101
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Berger M, Zeevi A, Farmer DG, Abu-Elmagd KM. Immunologic challenges in small bowel transplantation. Am J Transplant 2012; 12 Suppl 4:S2-8. [PMID: 23181675 DOI: 10.1111/j.1600-6143.2012.04332.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Since the introduction of tacrolimus, small-bowel and multivisceral transplantion has increased to 100-200/year in the United States. The intestine carries more passenger lymphocytes than other organs, and bidirectional trafficking of lymphocytes and other immunocytes begins as soon as the vascular clamp is released. Because of ischemia-reperfusion injury and exposure to ligands for Toll-like receptors from the lumen, the innate immune system of the graft is activated, causing inflammation which must be brought under control by regulatory cells. Inclusion of the liver in the allograft favors graft acceptance, but the mechanism of this effect has not been determined. Anti-HLA and other anti-donor antibodies clearly play a major role in determining the long-term fate of the graft, as reflected in 5-year graft survival. Development of new (de novo) HLA antibodies and/or increases in their titers or function-especially the ability to bind C1q and activate complement increase the risk of graft loss. Monitoring antidonor antibody production and the use of new therapies including complement inhibitors will contribute to increasing success of SBT.
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Affiliation(s)
- M Berger
- Immunology R&D, CSL Behring, LLC, King of Prussia, PA, USA.
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102
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Nazé F, Suin V, Lamoral S, Francart A, Brochier B, Roels S, Mast J, Kalai M, Van Gucht S. Infectivity of rabies virus-exposed macrophages. Microbes Infect 2012; 15:115-25. [PMID: 23159243 DOI: 10.1016/j.micinf.2012.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 10/29/2012] [Accepted: 10/30/2012] [Indexed: 11/17/2022]
Abstract
Rabies virus distributes widely in infected mice, including lymphoid tissues and spleen macrophages. The infection characteristics in murine macrophages and the infectivity of virus-exposed macrophages were examined upon inoculation in mice. In vitro, Mf4/4 spleen macrophages supported mild virus production (10(4)-fold less than neuroblastoma), with formation of typical virions. Bone marrow-derived macrophages (BMM) were most efficient to capture virus, but new virus production was not detected. Virus-induced cell death was significantly stronger in BMM, which might have eliminated BMM with productive infection. Still, viral RNA remained detectable in the remaining BMM for at least 4 weeks. Injection of in vitro-infected Mf4/4 in the nose or brain proved efficient to propagate infection in mice, even when cells were pre-incubated with neutralizing antibodies. Surprisingly, injection of ex-vivo-infected BMM in the brain also led to lethal infection in 8 out of 12 mice. Injection of infected Mf4/4 in the muscle mostly favoured a protective antibody response. Despite that macrophages are less fit to support virus production, they can still act as a source of infectious virus upon transfer in mice. This may be relevant for screening donor organs/cells, for which RT-PCR should be preferred over the traditional antigen or virus isolation assays.
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Affiliation(s)
- Florence Nazé
- National Reference Laboratory of Rabies, Viral Diseases, Communicable and Infectious Diseases, Scientific Institute of Public Health, Engeland St. 642, B-1180 Brussels, Belgium
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103
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Long-term survival, nutritional autonomy, and quality of life after intestinal and multivisceral transplantation. Ann Surg 2012; 256:494-508. [PMID: 22868368 DOI: 10.1097/sla.0b013e318265f310] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess long-term survival, graft function, and health-related quality of life (QOL) after visceral transplantation. BACKGROUND Despite continual improvement in early survival, the long-term therapeutic efficacy of visceral transplantation has yet to be defined. METHODS A prospective cross-sectional study was performed on 227 visceral allograft recipients who survived beyond the 5-year milestone. Clinical data were used to assess outcome including graft function and long-term survival predictors. The socioeconomic milestones and QOL measures were assessed by clinical evaluation, professional consultation, and validated QOL inventory. RESULTS Of 376 recipients, 227 survived beyond 5 years, with conditional survival of 75% at 10 years and 61% at 15 years. With a mean follow-up of 10 ± 4 years, 177 (92 adults, 85 children) are alive, with 118 (67%) recipients 18 years or older. Nonfunctional social support and noninclusion of the liver in the visceral allograft are the most significant survival risk factors. Nutritional autonomy was achievable in 160 (90%) survivors, with current serum albumin level of 3.7 ± 0.5 gm/dL and body mass index of 25 ± 6 kg/m(2). Despite coexistence or development of neuropsychiatric disorders, most survivors were reintegrated to society with self-sustained socioeconomic status. In parallel, most of the psychological, emotional, and social QOL measures significantly (P < 0.05) improved after transplantation. Current morbidities with potential impact on global health included dysmotility (59%), hypertension (37%), osteoporosis (22%), and diabetes (11%), with significantly (P < 0.05) higher incidence among adult recipients. CONCLUSIONS With new tactics to further improve long-term survival including social support measures, visceral transplantation has achieved excellent nutritional autonomy and good QOL.
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104
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Importance of liver biopsy findings in immunosuppression management: biopsy monitoring and working criteria for patients with operational tolerance. Liver Transpl 2012; 18:1154-70. [PMID: 22645090 DOI: 10.1002/lt.23481] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Obstacles to morbidity-free long-term survival after liver transplantation (LT) include complications of immunosuppression (IS), recurrence of the original disease and malignancies, and unexplained chronic hepatitis and graft fibrosis. Many programs attempt to minimize chronic exposure to IS by reducing dosages and stopping steroids. A few programs have successfully weaned a highly select group of recipients from all IS without apparent adverse consequences, but long-term follow-up is limited. Patients subjected to adjustments in IS are usually followed by serial liver chemistry tests, which are relatively insensitive methods for detecting allograft damage. Protocol biopsy has largely been abandoned for hepatitis C virus-negative recipients, at least in part because of the inability to integrate routine histopathological findings into a rational clinical management algorithm. Recognizing a need to more precisely categorize and determine the clinical significance of findings in long-term biopsy samples, the Banff Working Group on Liver Allograft Pathology has reviewed the literature, pooled the experience of its members, and proposed working definitions for biopsy changes that (1) are conducive to lowering IS and are compatible with operational tolerance (OT) and (2) raise concern for closer follow-up and perhaps increased IS during or after IS weaning. The establishment of guidelines should help us to standardize analyses of the effects of various treatments and/or weaning protocols and more rigorously categorize patients who are assumed to show OT. Long-term follow-up using standardized criteria will help us to determine the consequences of lowering IS and to define and determine the incidence and robustness of OT in liver allografts.
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Affiliation(s)
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- University of Pittsburgh Medical Center, 3459 5th Avenue, UPMC Montefiore E741, Pittsburgh, PA 15213, USA
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105
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Manzia TM, Angelico R, Toti L, Lai Q, Ciano P, Angelico M, Tisone G. Hepatitis C virus recurrence and immunosuppression-free state after liver transplantation. Expert Rev Clin Immunol 2012; 8:635-44. [PMID: 23078061 DOI: 10.1586/eci.12.66] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
HCV-related disease is the most common indication for liver transplantation (LT). HCV recurrence, which is almost universal, has a significant impact on patient and graft survival after LT and still represents a great unsolved issue for the liver transplant community. Several treatment strategies have been proposed. Since antiviral therapy has limited efficacy and can be administrated only in selected transplant recipients and additionally that immunosuppressive drugs have a negative impact on HCV re-infection, the achievement of an immunosuppression-free state after LT could play a central role in the avoidance of rapid HCV recurrence.
