Further studies on hepatic stimulatory substance (SS) after partial hepatectomy

The stimulatory substance (SS) that is found in the cytosol of regenerating dog livers and which promoted regeneration when injected into the portal vein after Eck fistula did not cause glomerular proliferation when active cytosol was injected into the renal artery. The finding was compatible with but did not prove organ specificity of hepatic SS. The development of SS was completely prevented by extirpation of all nonhepatic splanchnic organs at the same time as partial hepatectomy. This finding indicated that SS in the cytosol donors was a feature rather than an initiator of regeneration, and one that depended upon the collaboration of extrahepatic (including splanchnic hepatotrophic) factors.

Stimulation of hepatic regeneration after partial hepatectomy by infusion of a cytosol extract from regenerating dog liver

A cytosol liver extract was prepared from adult dog livers and from liver remnants that had been regenerating for one, two and three days after 72 per cent partial hepatectomy. Given intraportally, the most active of these cytosols did not stimulate proliferation in the livers of normal dogs. However, infused during a six hour period into the portal vein of test group dogs, the cytosol from 48 and, especially, 72 hour regenerating livers augmented the regeneration response ordinarily produced by 44 per cent partial depatectomy. The effect was delayed. It became identifiable 48 hours after infusion and rached a peak at 72 hours. Neither augmentation nor significant inhibition of the normal regeneration response was produced by cytosol from normal liver and 24 hour regenerating liver or by six hour infusion of insulin. The amplification effect of active cytosol was equivocal when the infusions were given intraperitoneally and was not demonstrable at all by the intravenous route. In these investigations, it is confirmed that there are growth control factors in regenerating liver but the nature or physiologic significance of the factor or factors has not been clarified.

The use of cyclosporin A and prednisone in cadaver kidney transplantation

Eighteen patients were treated with primary cadaveric renal transplantation using cyclosporin A therapy, and four more patients undersent cadaveric retransplantation. Eleven of the 22 recipients were conditioned with lymphoid depletion before transplantation, using thoracic duct drainage or lymphapheresis for two to eight and one-half weeks. Cyclosporin A was begun a few hours before grafting. The other 11 patients were pretreated with cyclosporin A for from one day to 18 days. After transplantation, the majority of patients in both subgroups of 11 had rejection develop, but in most, the immunologic process was readily controlled with relatively small dosages of prednisone. After follow-up periods of two to four and one-half months, one patient has died of the complications of a coronary artery reconstruction that was not related to the transplantation. Another graft was lost from rejection, and a third organ was removed because of ureteral necrosis. Nineteen of the original 22 cadaveric kidneys are functioning, including 17 of the 18 kidneys given to patients who were undergoing transplantation for the first time. The only loss in the latter group of 18 patients was in the patient who died after an open heart operation. Results of these studies have shown that cyclosporin A is a superior and safe immunosuppressive drug but that, for optimal use in cadaveric transplantation, it usually should not be given alone. Steroid therapy greatly amplified the value of cyclosporin A. Unless major delayed morbidity develops which is not obvious so far, this drug combination should permit revolutionary advances in the transplantation of all organs. Other adjuncts to the cyclosporin A-steroid combination, including lymphoid depletion techniques, will require further investigation.

Renal isotransplantation without immunosuppression

Four renal isografts have been performed and all have had satisfactory function for 7 1/2 to 17 2/3 years without prophylactic or therapeutic immunosuppression. Three of these patients originally had glomerulonephritis, and in one there was histologic evidence of recurrent disease, 7 1/2 years after transplantation, without proteinura and without change in renal function. Although this experience is small, it suggests that prophylactic immunosuppression is not appropriate for recipients of renal isografts.

Decline in survival after liver transplantation

Twenty-three recent cases of orthotopic liver transplantation were individually reviewed in an effort to determine why survival had declined from the 50% one-year survival rate of an immediately precedent series. In the series of 23, only six (26%) achieved one-year survival. Faulty case selection, technical complications, the use of damaged organs, and complications of immunosuppression were the main causes of death. Attention was directed to the possible use of preoperative lymphoid depletion to improve the effectiveness and safety of immunosuppression.

Significance of haematuria in hypertensive patients

Of 409 patients attending a clinic for control of hypertension, 74 (18%) were found to have haematuria, and all those with haematuria had significant renal impairment. The association of raised serum IgA levels and HLA BW35 in these patients suggests that some have the adult form of the IgA/C3 disease described in children.

