were defined as those associated with an audibly abnormal Doppler signal, a defect greater than 3 mm in length or greater than 50% luminal narrowing. Minor defects were defects visible by ultrasound but not meeting the above criteria. The major defects were repaired and scans following repair were without evidence of defects. The three minor defects were ignored. A nearly occluding thrombus was found in the portal vein of one patient. A thrombectomy was performed successfully. All patients have done well postoperatively. This report suggests that intraoperative duplex scanning may be of value in detecting technical imperfections in the vascular anastomoses during liver transplantation. Detection of a major defect intraoperatively allows immediate repair.

Role of macrophages in the immune response to hepatocytes

The purpose of this study was to determine the role of host macrophages in the development of allospecific cytolytic T cells (allo-CTLs) in response to purified allogeneic MHC Class I+, Class II- hepatocytes in vivo in hepatocyte sponge matrix allografts (HC-SMA). Depletion of antigen-presenting cells (APCs) from responder splenocytes in mixed lymphocyte hepatocyte culture (MLHC) inhibits the development of allo-CTLs in response to purified hepatocytes. First the ability of sponge macrophages to function as accessory cells in indirect presentation of hepatocyte Class I antigen was tested in MLHC. We found that addition of irradiated sponge cells (a source of sponge macrophages) restored the development of allo-CTLs in MLHC depleted of responder APCs. Therefore, radioresistant sponge macrophages can function as accessory cells in MLHC. We next employed silica as an immunotherapy targeted against host macrophages and assessed the effect on development of allo-CTLs in HC-SMA. We found that local (intrasponge) silica treatment completely inhibited the development of allo-CTLs in HC-SMA. Combined local and systemic silica treatment resulted in inhibition of allocytotoxicity comparable to local silica treatment alone in the doses tested. We conclude that host macrophages which infiltrate HC-SMA can function as accessory cells in vitro in MLHC and that both infiltrating host macrophages and lymphocytes participate in the development of an alloimmune response to purified hepatocytes in vivo. This interaction may involve indirect antigen presentation of hepatocyte Class I antigen by macrophages to host lymphocytes which accumulate in HC-SMA.

The management of T tube leaks in orthotopic liver transplant recipients with endoscopically placed nasobiliary catheters

Biliary tract problems remain an important cause of complication following orthotopic hepatic transplantation. We describe 12 liver transplantation patients who developed bile peritonitis secondary to a biliary leak after T tube removal. Each of these patients underwent an urgent ERCP that exhibited leakage outside the T tube tract and nondilated intrahepatic ducts. At the time of the ERCP, a nasobiliary catheter was inserted to divert the bile flow. All of these patients resolved their symptoms and closed their leak. We advocate endoscopic placement of a nasobiliary catheter as first-line therapy for significant T tube tract leaks after liver transplantation.

Liver transplantation for severe Amanita phalloides mushroom poisoning

Amanita phalloides mushroom poisoning is an increasingly common and potentially lethal problem for which liver transplantation offers definitive therapy in selected patients. When significant liver dysfunction appears, early transfer to a liver transplant center is important to identify appropriate candidates and to begin the search for a donor organ. The clinical course of five severely poisoned patients, four of whom underwent liver transplantation, is reviewed. Indications for transplantation included primarily a markedly prolonged prothrombin time that was only partially correctable and a constellation of findings including metabolic acidosis, hypoglycemia, hypofibrinogenemia, and increased serum ammonia, following a marked elevation in serum aminotransferase levels. Unlike viral fulminant hepatic failure, grade III or IV hepatic encephalopathy, marked elevation of the serum bilirubin level, and azotemia were not indications for transplantation. Resected livers demonstrated hepatocyte viability of 0% to 30%. Manifestations of Amanita poisoning complicating preoperative and/or postoperative care included severe diarrhea, gastrointestinal hemorrhage, hypophosphatemia, bowel edema, and marrow suppression with lymphopenia, thrombocytopenia, and neutropenia. All five patients are well 1 year later. This largest experience with liver transplantation for Amanita poisoning further defines the early clinical and laboratory indications for, and the unique complicating features of, transplantation in this setting.