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106
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What Do We Know About the Clinical Impact of Complete Withdrawal of Immunosuppression in Liver Transplantation? Transplant Proc 2012; 44:1530-2. [DOI: 10.1016/j.transproceed.2012.05.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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107
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Xia X, Chen W, Ma T, Xu G, Liu H, Liang C, Bai X, Zhang Y, He Y, Liang T. Mesenchymal stem cells administered after liver transplantation prevent acute graft-versus-host disease in rats. Liver Transpl 2012; 18:696-706. [PMID: 22344929 DOI: 10.1002/lt.23414] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute graft-versus-host disease is a serious and life-threatening complication of liver transplantation (LT) that occurs in 1% to 2% of liver allograft recipients. It is associated with a high mortality rate, and effective therapies are lacking. In our established rat model, a relative decrease in regulatory T cells (Tregs) was previously shown to be associated with acute graft-versus-host disease after liver transplantation (LT-aGVHD). Mesenchymal stem cells (MSCs) have been used to treat graft-versus-host disease after allogeneic hematopoietic stem cell transplantation, and they have been shown to induce Tregs, which have immunomodulatory effects. In this study, when a treatment with donor- or recipient-derived MSCs was administered from day 8 to day 14 after the typical symptoms of LT-aGVHD started, the recipients were not cured, and their survival time was not prolonged. However, when MSCs of different origins were administered from day 0 to day 6 after LT, the recipients survived significantly longer than the control group, and the surviving MSC-treated rats did not show typical LT-aGVHD symptoms. In vivo tracings of carboxyfluorescein diacetate succinimidyl ester-stained MSCs did not show significant accumulations in the target organs after administration. Flow cytometry analysis showed that the Treg ratios in peripheral blood were more higher for the MSC-treated groups versus the control group. More immunohistochemically stained forkhead box P3-positive cells were also found in the intestines of the MSC-treated groups versus the control group. Further investigations of the function of MSCs showed that they could increase the Treg ratio in a mixed lymphocyte reaction (MLR) and lead to a greater reduction in MLR proliferation in vitro. In conclusion, the post-LT administration of MSCs of either donor or recipient origin could prevent the onset of LT-aGVHD in our rat model.
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Affiliation(s)
- Xuefeng Xia
- Department of Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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108
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Li L, Wozniak LJ, Rodder S, Heish S, Talisetti A, Wang Q, Esquivel C, Cox K, Chen R, McDiarmid SV, Sarwal MM. A common peripheral blood gene set for diagnosis of operational tolerance in pediatric and adult liver transplantation. Am J Transplant 2012; 12:1218-28. [PMID: 22300520 DOI: 10.1111/j.1600-6143.2011.03928.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To identify biomarkers of operational tolerance in pediatric and adult liver transplant recipients, transcriptional profiles were examined from 300 samples by microarrays and Q-PCR measurements of blood specimens from pediatric and adult liver transplant recipients and normal tissues. Tolerance-specific genes were validated in independent samples across two different transplant programs and validated by Q-PCR. A minimal set of 13 unique genes, highly expressed in natural killer cells (p = 0.03), were significantly expressed in both pediatric and adult liver tolerance, irrespective of different clinical and demographic confounders. The performance of this gene set by microarray in independent samples was 100% sensitivity and 83% specificity and the AUC was 0.988 for only three genes by Q-PCR. 26% of adults and 64% of children with excellent liver allograft function, on minimal or dual immunosuppression, showed high prediction scores for tolerance. Novel peripheral transcriptional profiles can be identified in operational tolerance in pediatric and adult recipients of liver allografts, suggesting a high incidence of a pro-tolerogenic phenotype in stable patients on chronic immunosuppression. Given the high incidence of viral infections and malignancies in liver transplant recipients, this gene set provides an important monitoring tool that can move the field toward personalized and predictive medicine in organ transplantation.
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Affiliation(s)
- L Li
- Division of Nephrology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
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109
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Szabolcs P, Burlingham WJ, Thomson AW. Tolerance after solid organ and hematopoietic cell transplantation. Biol Blood Marrow Transplant 2012; 18:S193-200. [PMID: 22226107 DOI: 10.1016/j.bbmt.2011.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Paul Szabolcs
- Division of Blood and Marrow Transplantation and Cellular Therapies, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224, USA.
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110
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Burlingham WJ, Benichou G. Bidirectional alloreactivity: A proposed microchimerism-based solution to the NIMA paradox. CHIMERISM 2012; 3:29-36. [PMID: 22850252 PMCID: PMC3442809 DOI: 10.4161/chim.21668] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The NIMA paradox is the observation that in transplants of allogeneic kidneys or hematopoietic stem cells, siblings benefit from re-exposure to non-inherited maternal antigens (NIMA), whereas re-exposure to a transplant from mother herself, theoretically the ideal "NIMA" donor, does not yield clinical results superior to a father-donated allograft. Recent observations of bidirectional alloreactivity in kidney and cord blood transplantation offer a possible solution to this paradox. If correct, the proposed solution points the way to clinical applications of microchimerism in solid organ and hematopoetic transplants.
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111
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Association of donor-specific microchimerism with graft dysfunction in kidney transplant patients. Transpl Immunol 2012; 26:151-5. [DOI: 10.1016/j.trim.2011.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Revised: 11/07/2011] [Accepted: 11/07/2011] [Indexed: 11/24/2022]
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112
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Burra P. The adolescent and liver transplantation. J Hepatol 2012; 56:714-22. [PMID: 21963519 DOI: 10.1016/j.jhep.2011.07.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 06/04/2011] [Accepted: 07/04/2011] [Indexed: 01/09/2023]
Abstract
The outcome of liver transplantation is usually reported in terms of graft and patient survival, medical and surgical complications, and quality of life, but when it comes to transplanted adolescents such conventional parameters are unable to give a full account of their life with a new liver, and their transition from adolescence to adulthood is a time when they are particularly vulnerable. Adolescents with liver transplants have excellent survival rates, over 80% of them surviving more than 10 years. Graft loss is most often associated with complications such as chronic rejection, hepatic artery thrombosis, and biliary complications. Calcineurin inhibitors may have various side effects, including hypertension and nephrotoxicity. Liver-transplanted adolescents are also exposed to viral infections, among which Epstein-Barr virus is very common and associated with the onset of post-transplant lymphoproliferative disorders. Growth retardation may also be an issue in some liver transplant recipients. Future studies will determine the best way to assess the functional immune status of adolescents with a transplanted liver with a view to ensuring the best treatment to induce tolerance without the complications of excessive immunosuppression. Schooling may be disrupted due to adolescent transplant recipients' poor adherence. Non-adherence is associated with a poor medical outcome. Both physical and psychosocial functioning is reportedly lower among young liver transplant recipients than in the general population.
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Affiliation(s)
- Patrizia Burra
- Multivisceral Transplant Unit, Gastroenterology Section, Department of Surgical and Gastroenterological Sciences, Padova University Hospital, Padova, Italy.
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113
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Jankowska-Gan E, Sheka A, Sollinger HW, Pirsch JD, Hofmann MR, Haynes LD, Armbrust MJ, Mezrich JD, Burlingham WJ. Pretransplant immune regulation predicts allograft outcome: bidirectional regulation correlates with excellent renal transplant function in living-related donor-recipient pairs. Transplantation 2012; 93:283-90. [PMID: 22186938 PMCID: PMC3366360 DOI: 10.1097/tp.0b013e31823e46a0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tolerance to noninherited maternal antigens has provided clinical advantage when kidney transplants are exchanged between siblings but not when mother herself is the donor. This paradox prompted us to revisit the "two-way" hypothesis of transplant tolerance--that the immune status of both the organ recipient and the organ donor critically influences allograft outcome. METHODS We obtained peripheral blood monocyte cells from 29 living donor-recipient pairs before transplant and used the trans-vivo-delayed type hypersensitivity assay to measure immune regulation in both the recipient antidonor and donor antirecipient directions. RESULTS We found preexisting bidirectional regulation in all human leukocyte antigen (HLA)-identical sibling pairs tested (7/7), and one half (9/18) of the HLA haploidentical pairs. No significant regulation was found in four control living unrelated and two HLA haploidentical living-related donor recipient pairs, whereas unidirectional regulation was found in the remaining seven haploidentical pairs. Of the nine HLA haploidentical transplants with unidirectional or no pretransplant regulation, seven had an acute rejection episode and four of these experienced graft loss. In contrast, of the nine HLA haploidentical transplants with bidirectional regulation, only one had rejection. Renal function for the latter group was similar to HLA-identical kidney recipients at 3 years posttransplant. Significantly (P<0.05) lower mean serum creatinine values in bidirectional regulators were noted as early as 4 months and this difference became more pronounced at 12 (P<0.005) and 36 months (P<0.0001). CONCLUSIONS Contrary to the belief that only the recipient's immune status matters, the data indicate that pretransplant immune status of both donor and recipient influence posttransplant outcome.