Fifteen years of clinical liver transplantation

Liver transplantation in humans was first attempted more than 15 yr ago. The 1-yr survival has slowly improved until it has now reached about 50%. In our experience, 46 patients have lived for at least 1 yr, with the longest survival being 9 yr. The high acute mortality in early trials was due in many cases to technical and management errors and to the use of damaged organs. With elimination of such factors, survival increased. Further improvements will depend upon better immunosuppression. Orthotopic liver transplantation (liver replacement) is the preferred operation in most cases, but placement of an extra liver (auxiliary transplantation) may have a role under special circumstances.

Should the ruptured renal allograft be removed?

During a 16-month period when 93 renal transplants were performed, eight kidney graft ruptures were detected within 18 days of transplantation, without evidence of venous obstruction. Six grafts were removed at the time of an exploratory operation for rupture and only one showed signs of probable irreversible rejection when examined by microscopy. Two graft ruptures were repaired and one of these grafts has had good long-term function 22 months later. These observations suggest that if bleeding at the site of grafts has had good long-term function 22 months later. These observations suggest that if bleeding at the site of graft rupture can be securely controlled and if the conditions of the patient and of the graft are favorable except for the rupture, it may be possible to save more than one of eight grafts.

Liver replacement for pediatric patients

Between March 1963 and January 1978, 74 patients 18 years of age or younger have had liver replacements at the University of Colorado Medical Center, Denver. The most common cause of native liver failure was biliary atresis (48/74, 65%); the second most common cause was chronic aggressive hepatitis (12/74, 16%). Twenty-nine patients (39%) lived for at least one year, and 16 are still alive one to nine years after transplantation. Technical surgical problems, rejection, and infection were the main causes of death. Improved immunosuppression is needed; nevertheless, the quality of life in the long-term survivors has encouraged continuation of this difficult work.

Liver transplantation--1978

The development of liver transplantation has been made difficult because of the enormous technical difficulties of the procedure and because the postoperative management in early cases was defective in many instances. With surgical and medical improvements, the prospects for success have markedly increased recently. The wider use of thoracic duct fistula as an adjuvant measure during the first 1 or 2 postoperative months is being explored.

The quality of life after liver transplantation

The quality of life after liver transplantation ranges from poor to superior. The social and vocational outcome is dependent on the quality of homograft function and on the steroid doses necessary to maintain function. A good long-term prognosis is usually evident by 1 year postoperatively. The complete rehabilitation of so many patients has encouraged us to continue our efforts in this difficult field.

Growth-stimulating factor in regenerating canine liver

Extracts from dog livers which had been regenerating for 24, 48, and 72 h after hepatectomy were infused for 6 h into the left portal vein of animals which had fresh portacaval shunts (Eck fistula) and which were killed 2 and 3 days later. The brief exposure to the 48-h and especially the 72-h regenerating liver extracts induced a delayed proliferative response predominantly in the left liver lobes, with a slight spillover effect to the right liver lobes but none to the kidney. The response reached its peak 3 days later. In the left but not the right liver lobes, both the 48-h and the 72-h regenerating liver extract reversed the atrophy ordinarily caused by Eck fistula in 3 days and partly prevented the ultrastructural hepatocyte deterioration characteristic of Eck fistula. The active liver extracts apparently contained a growth-control factor or factors which is (are) not insulin or glucagon.

Liver allograft. Its use in chronic active hepatitis with macronodular cirrhosis, hepatitis B surface antigen

A patient suffering from chronic active hepatitis with macronodular cirrhosis, positive for hepatitis B surface antigen (HBsAg), was treated with an orthotopic liver allograft. The HBs antigenemia, as measured with several precipitation tests and by complement fixation, became negative after transplantation and remained so for about 2 1/2 months. During the interval, very low titers of the antigen were detectable by radioimmunoassay. At about three months after transplantation, she had an attack of acute hepatitis, at which time HBsAg became detectable by all tests. She recovered, but progressive liver disease developed during the remaining 1 1/2 years of her life. She died of disseminated nocardiosis and candidiasis with deteriorating hepatic function. The homograft at autopsy showed no evidence of rejection, but was the site of chronic active liver disease, although of a different pathologic pattern than that affecting her native liver. The differences in histology may reflect the influence of chronic immunosuppression on the features of chronic active hepatitis.