Comparison of in vivo and in vitro immune response to purified hepatocytes

We have previously reported that freshly isolated percoll-purified hepatocytes are MHC class I+, Class II- and stimulate allospecific cytotoxicity in mixed lymphocyte hepatocyte culture. In this report we determined the immunogenicity of purified hepatocytes in vivo using a modification of the sponge matrix allograft model. We found that hepatocytes were immunogenic in vivo because they stimulated the development of cytolytic effectors in allogeneic but not syngeneic hepatocyte sponge matrix allografts. These cytolytic effectors were not macrophages (because cytotoxicity was intact after nylon wool depletion of the bulk sponge effectors) but rather were Ly2+, L3T4- T cells. Cytolytic effectors in both MLHC and hepatocyte sponge matrix allografts demonstrated marked specificity for allogeneic MHC class I antigen of stimulator and donor hepatocytes, respectively. Allospecific cytolytic T cells developed in both MLHC and hepatocyte sponge matrix allografts across an isolated MHC class I genetic disparity but not across an isolated class II genetic disparity. Finally, sequential phenotypic analysis of host cells infiltrating allogeneic hepatocyte sponge matrix allografts demonstrated the presence of macrophages, Ly2+, L3T4- and Ly2-, L3T4+ T cells.

The pharmacokinetic advantage of local 6-mercaptopurine infusion in a canine renal transplant model

In light of recent technologic advances, we developed a canine renal allograft model utilizing implantable, programmable infusion pumps and biocompatible catheters to reexplore the concept of local immunosuppression. Thirteen mongrel dogs underwent bilateral nephrectomy and autotransplantation of 1 kidney via end-to-end renal-iliac artery and end-to-side renal-iliac vein anastomoses. The proximal end of an infusion catheter directed into the iliac artery was tunneled to a subcutaneously placed programmable pump. A second, sampling catheter was placed with its tip in the iliac vein just proximal to the venous anastomosis. During a period of i.a. infusion of heparinized saline ranging from 19 to 63 days, serum creatinine remained normal in all but 1 animal, which developed pyelonephritis and catheter-tip perforation of the iliac artery. No cases of arterial thrombosis or catheter migration were observed at necropsy. In 7 additional autotransplanted dogs, simultaneous iliac vein and systemic (jugular vein) concentrations of 6-mercaptopurine (6-MP), the major immunosuppressive metabolite of azathioprine, were determined during a continuous 24-hr i.a. infusion (10 mg/kg/24 hr). Following termination of the infusion, 10 mg/kg 6-MP was administered to the same 7 dogs as an i.v. bolus, and systemic drug concentrations were determined over a 4-hr period. Mean +/- SE total-body clearance and elimination half-life were 887 +/- 159 ml/min and 1.4 +/- 0.2 hr, respectively, in the i.v. bolus study, indicating that 6-MP is rapidly cleared from the systemic circulation. Unexpectedly, the kidney removed as much as 60-95% of locally infused 6-MP, reducing the amount of active drug entering the systemic circulation to 5-40% of that which would be present during an i.v. infusion of the same dose. According to the principles governing the advantages of i.a. infusions, these data demonstrate that 6-MP can be infused intrarenally to produce both a 4-fold increase in drug concentration within the kidney and an 80% decrease in systemic drug delivery when compared to same-dose i.v. administration. The overall result is the presence of a 30-fold gradient between local and systemic drug concentrations during intrarenal 6-MP infusion. We conclude that i.a. infusion of an immunosuppressive agent is technically feasible with preservation of renal function, and that 6-MP can be delivered locally in a canine model with great pharmacokinetic and potential therapeutic advantage.