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Affiliation(s)
- Ewa Jankowska-Gan
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - Adam Sheka
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - Hans W. Sollinger
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - John D. Pirsch
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - Michael R. Hofmann
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - Lynn D. Haynes
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - Michael J. Armbrust
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - Joshua D. Mezrich
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Division of Transplantation, Madison, WI 53792
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Division of Nephrology, Madison, WI 53972
| | - William J. Burlingham
- Address for Correspondence: Dr. William J. Burlingham, G4/702 CSC, 600 Highland Avenue, Madison, WI 53792, USA, Telephone number: (608)-263-0119, Fax number: (608)-263-7652,
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114
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Granot E, Loewenthal R, Jakobovich E, Gazit E, Sokal E, Reding R. Living related liver transplant following bone marrow transplantation from same donor: long-term survival without immunosuppression. Pediatr Transplant 2012; 16:E1-4. [PMID: 20819183 DOI: 10.1111/j.1399-3046.2010.01378.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We report long-term (seven yr) immunological tolerance in a 16-yr-old boy, to a liver allograft donated by his father following a bone marrow transplant at age 2.5 yr from the same donor. The bone marrow transplant was complicated by severe GVHD leading to liver failure and the ensuing need for a liver transplant, performed under planned avoidance of immunosuppression. At one wk post-transplant, although a liver biopsy was histologically compatible with acute rejection, favorable clinical and biochemical evolution precluded initiating immunosuppressive therapy, thus highlighting the need for caution when interpreting early histological changes so that administration of unnecessary immunosuppression can be avoided. Induction of tolerance in transplant recipients remains an elusive goal. In those patients who had received conventional bone marrow transplants and had endured the consequences of GVHD, development of macrochimerism may allow immunosuppression-free solid organ transplantation from the same donor.
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Affiliation(s)
- E Granot
- Pediatric Department, Kaplan Medical Center, Rehovot, Israel.
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115
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Alex Bishop G, Bertolino PD, Bowen DG, McCaughan GW. Tolerance in liver transplantation. Best Pract Res Clin Gastroenterol 2012; 26:73-84. [PMID: 22482527 DOI: 10.1016/j.bpg.2012.01.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 12/15/2011] [Accepted: 01/13/2012] [Indexed: 01/31/2023]
Abstract
Operational tolerance (OT) in liver transplant patients occurs much more frequently than OT of other transplanted organs; however the rate of OT varies considerably with the centre and patient population. Rates of OT range from 15% of the total liver transplant (LTX) patient population down to less than 5%. This review examines the reports of liver OT and compares the factors that could contribute to this variation. Multiple factors were examined, including the time from transplantation when weaning of immunosuppression (IS) was commenced, the rapidity of weaning, the contribution of maintenance and induction IS and the patient population transplanted. The approaches that might be used to increase the likelihood of OT are discussed and the approaches to monitoring OT in LTX patients are reviewed.
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Affiliation(s)
- G Alex Bishop
- Collaborative Transplantation Laboratory, Royal Prince Alfred Hospital and the University of Sydney, Australia.
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116
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Chen XB, Yang J, Xu MQ, Wen TF, Yan LN. Unsuccessful treatment of four patients with acute graft- vs-host disease after liver transplantation. World J Gastroenterol 2012; 18:84-9. [PMID: 22228975 PMCID: PMC3251810 DOI: 10.3748/wjg.v18.i1.84] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 06/23/2011] [Accepted: 06/30/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate appropriate therapeutic strategies for graft-vs-host disease (GVHD) following liver transplantation.
METHODS: Four patients who developed GVHD after liver transplantation in West China Hospital were included in this study. Therapeutic strategies with augmentation or withdrawal of immunosuppressants combined with supportive therapy were investigated in these patients. In addition, a literature review of patients who developed GVHD after liver transplantation was performed.
RESULTS: Although a transient response to initial treatment was detected, all four patients died of complications from GVHD: one from sepsis with multiple organ failure, one from gastrointestinal bleeding, and the other two from sepsis with gastrointestinal bleeding. Few consensuses for the treatment of GVHD after liver transplantation have been reached.
CONCLUSION: New and effective treatments are required for GVHD after liver transplantation to improve the prognosis of patients with this diagnosis.
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117
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Song EY, Chung HY, Joo SY, Roh EY, Seong MW, Shin Y, Park MH. Detection of HLA-DRB1 microchimerism using nested polymerase chain reaction and single-strand conformation polymorphism analysis. Hum Immunol 2011; 73:291-7. [PMID: 22244919 DOI: 10.1016/j.humimm.2011.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 12/14/2011] [Accepted: 12/21/2011] [Indexed: 01/09/2023]
Abstract
For the detection of microchimerism, molecular methods detecting donor-specific HLA-DRB1 alleles in the recipient are most commonly used. Nested polymerase chain reaction sequence specific primer (nested PCR-SSP) methods widely used to increase the sensitivity of detection have been reported to give frequent false-positive reactions. We have developed a new method combining nested PCR with single-strand conformation polymorphism analysis (nested PCR-SSCP) and tested the 1 to 0.00001% level of microchimerism for 27 different HLA-DRB1 alleles. For most (26/27) of the HLA-DRB1 alleles tested, this method could detect 0.01 to 0.001% of microchimerism and its sensitivity was equal to or better than that of nested PCR-SSP tested in parallel. Its specificity was verified by visualizing particular DRB1-specific SSCP bands under test. Nested PCR-SSP indicated frequent false-positive reactions, mainly caused by nonspecific amplification of DRB3/B4/B5 alleles present in the major (recipient) DNAs. We have compared a real-time quantitative PCR for non-human leukocyte antigen (HLA) target (insertion/deletion marker) using a commercial kit (AlleleSEQR Chimerism assay), and its microchimerism detection sensitivity (around 0.1%) was 1 step (10 times) lower than that of nested PCR-SSP or -SSCP methods for HLA-DRB1 alleles. We validated that the newly designed nested PCR-SSCP affords good sensitivity and specificity and may be useful for studying microchimerism in clinical settings.
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Affiliation(s)
- Eun Young Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul 110-744, Korea
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118
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Hoerning A, Kalkavan H, Rehme C, Menke J, Worm K, Garritsen HSP, Büscher R, Hoyer PF. Quantitative real-time ARMS-qPCR for mitochondrial DNA enables accurate detection of microchimerism in renal transplant recipients. Pediatr Transplant 2011; 15:809-18. [PMID: 21967552 DOI: 10.1111/j.1399-3046.2011.01581.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The presence of microchimerism in peripheral blood of solid organ transplant recipients has been postulated to be beneficial for allograft acceptance. Kinetics of donor cell trafficking and accumulation in pediatric allograft recipients are largely unknown. In this study, we implemented SNPs of the HVRs I and II of mitochondrial DNA to serve as molecular genetic markers to detect donor-specific cell chimerism after pediatric renal transplantation. Serial dilution of artificial chimeric DNA samples showed a linear correlation coefficient of R > 0.98 and a detection sensitivity of 0.01% with high reproducibility. Longitudinal semiquantitative analysis of donor-specific SNPs was then performed in peripheral blood mononuclear cells samples up to two yr post-transplant. Quantity of donor-specific cell chimerism in peripheral blood was highest in the early post-transplant period reaching values of ~10% after liver-kidney and 2.8% after renal transplantation. From one wk after transplantation, renal transplant patients exhibited an amount of donor-specific mtDNA ranging from 0.01% to 0.1%. We developed a highly accurate, sensitive, and rapid real-time quantitative PCR method using sequence-specific primers and fluorescent hydrolysis probes for the detection of at least 0.01% donor-specific cells in the recipient's peripheral blood after renal transplantation.
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Affiliation(s)
- André Hoerning
- Department of Pediatrics II, Children's Hospital, University of Duisburg-Essen, Essen, Germany.
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119
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Abstract
PURPOSE OF REVIEW Infusions of bone marrow-derived cells together with 'space making' continue to be tested in clinical organ transplant tolerance protocols. These trials are based on the hypothesis that this might produce initial multilineage chimerism. There is some evidence that this in turn induces regulatory cells that control alloimmunity. Although a wealth of knowledge is available from animal models, this review deals with what we know or can speculate about donor bone marrow cells and chimerism in human organ transplantation. RECENT FINDINGS Calcineurin inhibitors are employed in most of these protocols to blunt the initial immune response. One protocol also has a stepwise regulatory cell generating treatment with sirolimus before total withdrawal. A number of donor chimeric lineages including stem cells, dendritic cells, myeloid precursors, and various lymphoid subpopulations have been described. Currently, it is recognized that the nature of cells that make up the chimerism could influence graft rejection versus acceptance. Tolerogenic donor chimeric cells may also generate regulatory subsets, thus controlling alloimmunity on two fronts. SUMMARY It might be speculated that prolonged and sustained regulation or possible anergy induced by chimerism may eventually lead to clonal deletion, thereby bringing about classical immunologic tolerance.
