Portal diversion for the treatment of glycogen storage disease in humans

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Twenty-four-hour preservation of canine kidneys exposed to 45 and 60 minutes of warm ischaemia

This investigation was designed to test the ability of a new hyperbaric organ preservation system to preserve canine kidneys for 24 hours after they had been subjected to significant periods of warm ischaemia. In group I (45 minutes of warm ischaemia) all the kidneys functioned well, and the mean maximum serum creatinine was 4.4 ± 1.7 mg. per 100 ml. In group II (60 minutes of warm ischaemia) I dog died on account of acute tubular necrosis. The mean maximum serum creatinine was 5.4 ± 4.02 mg. per 100 ml. The results indicate that hyperbaric oxygen warrants serious consideration as an adjunct to organ preservation.

Delayed biliary duct obstruction after orthotopic liver transplantation

After orthotopic liver transplantation and biliary reconstruction by cholecystoduodenostomy, four of 40 patients developed delayed obstruction of the cystic duct. The recipients had the clinical syndrome of fulminating cholangitis with jaundice, fever, leukocytosis, toxemia, and bacteremia. All four patients died; of the four, two patients died despite late reoperation and re-establishment of bile drainage by choledochoenterostomy. In all four cases, a factor contributing to the biliary obstruction may have been infection of the extrahepatic biliary ducts with or without ulceration, and in three of the livers, there was evidence of infection of the ducts with CMV. If cholecystoduodenostomy is used in future cases, prompt re-exploration and conversion to choledochoenterostomy should be considered if the diagnosis of duct obstruction, cholangitis, and persistent bacteremia are made.

Renal transplantation in children. Analysis of 25 consecutive transplants in 19 recipients

Eighteen children aged 6 to 17 years received 24 cadaveric renal transplants between January 1965 and July 1971, and a further child received a kidney donated by her father. 12 children are alive with good functioning grafts and another 2 children are alive on haemodialysis awaiting a further renal graft. The clinical problems of renal transplantation in children are discussed with particular reference to the side effects of immunosuppressive therapy.

Immunopathological studies of orthotopic human liver allografts

Twenty-six specimens obtained from twenty human orthotopic liver allografts 10–968 days after transplantation were studied by light microscopy, electron microscopy, and immunofluorescence. The main lesions consisted of mononuclear-cell infiltration around the portal tracts, centrilobular cholestasis, liver-cell atrophy and reticulin collapse, obliterative intimal thickening of hepatic arteries, and fibrosis. Moderate amounts of IgG and/or IgM and complement (β1C/β1A globulin or C'lq) were observed in four of the liver samples and smaller deposits were present in another five. A further three specimens contained IgG without complement. IgA was detected in only one of the samples. The immunoglobulins were found in the walls of the portal and central veins and of the sinusoids in all thirteen positive liver samples, in the walls of branches of the hepatic artery in three, and in the cytoplasm of some of the mononuclear cells infiltrating the portal tracts in nine of the specimens. Fibrinogen was seen in eight of the samples, usually in the spaces of Disse. Accumulations of immunoglobulins and complement were less frequent in liver than in kidney and heart allografts. These findings suggest that in the failure of human liver allografts cell-mediated immunity and non-immunological factors may be more important than humoral antibody.

Thymectomy and renal homotransplantation

The course of forty-six consecutive patients were studied for 3½–5 years after renal homotransplantation from related and unrelated donors. Transthoracic thymectomy was performed before transplantation in twenty-four cases; the other twenty-two recipients served as controls. A similar spectrum of donor-recipient lymphocyte antigen compatibility was present in both the test and control series.

In both the related and non-related cases, there was no clinical evidence that the patients with thymectomy had either an early or late advantage in terms of survival, reduced drug dosages, or quality of renal function. However, pathologic studies with light and electron microscopy and with immunofluorescence revealed that the homografts in the thymectomized patients had fewer and less severe lesions of the kind that would be expected to limit the functional life time of these organs.

Human renal transplants. 3. Immunopathologic studies

Tissues obtained from 34 human renal allografts by biopsy, 1 to 31 months after transplantation, were studied by histologic, immunofluorescence, and immunoferritin techniques. Our purpose was to gain more precise information concerning the localization of immunoglobulins and complement in glomeruli and to describe the associated tubular and vascular changes. Localization of fluorescein-labeled antibodies (Fl-Abs) to IgG, IgM, β 1C, and C′1q was seen in glomeruli from 25 allografts and showed the following distribution of patterns: (a) diffuse linear, four; (b) diffuse granular, four; (c) focal linear, six; (d) focal granular, six; and (e) indeterminate, five. Ferritin-conjugated antibodies (Fer-Abs) localized in 21 allografts. Electron microscopic findings correlated with the foregoing immunofluorescence patterns. (a) Fer-Abs were bound on the endothelial side of the glomerular basement membrane and in the subendothelial space. (b) Fer-Abs were bound in subendothelial and subepithelial deposits similar to those seen in experimental acute or chronic serum sickness. (c and d) Fer-Abs were seen in the subendothelial space and mesangial matrix. Deposits were present in these areas and some bound Fer-Abs. The two groups were not readily separable on the basis of immunopathologic data. (e) Fer-Abs were mostly seen in the mesangial area. Nine allografts displaying little or no binding of Fl-Abs failed to bind Fer-Abs. Small amounts of fibrinogen were found in only six allografts, three of which showed diffuse granular fluorescence. In 12 allografts either Fl-Abs or Fer-Abs or both were bound in walls of blood vessels. The position of these reactants was in foreign deposits and in basement membranes of arteries and veins.

The immunopathologic findings seem to support best the hypothesis that damage to allografts is associated with deposition, in glomerular and vascular structures, of circulating antigen-antibody complexes which might contain, in part, transplantation antigens.