Transplant renal artery stenosis

A group of 31 patients with transplant renal artery stenoses was identified among 2002 patients undergoing renal transplantation at the University of Minnesota; 29 of the stenoses were at the anastomosis. A total of 43 procedures were performed to correct the stenosis. Angioplasty was performed 25 times, with 3 patients cured and 2 patients improved; 20 procedures resulted in a poor result (3) or a failure (17). The failures were usually due to recurrent stenosis (7 patients) or to arterial injury that resulted in graft loss (4 patients) or successful emergency surgery to save the transplant (3 cases). Surgical repair of the stenosis was performed 18 times. No grafts were lost and 13 patients were cured or improved. These data suggest that angioplasty for anastomotic stenosis yields poor results and that a surgical repair is probably warranted. All 7 patients who had a poor results or failed a technically successful intervention did not have a rise in creatinine secondary to captopril or had a systolic pressure gradient of less than 60 mmHg across the anastomosis. These data also suggest that patients without physiological evidence of renal artery stenosis may not have improvement in their hypertension following repair.

Gastric bezoar after hepatic transplantation

A gastric bezoar complicated the postoperative course of three children following successful hepatic transplantation. Two patients had evidence of extremely erratic absorption of the cyclosporine (CSA) used for immunosuppression. Gastric bezoars usually occur in patients with gastric dysmotility and/or patients ingesting poorly digestible material. Although several factors may contribute to bezoar formation after hepatic transplantation, a major predisposing factor may be the administration of the large quantities of olive oil required for solubilization of CSA.

Liver transplantation in a patient with protoporphyria

A 38-yr-old woman with liver disease due to protoporphyria underwent orthotopic liver transplantation. The resected liver was cirrhotic and contained a massive amount of protoporphyrin, with numerous birefringent pigment deposits. Transplantation was accomplished without difficulty following blood volume exchange to reduce the blood protoporphyrin level. Sequential biopsy specimens obtained through the 13th month after transplantation showed no accumulation of protoporphyrin pigment deposits in the new liver. Portal inflammation observed in the liver biopsy specimen at 6 mo after transplantation resolved spontaneously. Erythrocyte and serum protoporphyrin levels returned to values similar to those in the pretransplantation period when the patient had normal hepatic function; the fecal level was lower. Thus orthotopic liver transplantation can be successfully done in patients with protoporphyria who have severe liver disease. Prolonged follow-up is needed to determine the ultimate outcome, however, as the new liver remains susceptible to protoporphyrin-induced damage.

Modulation of MHC class I antigen decreases pancreatic islet immunogenicity

Pretreatment regimens directed at reducing the immunogenicity of pancreatic islets have emphasized the elimination or alteration of the major histocompatibility complex (MHC) class II-positive dendritic cells within the islet. Unfortunately, the efficacy of such pretreatment regimens has been extremely variable and the relative contribution of the dendritic cells to the overall immunogenicity of pancreatic islets has remained ambiguous. Recent evidence has suggested that the MHC class I antigen present on the endocrine cells within the islets may play an important role in the alloimmune response. This study utilized the in vitro mixed lymphocyte-islet co-culture system to determine if pretreatment of whole islets with an anti-MHC class I monoclonal antibody specific to the donor strain would block the generation of cytotoxic T lymphocytes (CTL) in the in vitro mixed lymphocyte-islet coculture. Pretreatment of B10.BR (H-2k) and DBA/2J (H-2d) islets with an allospecific anti-MHC class I monoclonal antibody blocked the generation of allospecific CTL when the pretreated islets were placed into coculture with C57Bl/6 (H-2b) splenocytes. If such a pretreatment regimen is similarly effective in vivo, it could potentially be used as an antirejection strategy in pancreatic islet allotransplantation.