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Gorantla VS, Schneeberger S, Moore LR, Donnenberg VS, Zimmerlin L, Lee WPA, Donnenberg AD. Development and validation of a procedure to isolate viable bone marrow cells from the vertebrae of cadaveric organ donors for composite organ grafting. Cytotherapy 2011; 14:104-13. [PMID: 21905958 DOI: 10.3109/14653249.2011.605350] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AIMS Donor-derived vertebral bone marrow (BM) has been proposed to promote chimerism in solid organ transplantation with cadaveric organs. Reports of successful weaning from immunosuppression in patients receiving directed donor transplants in combination with donor BM or blood cells and novel peri-transplant immunosuppression has renewed interest in implementing similar protocols with cadaveric organs. METHODS We performed six pre-clinical full-scale separations to adapt vertebral BM preparations to a good manufacturing practice (GMP) environment. Vertebral bodies L4-T8 were transported to a class 10 000 clean room, cleaned of soft tissue, divided and crushed in a prototype bone grinder. Bone fragments were irrigated with medium containing saline, albumin, DNAse and gentamicin, and strained through stainless steel sieves. Additional cells were eluted after two rounds of agitation using a prototype BM tumbler. RESULTS The majority of recovered cells (70.9 ± 14.1%, mean ± SD) were eluted directly from the crushed bone, whereas 22.3% and 5.9% were eluted after the first and second rounds of tumbling, respectively. Cells were pooled and filtered (500, 200 μm) using a BM collection kit. Larger lumbar vertebrae yielded about 1.6 times the cells of thoracic vertebrae. The average product yielded 5.2 ± 1.2 × 10(10) total cells, 6.2 ± 2.2 × 10(8) of which were CD45(+) CD34(+). Viability was 96.6 ± 1.9% and 99.1 ± 0.8%, respectively. Multicolor flow cytometry revealed distinct populations of CD34(+) CD90(+) CD117(dim) hematopoietic stem cells (15.5 ± 7.5% of the CD34 (+) cells) and CD45(-) CD73(+) CD105(+) mesenchymal stromal cells (0.04 ± 0.04% of the total cells). CONCLUSIONS This procedure can be used to prepare clinical-grade cells suitable for use in human allotransplantation in a GMP environment.
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Affiliation(s)
- Vijay S Gorantla
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Bozulic LD, Huang Y, Xu H, Wen Y, Ildstad ST. Differential outcomes in prediabetic vs. overtly diabetic NOD mice nonmyeloablatively conditioned with costimulatory blockade. Exp Hematol 2011; 39:977-85. [PMID: 21726515 DOI: 10.1016/j.exphem.2011.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/17/2011] [Accepted: 06/21/2011] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Autoimmune diabetes can be reversed with mixed chimerism. However, the myelotoxic agents currently required to establish chimerism have prevented the translation of this approach to the clinic. Here, we investigated whether multimodal costimulatory blockade would enhance chimerism and promote islet allograft tolerance in spontaneously diabetic nonobese diabetic (NOD) mice. MATERIALS AND METHODS Prediabetic and spontaneously diabetic NOD mice were preconditioned with anti-CD8 monoclonal antibody before conditioning with 500 cGy total body irradiation and transplantation with 30 × 10(6) B10.BR bone marrow cells. Overtly diabetic animals were conditioned similarly and transplanted with 300 to 400 B10.BR islets. After irradiation, both groups of recipients were treated with anti-CD154, anti-OX40L, and anti-inducible T-cell costimulatory monoclonal antibodies. Urine, blood glucose levels, and chimerism were monitored. RESULTS Conditioning of NOD mice with costimulatory blockade significantly enhanced engraftment, with 61% of mice engrafting at 1 month. Eleven of 12 chimeric animals with engraftment at 1 month remained diabetes-free over a 12-month follow-up, whereas nonchimeric animals progressed to diabetes. In contrast, similar conditioning prolonged islet allograft survival in only 2 of 11 overtly diabetic NOD recipients. Chimerism levels in the 9 islet rejector animals were 0%. CONCLUSIONS Although nonmyeloablative conditioning reversed the autoimmune process in prediabetic NOD mice, the same regimen was significantly less effective in establishing chimerism and reversing autoimmune diabetes in spontaneously diabetic NOD mice.
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Five hundred intestinal and multivisceral transplantations at a single center: major advances with new challenges. Ann Surg 2011; 250:567-81. [PMID: 19730240 DOI: 10.1097/sla.0b013e3181b67725] [Citation(s) in RCA: 250] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the evolution of visceral transplantation in the milieu of surgical technical modifications, new immunosuppressive protocols, and other management strategies. SUMMARY BACKGROUND DATA With the clinical feasibility of intestinal and multivisceral transplantation in 1990, multifaceted innovative tactics were required to improve outcome and increase procedural practicality. METHODS Divided into 3 eras, 453 patients received 500 visceral transplants. The primary used immunosuppression was tacrolimus-steroid-only during Era I (5/90–5/94), adjunct induction with multiple drug therapy during Era II (1/95–6/01), and recipient pretreatment with tacrolimus monotherapy during Era III (7/01–11/08). During Era II/III, donor bone marrow was given (n = 79), intestine was ex vivo irradiated (n = 44), and Epstein-Barr-Virus (EBV)/cytomegalovirus (CMV) loads were monitored. RESULTS Actuarial patient survival was 85% at 1-year, 61% at 5-years, 42% at 10-years, and 35% at 15-years with respective graft survival of 80%, 50%, 33%, and 29%. With a 10% retransplantation rate, second/third graft survival was 69% at 1-year and 47% at 5-years. The best outcome was with intestine-liver allografts. Era III rabbit antithymocyte globulin or alemtuzumab pretreatment-based strategy was associated with significant (P < 0.0001) improvement in outcome with 1- and 5-year patient survival of 92% and 70%. CONCLUSION Survival has greatly improved over time as management strategies evolved. The current results clearly justify elevating the procedure level to that of other abdominal organs with the privilege to permanently reside in a respected place in the surgical armamentarium. Meanwhile, innovative tactics are still required to conquer long-term hazards of chronic rejection of liver-free allografts and infection of multivisceral recipients.
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Orlando G. Finding the right time for weaning off immunosuppression in solid organ transplant recipients. Expert Rev Clin Immunol 2011; 6:879-92. [PMID: 20979553 DOI: 10.1586/eci.10.71] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Solid organ transplantation (SOT) requires lifelong immunosuppression (IS) to prevent rejection and graft loss. The currently adopted immunosuppressive protocols are numerous and are based on the administration of at least two molecules with diverse mechanisms of action. Owing to the fact that the majority of immunosuppressants act non-selectively, the immune system is normally oversuppressed, and as a result is less able to both defend the host against infection and to control the spread of malignant cells. Consequently, long-term IS is burdened by chronic toxicity, which may be highly invalidating and may significantly influence patient's quality of life, compliance to treatment, overall success rate, and patient and graft survival. In an ideal scenario, SOT recipients should initially receive just enough IS to favor the onset of clinical operational tolerance (COT), a condition where the immune system of the host does not attack the graft in the absence of any immunosuppressant. COT has been documented after liver transplantation (LT) and renal transplantation (RT). First, COT was accidentally detected in patients who were nonadherent to treatment and who spontaneously decided to stop all IS without any medical guidance or surveillance. Later, it was described in recipients who required IS withdrawal following the occurrence of malignant diseases. Based on strikingly convincing experimental data, several tolerogenic protocols have recently been applied in patients but overall the results have been disappointing. The current literature demonstrates that COT can be safely achieved in stable LT recipients, with completely different strategies. Importantly, the onset of an episode of acute rejection during the attempt of IS withdrawal would not worsen the clinical outcome. On the contrary, COT remains a major challenge after RT because the onset of acute rejection will substantiate in graft loss. Currently, a major field of investigation aims to define markers of COT, which will allow the selection of individuals who are more prone to develop COT. Preliminary results in both RT and LT have just been announced; however, these markers will require validation in prospective studies.
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Affiliation(s)
- Giuseppe Orlando
- Nuffield Department of Surgery, University of Oxford, Oxford, UK.