Liver regeneration in dogs: morphologic and chemical changes

Forty-four percent and 72% hepatectomy were carried out in dogs and the animals were sacrificed for biochemical and pathologic studies from 0.5 to 6 days later. Compensatory hypertrophy and hyperplasia (“regeneration”) were evident within 1 day, reached a maximum in 3 days, and were almost complete by 6 days. Coincident with the histologic events of regeneration were decreases in responsiveness of receptor adenyl cyclase to glucagon stimulation, increases of cyclic AMP, inconsistent changes in plasma insulin, and increases in plasma glucagon. These studies have standardized hepatic resection in dogs and they have focused attention upon some possible mechanisms that will require further study.

The effect of splanchnic viscera removal upon canine liver regeneration

The influence of portal blood factors on canine liver regeneration was studied with graded nonhepatic splanchnic evisceration, coupled with 44 and 72 per cent hepatectomies. In one type of experiment, the pancreas was retained while the rest of the intra-abdominal gastrointestinal tract was removed. In a second variety, total pancreatectomy was performed with preservation of the intra-abdominal organs. In a third kind of experiment, total nonhepatic splanchnic evisceration was performed. Liver regeneration after hepatectomy was decreased by all three kinds of viscera removed as judged by deoxyribonucleic acid synthesis, autoradiography and mitotic index. Pancreatectomy and nonpancreatic splanchnic evisceration caused almost equal decreases in the regenerative response. Total nonhepatic splanchnic evisceration essentially halted regeneration during the first three postoperative days and intraportal infusions of insulin or glucagon, or both together, did not reverse this effect. The decrease in liver membrane bound adenyl cyclase activity and biphasic change in liver cyclic 3', 5' -adenosine monophosphate concentrations normally seen after partial hepatectomy were disrupted after the various eviscerations. Adenyl cyclase activity and cyclic 3', 5' -adenosine monophosphate concentrations tended to be higher than normal in the eviscerated dogs. These observations provide more support for our previously proposed hypothesis that control of liver regeneration is by multiple factors. Pancreatic hormones are important modifiers of this response but, by no means, exercise exclusive control. Other substances of gastrointestinal origin, presumably including hormones and nutrient supply apparently play important specific roles. The volume of portal flow is a secondary and nonspecific, but possibly significant, factor.

The effect upon the liver of evisceration with or without hormone replacement

All, or nearly all, of the nonhepatic splanchnic viscera were removed in dogs. In most untreated dogs, the liver cells underwent changes similar to those caused by portacaval shunt, including structural deterioration of organelles and fatty metamorphosis. The rate of division of the hepatocytes, as measured by the mitotic index and by autoradiography, was depressed as were deoxyribonucleic acid synthesis and adenylate cyclase activity. These changes were restored to, or toward, normal with the intraportal administration of commercial or purified insulin but not with glucagon or epidermal growth factor. The results of both the pathologic and biochemical studies were consistent, except for an incongruity in some of the dogs in which the colon was retained.

Acute neurological complications after liver transplantation with particular reference to intraoperative cerebral air embolus

Nine of 48 adult patients who underwent orthotopic liver transplantation developed significant clinical neurological abnormalities recognized shortly after operation. Decrease in consciousness occurred with resultant coma, focal and generalized seizures and the occasional appearance of a state of akinetic mutism. Neuropathological abnormalities consisted of multifocal areas of infarction in cerebral cortex and basal ganglia in five patients, central pontine myelinolysis in five (often more extensive than usually reported), Wernicke's encephalopathy in three, glial nodules in two, and fungal abscesses in one. Alzheimer II astrocytosis was found in all brains available for retrospective study. There was direct evidence in two of the patients that air embolization from the homografts had occurred. Correlation of this with the brain infarcts in these and other cases seems reasonable. The ease with which air passed to the systemic circulation is explicable by the right to left venous--arterial shunts that are common in chronic liver disease. With the delination of this cause for the neurologic complications, measures to prevent it in future cases have been described.