Biliary complications after liver transplantation in children

To evaluate the role of interventional radiologic procedures in the diagnosis and treatment of biliary complications in children after liver transplantation, the authors reviewed the cases of 58 pediatric patients who underwent transplantation over a 4-year period. In 21 patients suspected of having biliary complications, 31 diagnostic percutaneous transhepatic cholangiographic studies, 19 transhepatic biliary drainages, eight pressure-flow studies, five percutaneous drainages of abdominal fluid collections, 11 balloon dilations, and one basketing procedure were performed. Biliary complications were seen in 38% of allografts, with obstruction being more common than leakage. Complications were most frequent in patients with cholecystojejunostomy reconstructions. Only two children had biliary complications that were thought to be related to arterial compromise. No significant intervention was required in 17% of complications. Percutaneous techniques were associated with a low frequency of significant complications (6%). The authors conclude that interventional radiologic techniques can be used effectively in the evaluation and management of biliary complications in pediatric hepatic transplant recipients.

Factors influencing early survival after liver transplantation

The purpose of this study was to analyze data from all adult and pediatric liver transplants performed between January 1, 1983 and January 15, 1986 at the University of Minnesota Hospital and identify perioperative variables that predict patient survival and could aid in patient selection. Charts, intraoperative anesthesia records, blood bank records, flow sheets, outpatient records, and autopsy reports were examined in 45 pediatric and 15 adult patients who underwent primary orthotopic liver transplantation. Analysis of the data can be summarized as follows: (1) Pediatric patients whose coagulation parameters could not be corrected prior to operation and who consequently required preoperative exchange transfusion had poorer outcomes than those not requiring an exchange to correct coagulation parameters. (2) The rapid infusion technique for massive blood transfusion resulted in significantly decreased blood loss and intraoperative blood product replacement. (3) Twenty-four hour postoperative factor V levels were good predictors of survival. Patients with poor factor V levels required rigorous replacement of coagulation factors. (4) Pediatric patients with uncorrectable coagulopathies requiring immediate postoperative exchange transfusion had extremely high mortality.

Liver transplantation today

Clinical liver transplantation has been performed for more than 25 years. In the 1980s the survival has markedly improved as a result of better patient selection, improved operative techniques, and better understanding of rejection and immunosuppression. This review examines the improvements in liver transplantation that have led to one-year patient survival rates of better than 80%.

Effect of immunodepletion of MHC class II-positive cells from pancreatic islets on generation of cytotoxic T-lymphocytes in mixed islet-lymphocyte coculture

In vitro manipulation of pancreatic islets to decrease islet immunogenicity before transplantation has largely been directed at eliminating the major histocompatibility complex (MHC) class II-positive passenger leukocytes from the islets. The mixed islet-lymphocyte coculture (MILC) system was used to quantitate the efficacy of immunodepletion of MHC class II-positive cells from pancreatic islets in terms of reducing immunogenicity. With these experiments we compared the in vitro immunogenicity of MHC class II-depleted islets with untreated islets. B10.BR (H-2k) islets were treated with anti-Iak alloserum followed by complement. This treatment successfully eliminated MHC class II-positive cells from the islets, as demonstrated by indirect immunofluorescence techniques. Depleted islets generated slightly lower amounts of allospecific cytotoxic T-lymphocyte (CTL) activity when exposed to C57BL/6 (H-2b) splenocytes in the MILC than untreated control islets. Although the amount of CTL generated by the depleted islets was slightly less than that generated by untreated islets, there was significant stimulation of CTL by the MHC class II-depleted islets. Therefore, the presence or absence of MHC class II cells within the islet is unlikely to be the decisive factor contributing to islet immunogenicity.

Afferent and efferent pathways in T cell responses to MHC class I+, II-hepatocytes