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Schneeberger S, Landin L, Jableki J, Butler P, Hoehnke C, Brandacher G, Morelon E. Achievements and challenges in composite tissue allotransplantation. Transpl Int 2011; 24:760-9. [PMID: 21554424 DOI: 10.1111/j.1432-2277.2011.01261.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Overall, more than 60 hand/forearm/arm transplantations and 16 face transplantations have been performed in the past 12 years. In the European experience summarized here, three grafts have been lost in response to a vascular thrombosis (n = 1), rejection and incompliance with immunosuppression (n = 1) and death (n = 1). The overall functional and esthetic outcome is very satisfactory, but serious side effects and complications related to immunosuppression are challenges hindering progress in this field. The high levels of immunosuppression, skin rejection, nerve regeneration, donor legislation and the acceptance level need to be addressed to promote growth of this promising new field in transplantation and reconstructive surgery.
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Affiliation(s)
- Stefan Schneeberger
- Center for Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria.
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125
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Abstract
Every liver transplant (LT) center has had patients who either self-discontinue immunosuppressive (IS) therapy or are deliberately withdrawn due to a research protocol or clinical concern (ie, lymphoproliferative disorder [LPD], overwhelming infection). This is understandable because maintenance IS therapy, particularly calcineurin inhibitors (CNI), is associated with significant cost, side effects, and considerable long-term morbidity and mortality. Detrimental effects of IS therapy include increased risk of cardiovascular disease, metabolic syndrome, bone loss, opportunistic and community-acquired infections, and malignancy. In fact, LT recipients have among the highest rates of chronic kidney disease and associated mortality among all nonkidney solid organ recipients. This mortality is only ameliorated by undergoing a curative kidney transplant, usurping costs and valuable organ resources. The search for improved treatment algorithms includes trial and error CNI dose minimization, the use of alternative IS agents (antimetabolites, mammalian target of rapamycin [mTOR] inhibitors), or even complete CNI withdrawal. Yet those who are successful in achieving such operational tolerance (no immunosuppression and normal allograft function) are considered lucky. The vast majority of recipients will fail this approach, develop acute rejection or immune-mediated hepatitis, and require resumption of IS therapy. As such, withdrawal of IS following LT is not standard-of-care, leaving clinicians to currently maintain transplant patients on IS therapy for life. Nonetheless, the long-term complications of all IS therapies highlight the need for strategies to promote immunologic or operational tolerance. Clinically applicable biomarker assays signifying the potential for tolerance as well as tolerogenic IS conditioning are invariably needed if systematic, controlled rather than "hit or miss" approaches to withdrawal are considered. This review will provide an overview of the basic mechanisms of tolerance, particularly in relation to LT, data from previous IS withdrawal protocols and biomarker studies in tolerant recipients, and a discussion on the prospect of increasing the clinical feasibility and success of withdrawal.
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Affiliation(s)
- Josh Levitsky
- Division of Hepatology and Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Thangavelu G, Murphy KM, Yagita H, Boon L, Anderson CC. The role of co-inhibitory signals in spontaneous tolerance of weakly mismatched transplants. Immunobiology 2011; 216:918-24. [PMID: 21281982 PMCID: PMC4030676 DOI: 10.1016/j.imbio.2011.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 01/02/2011] [Accepted: 01/04/2011] [Indexed: 01/22/2023]
Abstract
The immune system of female H-2(b) (C57BL/6) mice is a strong responder against the male minor-H antigen. However rejection or acceptance of such weakly mismatched grafts depends on the type of tissue transplanted. The mechanism responsible for such spontaneous graft acceptance, and its relationship to the natural mechanisms of tolerance of self antigens is unknown. Co-inhibitory molecules negatively regulate immune responses, and are important for self tolerance. We examined whether co-inhibitory molecules play a critical role in "spontaneous" allograft tolerance. Naïve or donor sensitized diabetic female C57BL/6 (B6) wild type (WT), PD-1(-/-), and BTLA(-/-) mice were transplanted with freshly isolated syngeneic male islet grafts. The role of co-inhibitors during priming of anti-donor responses and graft challenge was also assessed using monoclonal antibodies targeting co-inhibitory receptors. Among the co-inhibitor (CTLA-4, PD-1) specific antibodies tested, only anti-PD-1 showed some potential to prevent spontaneous acceptance of male islet grafts. All BTLA(-/-) and almost all PD-1(-/-) recipients maintained the ability to spontaneously accept male islet grafts. While spontaneous graft acceptance in naïve recipients was only weakly PD-1 dependent, tolerance induced by the accepted islets was found to be highly PD-1 dependent. Furthermore, spontaneous graft acceptance in pre-sensitized recipients showed an absolute requirement for recipient PD-1 but not BTLA. Thus, the PD-1 pathway, involved in self tolerance, plays a critical role in spontaneous tolerance induced by weakly mismatched grafts in naïve recipients and spontaneous graft acceptance in pre-sensitized recipients.
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Affiliation(s)
- Govindarajan Thangavelu
- Department of Surgery Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada T6G 2E1
| | - Kenneth M. Murphy
- Department of Pathology and Centre for Immunology, Howard Hughes Medical Institute, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hideo Yagita
- Department of Immunology, Juntendo University School of Medicine, Tokyo Japan
| | | | - Colin C. Anderson
- Department of Surgery Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada T6G 2E1
- Department of Medical Microbiology and Immunology, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada T6G 2E1
- Address correspondence to: Colin C. Anderson, 5-126A Li Ka Shing Centre, Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada T6G 2E1 Tel: 780-492-6036 Fax: 780-492-5348
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127
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Identification of tolerant recipients following liver transplantation. Int Immunopharmacol 2010; 10:1501-4. [DOI: 10.1016/j.intimp.2010.06.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Accepted: 06/16/2010] [Indexed: 12/28/2022]
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128
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Talisetti A, Hurwitz M, Sarwal M, Berquist W, Castillo R, Bass D, Concepcion W, Esquivel CO, Cox K. Analysis of clinical variables associated with tolerance in pediatric liver transplant recipients. Pediatr Transplant 2010; 14:976-9. [PMID: 21108705 DOI: 10.1111/j.1399-3046.2010.01360.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tolerance has been defined as stable graft function off IMS. We reviewed the data of 369 pediatric liver transplant patients to examine demographic differences that may have a PV of pediatric LT tolerance. Of the 369 patients, 280 patients were stable with detectable blood levels of IMS agents and with good graft function without biopsy proven REJ > 1 yr posttransplantation, 18 patients were noted to be TOL off IMS, 27 patients were taking MIS with drug levels below detectable range by standard laboratory parameters, and 44 patients developed one or more episodes of biopsy proven acute or chronic REJ > 1 yr post-transplantation. Variables, including percentage of biliary atresia, type of transplanted organ, history of EBV infection, patient and donor gender, and ABO blood type mismatch between recipient and donor did not have PV of tolerance. Average age in years was 1.37 ± 1.53 (0.3-4.9) for TOL, 1.14 ± 0.89 (0.4-3.1) for MIS and 3.35 ± 4.45 (0.3-16) for REJ. Age difference of TOL/MIS vs. REJ was significant (p =0.002) and TOL vs. REJ was significant (0.01). Age at the time of transplantation is an important predictor in the development of pediatric LT tolerance.
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Affiliation(s)
- Anita Talisetti
- Department of Pediatrics, Stanford University, Stanford, CA, USA.