Renal homotransplantation with venous outflow or infusion of antigen into the portal vein of dogs or pigs. Transplantation at portal site

Kidneys were transplanted in mongrel dogs so that renal venous drainage was into the portal system of the hosts. Thirty-one recipients were not treated, 11 were given one dose of 3 mg of azathioprine per kg, and 11 were given 2 mg of azathioprine per day. Survival was not statistically increased compared with that in three comparable series in which renal venous drainage was into the vena cava, nor were the histopathological findings favorably altered in the "portal" kidneys. The injection of semisoluble antigen into the portal vein at the same time as renal transplantation at the caval site, had an effect no different from that if the antigen were given systemically during caval site transplantation. The conclusion that drainage of grafts into the portal vein was not beneficial was reached in 20 pigs evenly divided between the portal and vena caval sites, and in 12 pairs of dog to pig or pig to dog xenografts. Thus, none of these experiments has identified an advantage of antigen delivery into the portal as opposed to the systemic venous system.

Fungus infections after liver transplantation

The problem of fungus infections after liver transplantation was studied. In 100 consecutive recipients of orthotopic liver homografts there were 10 and 8 examples, respectively, of localized and disseminated infections caused by Candida species. Candidemia was demonstrated in 8 of these 18 patients. One patient who had a localized Candida infection also had disseminated cryptococcosis. An additional 31 patients were infested in that Candida could be cultured from sites where it is not normally found, such as the blood (8 examples), urine (8), ascitic fluid (8), and wounds (22). This exorbitant incidence of monilial infections and infestations was associated with a high frequency of complications involving the homograft as well as the hosts' gastrointestinal tract during the post-transplantation period. The yeasts found in blood, urine, ascitic fluid and elsewhere were thought to have originated from the gut. Ten of the 100 patients had aspergillosis which was localized in 7 instances and disseminated in 3. The lung was the most frequently affected organ. The fungus infections played a contributory role in the downhill course of our patients but in the event of death more fundamental and more frequent causes of failure were technical complications involving the homografts, difficulties in controlling rejection with reasonable immunosuppressive doses and bacterial sepsis. Suggestions have been made for the better control of fungal infections in liver recipients.

Liver replacement for alpha1-antitrypsin deficiency

A 16-year-old girl with advanced cirrhosis and severe alpha 1-antitrypsin deficiency of the homozygous Pi ZZ phenotype was treated by orthotopic liver transplantation. After replacement of the liver with a homograft from a donor with the normal Pi MM phenotype, the alpha 1-antitrypsin concentration in the recipient's serum rose to normal; it had the Pi MM phenotype. Two and a third years later, chronic rejection necessitated retransplantation. Insertion of a homograft from a heterozygous Pi MZ donor was followed by the identification of that phenotype in the recipient's serum. Neither liver graft developed the alpha 1-antitrypsin glycoprotein deposits seen with the deficiency state. These observations confirm that this hepatic-based inborn error of metabolism is metabolically cured by liver replacement.

Biliary complications after liver transplantation: with special reference to the biliary cast syndrome and techniques of secondary duct repair

In 93 consecutive cases of orthotopic liver transplantation, there were 24 example of biliary obstruction and eight of bile fistula formation. Six of the obstructed livers developed biliary cast formation so extensive that the smaller intrhepatic ducts became plugged to an extent that they could no longer have been treated by surgical mena. In each of the six cases, the most important causative factor was neglected obstruction of the large bile ducts with the intrahepatic lesions apparently being late and secondary. Stone and/or cast formation also occurred in other obstructed livers in the presence of bile fustulas, but these deposits were limited to the large ducts where they could have been or were removed. Although homograft bile undoubtedly has increased lithogenicity at certain posoperative times, the data from the present study have shown that biliary sludge formation essentially is always associated with defective bile duct reconstruction, and the observations have underscored the urgency with which reoperation must be considered. Techniques of secondary intervention have been described, with emphasis on conversion of cholecystojejunostomy to choledochojejunostomy. This operation has permitted salvage of homografts in eight of nine trials and the survival of seven patients.

Infections complicating orthotopic liver transplantation: a study emphasizing graft-related septicemia

In 93 recipients of 102 orthotopic liver homografts, the incidence of bacteremia or fungemia exceeded 70%. The graft itself was usually an entry site for systemic infection after both immunologic and nonimmunologic parenchymal injury, especially if there was defective biliary drainage. The role of the homograft itself as the special infectious risk factor has prompted increased use of defunctionalized jejunal Roux limbs to reduce graft contamination. It has also stimulated very aggressive postoperative diagnostic efforts to rule out remedial mechanical complications of the transplant.