We have previously reported that purified hepatocytes stimulate significant in vitro allospecific cytotoxicity when cocultured with naive responder splenocytes in the mixed lymphocyte hepatocyte culture (MLHC). In this report we examined the expression of MHC antigens on the surface of hepatocytes, the phenotypic lymphocyte subset(s) that respond(s) to allogeneic hepatocytes, and the phenotype of allospecific cytolytic effectors generated in MLHC. Hepatocytes expressed MHC class I but not MHC class II antigens by immunofluorescent microscopy and fluorescence activated cell sorting. The lack of MHC class II on the surface of hepatocytes was also indirectly supported by the inability of hepatocytes to stimulate proliferation of a class II-directed allospecific helper T cell clone. The generation of allospecific cytotoxicity in MLHC required the participation of L3T4+, Ly2- T cells and L3T4-, Ly2+ T cells in the naive responder splenocyte population since depletion of these subsets with mAb and complement abrogated the development of allo-CTLs. Furthermore, adherent accessory cells in the naive responder splenocyte population appeared to play a role in the generation of allospecific cytotoxicity in MLHC since depletion of this population by plastic adherence and passage through a Sephadex G10 column resulted in significantly reduced allospecific cytotoxicity. Depletion of day 5 allosensitized cells of Ly2+ but not L3T4+ T cells by mAb and complement eliminated allospecific cytotoxicity--indicating that cytolytic effectors generated in MLHC appear to be L3T4-, Ly2+ T cells.

Pharmacokinetics of 6-thiouric acid and 6-mercaptopurine in renal allograft recipients after oral administration of azathioprine

The immunosuppressive activity of azathioprine (AZA) is unpredictable and depends on the formation of intracellular thiopurine ribonucleotides. However, the quantification of these active thiopurines presents difficult analytical problems. It has recently been postulated that plasma concentrations of 6-thiouric acid (6-TU) and 6-mercapto-purine (6-MP), metabolites of AZA, may provide more readily measurable indices of the pharmacologic activity of AZA. In order to evaluate the utility of 6-TU and 6-MP plasma concentrations in monitoring AZA therapy, we studied their pharmacokinetics in 6 renal transplant patients, and their in vitro immunosuppressive potency in a mixed lymphocyte proliferation assay. A peak plasma 6-TU concentration of 710.7 ng/ml was observed at 3.8 h after oral dosing. Good correlation was observed between the elimination t1/2 of 6-TU and serum creatinine, and between AUC over 24 h and serum creatinine. However, we did not observe a second peak in plasma 6-TU concentration that could be attributed to the degradation of active AZA metabolites. 6-MP plasma concentrations in the patients were low (mean peak concentration 36.0 ng/ml) and rapidly disappeared within 8 h. In vitro immunosuppressive activity could not be demonstrated for 6-TU over a concentration range of 1.25 ng/ml to 0.25 mg/ml. We conclude that 6-TU is pharmacologically inert and is primarily eliminated by the kidneys. Our findings currently do not support the use of plasma concentrations of 6-TU or 6-MP to monitor AZA therapy. In order to optimize AZA therapy, analytical techniques that are technically feasible and that can directly quantify the active intracellular thiopurines are being explored.

Generation of allospecific cytolytic T-lymphocytes stimulated by pure pancreatic beta-cells in absence of Ia+ dendritic cells

A murine mixed islet-lymphocyte coculture system (MILC) was used to quantitate the immunogenicity of a pure population of pancreatic beta-cells to more clearly define whether stimulator major histocompatibility complex (MHC) class II-positive dendritic cells are a major component leading to islet immunogenicity. Pancreatic beta-cells express MHC class I antigen but not class II antigen. These experiments compared the in vitro immunogenicity of fluorescence-activated cell sorted (FACS-IV) pure beta-cells (MHC class I-positive cells only) relative to unpurified dispersed islet cells (MHC class I-positive cells and class II-positive cells). The results demonstrated the surprising finding that pure DBA/2J (H-2d) pancreatic beta-cells stimulated a strong cytotoxic T-lymphocyte (CTL) response when exposed to C57BL/6 (H-2b) allosplenocytes in the MILC, similar to DBA/2J nonpurified dispersed islet cells. Furthermore, the stimulation of CTL by both purified beta-cells and nonpurified dispersed islet cells was blocked by addition of MHC-specific anti-class I monoclonal antibody directed against stimulator MHC antigen. The data imply that the highly immunogenic MHC class II-positive passenger leukocytes present in the islets were not necessary for the generation of the immune response in the presence of MHC class I-positive beta-cells. Although most of the pretreatment regimens attempting to decrease islet immunogenicity have been directed at eliminating the MHC class II-positive passenger leukocytes from the islets, this work suggests that modulation of MHC class I antigen may be an important approach.