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Long-Term Survival of Composite Hemiface/Mandible/Tongue Allografts Correlates With Multilineage Chimerism Development in the Lymphoid and Myeloid Compartments of Recipients. Transplantation 2010; 90:843-52. [DOI: 10.1097/tp.0b013e3181f28bb0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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130
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Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors. Ann Surg 2010; 252:652-61. [PMID: 20881772 DOI: 10.1097/sla.0b013e3181f5f23a] [Citation(s) in RCA: 189] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate patient survival and allograft function and health-related quality of life (HRQOL) 20 years after orthotopic liver transplantation (LT). SUMMARY OF BACKGROUND DATA Although LT is the established treatment of choice for acute and chronic liver failure, allograft function and recipient HRQOL 20 years after LT remain undefined. METHODS We performed a prospective, cross-sectional study of LT recipients surviving 20 years or more. Clinical data were reviewed to identify factors associated with 20-year survival. Survivors were directly contacted and offered a survey to assess HRQOL (SF-36; Liver Disease Quality of Life), social support, and cognition (Neuropsychological Impairment Scale). Logistic regression analysis was performed to identify clinical factors influencing HRQOL 20 years after LT. RESULTS Between February 1, 1984 and December 31, 1988, a total of 293 patients (179 adults, 114 children) received 348 LTs. Of the 293 patients, 168 (56%) survived for 20 years or more. Actuarial 20-year survival was 52% (patient) and 42% (graft). Factors associated with 20-year survival included recipient age <18 (P = 0.01), nonurgent LT (P = 0.01), no retransplantation (0.02), female gender (0.03), absence of biliary complications (P = 0.04), and short total ischemia time (P = 0.05). Rejection episodes were seen in a greater proportion of 20-year survivors than in nonsurvivors (35% vs. 27%; P = 0.3). Of the 168 survivors, 87 were contacted, and 68 (78%) completed the HRQOL surveys. Compared with the general population, survivors had lower physical scores (P < 0.01) but comparable mental scores on the SF-36. Overall HRQOL was significantly better in 20-year survivors than in patients with chronic liver disease, congestive heart failure, or diabetes. Clinical factors associated with improved post-LT HRQOL were younger age at LT, allograft longevity, and strong social support. More than 90% of pediatric survivors completed high school. After LT, 34% of pediatric recipients married, and 79% remained married at 20 years' follow-up. CONCLUSIONS More than 50% of LT recipients survive 20 years, achieve important socioeconomic milestones, and report quality of life superior to patients with liver disease or other chronic conditions. LT is a durable surgery that restores both long-term physiologic and psychologic well-being in patients with end-stage liver disease.
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131
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Moroso V, Metselaar HJ, Mancham S, Tilanus HW, Eissens D, van der Meer A, van der Laan LJW, Kuipers EJ, Joosten I, Kwekkeboom J. Liver grafts contain a unique subset of natural killer cells that are transferred into the recipient after liver transplantation. Liver Transpl 2010; 16:895-908. [PMID: 20583081 DOI: 10.1002/lt.22080] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In contrast to other solid organ transplantations, liver grafts have tolerogenic properties. Animal models indicate that donor leukocytes transferred into the recipient after liver transplantation (LTX) play a relevant role in this tolerogenic phenomenon. However, the specific donor cell types involved in modulation of the recipient alloresponse are not yet defined. We hypothesized that this unique property of liver grafts may be related to their high content of organ-specific natural killer (NK) and CD56(+) T cells. Here, we show that a high proportion of hepatic NK cells that detach from human liver grafts during pretransplant perfusion belong to the CD56bright subset, and are in an activated state (CD69(+)). Liver NK cells contained perforin and granzymes, exerted stronger cytotoxicity against K562 target cells when compared with blood NK cells, and secreted interferon-gamma, but no interleukin-10 or T helper 2 cytokines, upon stimulation with monokines. Interestingly, whereas the CD56bright subset is classically considered as noncytolytic, liver CD56bright NK cells showed a high content of cytolytic molecules and degranulated in response to K562 cells. After LTX, but not after renal transplantation, significant numbers of donor CD56dim NK and CD56(+) T cells were detected in the recipient circulation for approximately 2 weeks. In conclusion, during clinical LTX, activated and highly cytotoxic NK cells of donor origin are transferred into the recipient, and a subset of them mixes with the recirculating recipient NK cell pool. The unique properties of the transferred hepatic NK cells may enable them to play a role in regulating the immunological response of the recipient against the graft and therefore contribute to liver tolerogenicity.
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Affiliation(s)
- Viviana Moroso
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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132
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Abstract
Liver transplantation was the product of five interlocking themes. These began in 1958-1959 with canine studies of then theoretical hepatotrophic molecules in portal venous blood (Theme I) and with the contemporaneous parallel development of liver and multivisceral transplant models (Theme II). Further Theme I investigations showed that insulin was the principal, although not the only, portal hepatotrophic factor. In addition to resolving long-standing controversies about the pathophysiology of portacaval shunt, the hepatotrophic studies blazed new trails in the regulation of liver size, function, and regeneration. They also targeted inborn metabolic errors (e.g., familial hyperlipoproteinemia) whose palliation by portal diversion presaged definitive correction with liver replacement. Clinical use of the Theme II transplant models depended on multiple drug immunosuppression (Theme III, Immunology), guided by an empirical algorithm of pattern recognition and therapeutic response. Successful liver replacement was first accomplished in 1967 with azathioprine, prednisone, and antilymphoid globulin. With this regimen, the world's longest surviving liver recipient is now 40 years postoperative. Incremental improvements in survival outcome occurred (Theme IV) when azathioprine was replaced by cyclosporine (1979), which was replaced in turn by tacrolimus (1989). However, the biologic meaning of alloengraftment remained enigmatic until multilineage donor leukocyte microchimerism was discovered in 1992 in long-surviving organ recipients. Seminal mechanisms were then identified (clonal exhaustion-deletion and immune ignorance) that linked organ engraftment and the acquired tolerance of bone marrow transplantation and eventually clarified the relationship of transplantation immunology to the immunology of infections, neoplasms, and autoimmune disorders. With this insight, better strategies of immunosuppression have evolved. As liver and other kinds of organ transplantation became accepted as healthcare standards, the ethical, legal, equity, and the other humanism issues of Theme V have been resolved less conclusively than the medical-scientific problems of Themes I-IV.
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Affiliation(s)
- Thomas E. Starzl
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA 15213
| | - John J. Fung
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio 44195
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133
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Abstract
In the clinical arena of transplantation, tolerance remains, for the most part, a concept rather than a reality. Although modern immunosuppression regimens have effectively handled acute rejection, nearly all organs except the liver commonly suffer chronic immunologic damage that impairs organ function, threatening patient and allograft survival. In addition to the imperfect control of the donor-directed immune response, there are additional costs. First, there is the burden of mortality from infection and malignancy that can be directly attributed to a crippled immune system. Second, there are insidious effects on renal function, cardiovascular profile (hypertension, hyperglycemia, and dyslipidemia), bone health, growth, psychological and neurocognitive development, and overall quality of life. It is likely that the full consequences of lifelong immunosuppression on our pediatric transplant recipients will not be fully appreciated until survival routinely extends beyond 1 or 2 decades after transplantation. Therefore, it can be argued that the holy grail of transplantation tolerance is of the utmost importance to children who undergo solid organ transplantation.
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134
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Mathew JM, Ciancio G, Burke GW, Garcia-Morales RO, Rosen A, Wang E, Gomez CI, Blomberg BB, Fuller L, Esquenazi V, Ricordi C, Miller J. Immune "tolerance profiles" in donor bone marrow infused kidney transplant patients using multiple ex vivo functional assays. Hum Immunol 2010; 71:566-76. [PMID: 20153397 DOI: 10.1016/j.humimm.2010.02.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 01/29/2010] [Accepted: 02/04/2010] [Indexed: 11/25/2022]
Abstract
Ex vivo identification of donor-specific unresponsiveness in organ transplant recipients is important for immunosuppression (IS) minimization. We tested three groups of stable living, related-donor kidney transplant patients up to 11 years postoperatively, i.e., 20 haploidenticals with donor bone marrow cell (DBMC) infusions, eight noninfused haploidentical controls (haplo controls), and 11 HLA-identical controls (HLA-id), using multiple ex vivo immune assays. We observed that no patients developed donor-specific antibodies. The majority showed donor-specific CTL unresponsiveness from year 1 onward. Thirteen of 20 DBMC recipients became specifically donor MLR nonreactive. Depletion of donor cells in DBMC recipients still MLR reactive increased donor-specific reactivity by 75% +/- 36% (p = 0.04). Adding them back in low concentration caused antigen specific inhibition. The frequencies of ELISPOT granzyme-B and interferon-gamma-producing cells somewhat paralleled the CTL and MLR responses. In the trans vivo DTH, 14 of 19 DBMC recipients demonstrated donor-specific unresponsiveness and 16 of 19 showed "linked suppression," vs none of eight and one of eight haplo controls and vs six of 10 and one of 10 HLA-ids, respectively. Most importantly, when all six assays were performed simultaneously, 10 of 18 DBMC, five of 10 HLA-ids, and no haplo controls were specifically donor unresponsive long term. We propose that a cluster analysis combining these assays will reveal tolerant recipients in whom IS minimization may safely be tested. This appears to have occurred in many DBMC-infused recipients.