An implantable pump for intrarenal infusion of immunosuppressants in a canine autotransplant model

We developed a canine renal allograft model utilizing implantable infusion pumps and biocompatible catheters to investigate the pharmacokinetics of local immunosuppressive drug administration. Seven mongrel dogs underwent bilateral nephrectomy and autotransplantation of one kidney to the iliac vessels. The proximal end of an infusion catheter directed into the iliac artery was tunneled to a subcutaneously placed programmable pump. A second, sampling catheter was placed with its tip in the iliac vein. Simultaneous regional (iliac vein) and systemic (jugular vein) venous concentrations of 6-mercaptopurine (6-MP), the immunosuppressive metabolite of azathioprine, were determined during a continuous 24-h intraarterial infusion (10 mg/kg/24 hr). The gradient between regional and systemic 6-MP concentrations was maximal initially when the pump was turned on, continuously decreased until steady state was reached, and disappeared immediately after the pump was turned off. The mean ratio of steady-state iliac vein to systemic 6-MP concentrations was 5.0 +/- 1.4, demonstrating a pharmacokinetic advantage of continuous intraarterial 6-MP infusion to the autotransplanted kidney. The novel canine renal allograft model described herein overcomes the technical limitations of earlier models and represents a foundational step in the design of intrarenal infusion patterns of immunosuppressive agents which we expect to prolong survival of the allotransplanted kidney with minimal systemic drug exposure and side effects.

Infection and rejection of primary hepatic transplant in 93 consecutive patients treated with triple immunosuppressive therapy

Ninety-three consecutive patients who underwent primary orthotopic hepatic transplantation were treated, after transplantation, with prophylactic immunosuppressive therapy consisting of cyclosporine, prednisone and azathioprine. Weekly percutaneous biopsies were performed to diagnose rejection rapidly. Rejection was treated using a sequential multidrug therapeutic approach based on histologic findings. Mild rejection was initially treated with steroids; moderate to severe rejection was initially treated with steroids; moderate to severe rejection was treated with Minnesota antilymphoblast globulin (mALG) or OKT3 monoclonal antibody (Orthoclone, Ortho Pharmaceutical Corp.), or both. The one year actuarial survival rate for adults was 80 per cent and for children, 70 per cent. The incidence of biopsy-proved rejection was 75 per cent in adults and 80 per cent in children; however, the rejection was relatively easily reversed in both groups using biopsy-guided multimodal therapy. In 21 of 22 patients treated with steroids alone, rejection was reversed. Forty-one patients with moderate to severe rejection required treatment with mALG or OKT3, or both; in 38, rejection was resolved, and in three, chronic rejection required retransplantation. The incidence of bacterial, fungal and viral infections was high after transplantation and was further exacerbated by antirejection therapy requiring mALG Or OKT3, or both. Although the rate of infections was high, most were easily treated with antimicrobial agents. Thus, triple drug immunoprophylaxis followed by biopsy-guided antirejection therapy provided effected treatment of rejection without promoting fatal infections.

Single-center 1-15-year results of renal transplantation in patients with systemic lupus erythematosus