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Affiliation(s)
- James M Mathew
- Department of Surgery and Comprehensive Transplant Center, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
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135
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Abstract
Non-self cells can circulate in the body of an individual after any sort of contact with an allogeneic source of cells, thus creating a situation of chimerism that can be transient or prolonged over time. This situation may appear after stem cell transplantation, pregnancy, transfusion or transplantation. Concerning transplantation, many hypotheses have been formulated regarding the existence, persistence and role of these circulating cells in the host. We will review the principal hypotheses that have been formulated for years since the first description of non-self circulating cells in mammals to the utilization of artificially induced chimerism protocols for the achievement of tolerance.
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Affiliation(s)
- Josep-Maria Pujal
- Translational Research Laboratory, Institut Català d'Oncologia, Hospital Duran i Reynals, Avda Gran Via s/n, Km 2.7, 08907 L'Hospitalet de Llobregat, Barcelona, Spain.
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136
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Xu G, Wang L, Chen W, Xue F, Bai X, Liang L, Shen X, Zhang M, Xia D, Liang T. Rapamycin and tacrolimus differentially modulate acute graft-versus-host disease in rats after liver transplantation. Liver Transpl 2010; 16:357-63. [PMID: 20209637 DOI: 10.1002/lt.22003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute graft-versus-host disease (aGVHD) is a serious complication of liver transplantation (LTx); it occurs in 1% to 2% of liver allograft recipients. The condition has a poor prognosis and poses major diagnostic and therapeutic challenges. A rat model of aGVHD after LTx has been developed, and a relative decrease in regulatory T (Treg) cells has been shown to be associated with this model. Interest has been expressed in the effects of different immunosuppressive agents on CD4+CD25+Foxp3+ Treg cell homeostasis. Rats with aGVHD after LTx were treated with tacrolimus (FK506), rapamycin (RAPA), or no immunosuppressive drug. Those that received RAPA survived longer (91.4 + or - 8.1 days) than those in the FK506 group (62.3 + or - 13.4 days) or the control group (22.9 + or - 1.2 days). Flow cytometry analysis showed that Treg cells, as a percentage of peripheral blood mononuclear cells (PBMCs), were more abundant in the RAPA group (6.8% + or - 0.8%) than in the FK506 group (1.7% + or - 0.4%) or the control group (2.0% + or - 0.4%). Immunohistochemistry demonstrated more Foxp3+ staining of intestinal cells in the RAPA group than in the FK506 group or the control group. In conclusion, the reduced mortality induced by RAPA in a rat model of aGVHD after LTx was associated with higher percentages of CD4+CD25+Foxp3+ Treg cells in PBMCs in blood and tissues than those occurring after the administration of FK506.
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Affiliation(s)
- Guodong Xu
- Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Combined Multiorgan Transplantation (Ministry of Public Health), First Affiliated Hospital, Hangzhou, People's Republic of China
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137
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Juan Alberto Fierro C. Monitoreo inmunológico: el comienzo de una nueva era en trasplantes. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70529-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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138
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Bosma BM, Metselaar HJ, Gerrits JH, van Besouw NM, Mancham S, Groothuismink ZMA, Boor PPC, van der Laan LJW, Tilanus HW, Kuipers EJ, Kwekkeboom J. Migration of allosensitizing donor myeloid dendritic cells into recipients after liver transplantation. Liver Transpl 2010; 16:12-22. [PMID: 19866483 DOI: 10.1002/lt.21961] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It is thought, but there is no evidence, that myeloid dendritic cells (MDCs) of donor origin migrate into the recipient after clinical organ transplantation and sensitize the recipient's immune system by the direct presentation of donor allo-antigens. Here we show prominent MDC chimerism in the recipient's circulation early after clinical liver transplantation (LTx) but not after renal transplantation (RTx). MDCs that detach from human liver grafts produce large amounts of pro-inflammatory [tumor necrosis factor alpha and interleukin 6 (IL-6)] and anti-inflammatory (IL-10) cytokines upon activation with various stimuli, express higher levels of toll-like receptor 4 than blood or splenic MDCs, and are sensitive to stimulation with a physiological concentration of lipopolysaccharide (LPS). Upon stimulation with LPS, MDCs detaching from liver grafts prime allogeneic T cell proliferation and production of interferon gamma but not of IL-10. Soluble factors secreted by liver graft MDCs amplify allogeneic T helper 1 responses. In conclusion, after clinical LTx, but not after RTx, prominent numbers of donor-derived MDCs migrate into the recipient's circulation. MDCs detaching from liver grafts produce pro-inflammatory and anti-inflammatory cytokines and are capable of stimulating allogeneic T helper 1 responses, and this suggests that MDC chimerism after clinical LTx may contribute to liver graft rejection rather than acceptance.
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Affiliation(s)
- Brenda M Bosma
- Department of Gastroenterology and Hepatology, University Medical Center, Rotterdam, the Netherlands
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139
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Golling M, Sadeghi M, Zipperle S, Fonouni H, Golriz M, Mehrabi A. In vitrocytokine responses in liver transplant recipients treated with cyclosporine A and tacrolimus. Clin Transplant 2009; 23 Suppl 21:83-91. [DOI: 10.1111/j.1399-0012.2009.01114.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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140
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Abstract
1. Hepatitis C virus (HCV) RNA+ liver allograft recipients invariably reinfect the liver allograft within hours after transplantation, and the majority (>70%) develop chronic hepatitis. The rate at which these patients experience progression to cirrhosis and the overall percentage are significantly increased in comparison with HCV infection in the nontransplant setting. 2. Core needle biopsy evaluation is used to establish the diagnosis of recurrent HCV, which can be difficult to distinguish from acute cellular rejection and other causes of allograft dysfunction. In the vast majority of cases, however, distinguishing recurrent HCV from other posttransplant syndromes is reliably achieved by a careful examination of hematoxylin and eosin-stained sections and correlation with clinical and serological data. 3. Recurrent HCV often coexists with other causes of liver allograft dysfunction, and the determination of the most important cause of injury and whether other causes of injury are present is important. Included are residual changes of preservation/reperfusion injury, biliary sludging/structuring, acute cellular and chronic rejection, and autoimmune hepatitis. 4. The complex interplay between immunosuppression management, viral replication, and the recipient immune system results in distinct patterns of recurrent chronic HCV in the liver allograft: (1) conventional or usual acute and chronic HCV, which resembles that seen in the general population with HCV; (2) fibrosing cholestatic hepatitis; and (3) plasma cell-rich HCV, which might represent a variant of, or overlap with, autoimmune hepatitis and rejection. 5. The variable but usually hastened histopathological progression toward cirrhosis in HCV+ allografts is similar to that seen in the nontransplant setting, but in allografts, the overall severity of lymphocytic inflammation is less, and ductular reactions, stellate cell activation, and subsinusoidal fibrosis are accentuated. Hepatic stressors and causes of an impaired ability of hepatocytes to replicate include persistently high levels of viral replication, HCV-specific CD4+ T responses, advanced donor age, high levels or rapid withdrawal of immunosuppression, and coexistent liver damage from preservation/reperfusion injury, biliary structuring, or coexistent cytomegalovirus or herpes 6 viral infection. 6. Immunological effector mechanisms involved in the rejection and control of HCV replication/HCV elimination show significant overlap. Patients with very high levels of HCV RNA rarely show significant clinically significant acute or chronic rejection, whereas their occurrence is frequently associated with very low levels or clearance of HCV RNA. Studying the evolution from recurrent HCV to acute rejection in patients treated with interferon and/or weaned from immunosuppression might provide valuable insights into the relationship between these 2 processes as well as liver allograft acceptance.
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Affiliation(s)
- Anthony J Demetris
- Division of Transplantation, Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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141
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Abstract
The achievement of an immunosuppression (IS)-free state after transplantation represents the ultimate goal of any immunosuppressive regimen. While clinical operational tolerance (COT) remains the exception after other types of solid organ transplantation, several cases of COT have been described after liver transplantation (LT). Overall, the experience gained so far worldwide demonstrates that COT can be achieved safely in one quarter of selected individuals, irrespective of the immunological background of donor and recipient, patient age, indication for LT, study endpoint, length of the weaning period and of pre/post-weaning follow-up, presence or not of chimerism. However, most transplant physicians still believe that the achievement of COT is still out of reach for the majority of LT recipients because of the potential risk for transplant survival, the non-randomized nature of most of the studies reported so far, and the selective nature of the patients enrolled in such studies, making them non-representative of the whole population of LT recipients. Despite these concerns, the present article demonstrates that this attitude is potentially no longer justified, given the growing evidence that a permanent and stable IS-free state can be achieved in a proportion of individuals who have received a LT for non-immune mediated liver diseases.