Initially, poor long-term prognosis in patients with SLE and fear of recurrent disease dissuaded renal transplantation in this group of patients. However, in 1975 the Advisory Committee to the Renal Transplant Registry reported satisfactory 1-2-year results in 56 patients with SLE from 36 institutions. Subsequently, renal transplantation for SLE patients with end-stage renal disease has become more accepted, though it has been recommended that transplantation be postponed for at least one year after initiating dialysis. Five cases of recurrent lupus nephritis have been reported in the literature. However, since the long-term outcome after transplantation in this group of patients is not well established, we have examined the long-term outcome in SLE patients who underwent renal transplantation at the University of Minnesota. Thirty-two SLE patients receiving 33 transplants between December 1969 and December 1987 were studied retrospectively and compared with controls matched for age, sex, donor source, HLA match, date of transplant, and diabetic status. A total of 69% (22/32) of patients underwent less than 1 year of dialysis prior to transplantation, and 50% (16/32) experienced biopsy-proved acute rejection, which was reversible in 67% (11/16). Actuarial graft function and patient survival rate in SLE patients were not significantly different from those in the matched control group. Duration of prior dialysis did not affect outcome. Surviving grafts have excellent function as measured by serum creatinine (1.3 +/- 0.4 mg/dl, means +/- SD). Causes of death were sepsis (5) and myocardial infarction (1). One patient lost the graft from rejection after withdrawal of immunosuppression because of a malignancy one month posttransplant. Three patients lost graft function due to chronic rejection. To date no patients have had evidence of recurrent SLE nephritis.

Orthotopic liver transplantation: nonoperative management of early, acute portal vein thrombosis

We report a case of acute portal vein thrombosis that occurred 1 week after orthotopic liver transplantation in a patient with sclerosing cholangitis. Unlike other patients reported in the literature who were first seen with variceal bleeding or acute hepatic failure, this patient initially had mild clinical signs, consisting of an abnormal prothrombin time, an increase in liver function test values, and enlarging but nonbleeding gastroesophageal varices. Whereas patients with more extreme symptoms often die or require retransplantation, this patient was managed nonoperatively. Spontaneous lysis of the portal vein thrombus occurred over the ensuing 2 weeks. The diagnosis and management of this milder form of early, acute portal vein thrombosis are discussed.

In vitro generated allospecific cytolytic T lymphocytes injure pancreatic islets

The role of cytotoxic T lymphocytes in the rejection of pancreatic islet allografts remains poorly defined. The present study was designed to assess the ability of in vitro generated cytolytic T lymphocytes to produce allospecific functional and structural damage of mouse pancreatic islets. A mixed lymphocyte-islet coculture model (MLIC) has been developed, in which islets from DBA/2J mice (H-2d) stimulate the generation of allospecific cytolytic T lymphocytes (C57B1/6, H-2b), as measured by lysis of allospecific chromium-labeled tumor targets. Responder C57B1/6 splenocytes sensitized to DBA/2J islets were harvested from the MLIC on Day 5 and cocultured with either freshly isolated DBA/2J or B10.BR (H-2K) islets. Islet injury was determined by assessment of beta cell function after 8 hr (as measured by insulin release in response to a glucose challenge) and islet destruction after 24 hr of coculture with the sensitized splenocytes. Whereas coculture of third party B10.BR islets with MLIC-sensitized C57B1/6 anti-DBA splenocytes had no effect on insulin release or structure, incubation of allospecific DBA/2J islets with these splenocytes resulted in inhibition of insulin release after 8 hr and disintegration of the islets by 24 hr. The depletion of MLIC-sensitized C57B1/6 anti-DBA splenocytes with anti-Lyt2 monoclonal antibody, but not anti-L3T4 monoclonal antibody, prevented the allospecific destruction of fresh islets by the splenocytes in culture. This study suggests that allospecific, cytotoxic T lymphocytes may play an important role in the effector mechanism of pancreatic islet allograft destruction.

Couette membrane filtration with constant shear stress

Recent developments in the field of blood component separation have revealed the usefulness of membrane filtration using couette type configurations and Taylor vortices as an efficient and effective method. The authors have analyzed in detail the physical and chemical effects on whole blood separated into protein rich plasma, and concentrated red blood cell suspensions, using this technique. The authors also have calculated and demonstrated the technical specifications required to provide laminar flow with Taylor Vortex formation throughout the device, as well as those required to retain constant shear stress on the blood components as viscosity changes. By maintaining constant shear stress below a critical level, it is possible to avoid shear induced hemolysis and to maintain maximal separation efficiency throughout the procedure. The device has further been designed to alter the filtration velocity along the membrane so that the critical filtration velocity is nowhere exceeded, i.e., concentration polarization effects are prevented.

A single-center experience of renal transplantation in thirteen Jehovah's Witnesses

The beneficial effects of pretransplant blood transfusions on the success rate of renal transplantation have been so overwhelmingly emphasized that there is virtually no information on the fate of grafts in nontransfused patients transplanted during the last decade. Since 1979, all patients who have undergone renal transplantation at the University of Minnesota have routinely received random blood transfusions except Jehovah's Witnesses. Jehovah's Witnesses refuse transfusions but will accept renal allografts. From 1979 to May 30, 1987, primary renal allografts were placed in thirteen nontransfused Jehovah's Witnesses; six patients received kidneys from mismatched living-related donors, two patients received HLA-identical sibling grafts, and five patients received cadaveric renal allografts. The range of follow-up of the thirteen patients was 3-93 months, with a mean of 45 months and a median of 50 months. The outcomes after renal transplantation in Jehovah's Witnesses were compared with those of a paired control group (n = 25) matched for age, date of transplant, donor source, and diabetic status. The overall three-year actuarial patient and graft survival rates of the Jehovah's Witnesses were 83 per cent and 66 per cent, versus 80 per cent and 77 per cent for the controls. Although the outcomes after renal transplantation in Jehovah's Witnesses were similar to those of the control group, the Jehovah's Witnesses had an increased susceptibility to rejection episodes. The cumulative percentage of incidence of primary rejection episodes was 77 per cent at three months in the Jehovah's Witnesses versus 44 per cent at 21 months in the matched control group. The consequence of early allograft dysfunction from rejection was particularly detrimental to Jehovah's Witnesses who developed severe anemia (hemoglobin (Hgb)* 4.5 g per cent)-two early deaths occurred in the subgroup with this combination of problems. The overall results suggest that renal transplantation can be safely and efficaciously applied to most Jehovah's Witnesses but those with anemia who undergo early rejection episodes are a high-risk group relative to other transplant patients.

Imaging of vascular complications after hepatic transplantation

Vascular complications after hepatic transplantation can compromise graft and patient survival. Angiography defines the need for revascularization or retransplantation, but the value of noninvasive imaging in this setting is not clear. To assess the relative merit of noninvasive imaging techniques (sonography, scintigraphy, CT, and MR), we retrospectively reviewed 19 major vascular complications that occurred in 15 of 98 hepatic recipients over a 3 1/2-year period. Portal venous thrombosis was seen in seven patients, donor aortic or hepatic arterial thrombosis in seven, and inferior vena caval thrombosis in five. Sonography provided the initial diagnosis of portal venous thrombosis in three, arterial compromise in five, and caval obstruction in four. CT was the first diagnostic examination to identify portal occlusion in two, donor aortic thrombosis in one, and inferior vena caval thrombosis in one. Scintigraphy and MR imaging provided complementary data. Both sonography and CT are useful in the evaluation of vascular complications that occur after hepatic transplantation; however, neither is sufficiently sensitive to obviate angiographic assessment.

Biliary complications after liver transplantation in patients with preexisting sclerosing cholangitis

To determine if biliary complications after liver transplantation are more frequent in patients with preexisting sclerosing cholangitis and to clarify the role of interventional procedures in this setting, the authors reviewed all 40 adult cases in which liver transplantation was performed at their institution over a 3 1/2-year period. Biliary complications, particularly strictures at the choledochojejunostomy and debris in the intrahepatic and common ducts, were seen in six of ten liver transplant patients (60%) with preexisting sclerosing cholangitis; this is six times the frequency of biliary complications seen in other adult recipients (10%). Biliary complications were definitively diagnosed and managed with interventional radiologic procedures. Obstruction due to anastomotic strictures required treatment with balloon dilation in all six of the affected patients. Obstructive biliary complications occur in many liver recipients with preexisting sclerosing cholangitis. These complications require aggressive radiologic assessment and intervention but to date have not adversely affected survival.