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Affiliation(s)
- Giuseppe Orlando
- Transplantation Research Immunology Group, Nuffield Department of Surgery, University of Oxford, Headington, Oxford OX3 9DU, UK.
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142
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Ayala R, Grande S, Albizua E, Crooke A, Meneu JC, Moreno A, Pérez B, Gilsanz F, Moreno E, Martínez-Lopez J. Long-term follow-up of donor chimerism and tolerance after human liver transplantation. Liver Transpl 2009; 15:581-91. [PMID: 19479801 DOI: 10.1002/lt.21736] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We aimed to quantify peripheral donor chimerism (DC) and to analyze its association with graft and recipient outcome. Forty-two liver transplant recipients and their respective donors were studied, providing a total of 148 posttransplantation serum samples. DC was assessed with real-time quantitative polymerase chain reaction (qPCR) to detect polymorphic markers. DC did not decrease with time post-transplantation and was higher in child recipients versus adults and in recipients of deceased donor liver transplants versus recipients of live donor liver transplants. Higher levels of DC were detected in Rh-positive blood group donors, in O blood group recipients versus A blood group recipients, and in recipients with hepatitis C virus versus recipients with alcoholic cirrhosis. High DC was associated with patients with organ damage due to recurrent disease and rejection. Stable, high levels of DC, in the absence of other major clinical events, may thus be a marker of transplantation tolerance, and this knowledge may help to tailor immunosuppressive treatment. In conclusion, qPCR is a useful technique for DC follow-up in liver transplantation, although the evolution of DC levels should be analyzed in accordance with the clinical outcome of the patient.
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Affiliation(s)
- Rosa Ayala
- Haematology Service, Hospital 12 de Octubre, Madrid, Spain
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143
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Pons JA, Ramírez P, Revilla-Nuin B, Pascual D, Baroja-Mazo A, Robles R, Sanchez-Bueno F, Martinez L, Parrilla P. Immunosuppression withdrawal improves long-term metabolic parameters, cardiovascular risk factors and renal function in liver transplant patients. Clin Transplant 2009; 23:329-36. [DOI: 10.1111/j.1399-0012.2008.00944.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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144
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Correlation of Donor Leukocyte Chimerism With Pulmonary Allograft Survival After Immunosuppressive Drug Withdrawal in a Porcine Model. Transplantation 2009; 87:1468-77. [DOI: 10.1097/tp.0b013e3181a3c4cb] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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145
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Thin L, Macquillan G, Adams L, Garas G, Seow C, Cannell P, Augustson B, Mitchell A, Delriveire L, Jeffrey G. Acute graft-versus-host disease after liver transplant: novel use of etanercept and the role of tumor necrosis factor alpha inhibitors. Liver Transpl 2009; 15:421-6. [PMID: 19326415 DOI: 10.1002/lt.21704] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute graft-versus-host disease following orthotopic liver transplantation is a rare but feared complication arising in 1% to 2% of cases with a dismal prognosis. It most often presents as fever, rash, and diarrhea with or without pancytopenia. Patients die from complications of marrow failure such as sepsis or bleeding. Because of its low incidence, there is no clear treatment protocol for this complication. Both increasing and withdrawing immunosuppression have been attempted with variable success. Although anti-tumor necrosis factor alpha therapy has been widely used for the treatment of steroid-resistant acute graft-versus-host disease in the hematopoietic stem cell transplant setting, there previously have been no reported cases of its use in liver transplantation. The aim of this report is to review a case of acute graft-versus-host disease and the use of etanercept to manage this complication. Etanercept has never previously been used in liver transplantation complicated by acute graft-versus-host disease. In the hematology literature, the success of its use is offset by significant rates of serious infectious (especially fungal) complications. However, preliminary results are encouraging and offer insight into its use as a potentially viable therapeutic option. We report the first successful use of etanercept in liver transplantation-associated graft-versus-host disease, albeit complicated by invasive aspergillosis, and recommend concurrent antifungal prophylaxis when the drug is used in this setting.
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Affiliation(s)
- Lena Thin
- West Australian Liver Transplant Service, Perth, Western Australia, Australia.
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146
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Janes S, Dhaliwal P, Wood K. Tolerance in renal transplantation: is mixed chimerism the missing link? Nephrol Dial Transplant 2009; 24:1726-9. [PMID: 19264747 PMCID: PMC2684754 DOI: 10.1093/ndt/gfp084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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147
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Lerut J, Bonaccorsi-Riani E, Finet P, Gianello P. Minimization of steroids in liver transplantation. Transpl Int 2009; 22:2-19. [PMID: 19121145 DOI: 10.1111/j.1432-2277.2008.00758.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Because of the markedly improved short-term results of liver transplantation (LT) and persistently high number of long-term complications, the attention of transplant physicians should be focused on minimizing immunosuppressive therapy as much as possible. Steroid-based immunosuppression is responsible for a substantial post-LT morbidity and mortality, hence, minimization of its use is of utmost importance to improve the quality of life of the successfully transplanted liver recipient. This literature review shows that LT can be performed safely with steroid-minimal immunosuppression without compromising graft and patient survival. The tendency in clinical practice is to move more and more from steroid withdrawal to steroid avoidance protocols.
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Affiliation(s)
- Jan Lerut
- Department of Abdominal and Transplantation Surgery, Université catholique de Louvain, Brussels, Belgium.
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148
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149
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Tolerance and Future Directions for Composite Tissue Allograft Transplants: Part II. Plast Reconstr Surg 2009; 123:7e-17e. [DOI: 10.1097/prs.0b013e318193467d] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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150
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Tokita D, Sumpter TL, Raimondi G, Zahorchak AF, Wang Z, Nakao A, Mazariegos GV, Abe M, Thomson AW. Poor allostimulatory function of liver plasmacytoid DC is associated with pro-apoptotic activity, dependent on regulatory T cells. J Hepatol 2008; 49:1008-18. [PMID: 18926588 PMCID: PMC2631180 DOI: 10.1016/j.jhep.2008.07.028] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 06/20/2008] [Accepted: 07/09/2008] [Indexed: 01/22/2023]
Abstract
BACKGROUND/AIMS The liver is comparatively rich in plasmacytoid (p) dendritic cells (DC), - innate immune effector cells that are also thought to play key roles in the induction and regulation of adaptive immunity. METHODS Liver and spleen pDC were purified from fms-like tyrosine kinase ligand-treated control or lipopolysaccharide-injected C57BL/10 mice. Flow cytometric and molecular biologic assays were used to characterize their function and interaction with naturally occurring regulatory T cells (Treg). RESULTS While IL-10 production was greater for freshly isolated liver compared with splenic pDC, the former produced less bioactive IL-12p70. Moreover, liver pDC expressed a low Delta4/Jagged1 Notch ligand ratio, skewed towards T helper 2 cell differentiation/cytokine production, and promoted allogeneic CD4(+)T cell apoptosis. T cell proliferation in response to liver pDC was, however, enhanced by blocking IL-10 function at the initiation of cultures. In the absence of naturally occurring CD4(+)CD25(+) regulatory T cells, similar levels of T cell proliferation were induced by liver and spleen pDC and the pro-apoptotic activity of liver pDC was reversed. CONCLUSIONS The inferior T cell allostimulatory activity of in vivo-stimulated liver pDC may depend on the presence and function of Treg, a property that may contribute to inherent liver tolerogenicity.
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Affiliation(s)
- Daisuke Tokita
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Tina L. Sumpter
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Giorgio Raimondi
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Alan F. Zahorchak
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Zhiliang Wang
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Atsunori Nakao
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - George V. Mazariegos
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Masanori Abe
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Angus W. Thomson
- Thomas E. Starzl Transplantation Institute and Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA,Corresponding author: Dr. Angus W. Thomson, Departments of Surgery and Immunology, University of Pittsburgh School of Medicine, Thomas E. Starzl Transplantation Institute, 200 Lothrop Street, Biomedical Science Tower, W1540, Pittsburgh, PA 15213, Office: (412) 624-6392, Fax: (412) 624-1172,
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