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Poudel S, Gupta S, Saigal S. Basics and Art of Immunosuppression in Liver Transplantation. J Clin Exp Hepatol 2024; 14:101345. [PMID: 38450290 PMCID: PMC10912712 DOI: 10.1016/j.jceh.2024.101345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 01/09/2024] [Indexed: 03/08/2024] Open
Abstract
Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.
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Affiliation(s)
- Shekhar Poudel
- Fellow Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Liver Transplant and Gastrointestinal Surgery, Centre for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Principal Director and Head, Transplant Hepatology, Centre for Liver and Biliary Sciences, Max Super Specialty Hospital, Saket, New Delhi, India
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Nuqali A, Bellumkonda L. Dual organ transplantation: when heart alone is not enough. Curr Opin Organ Transplant 2023; 28:370-375. [PMID: 37582057 DOI: 10.1097/mot.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW The number of dual organ transplantations (DOT) are steadily increasing over the past few years. This is both a reflection of increasing complexity and advanced disease process in the patients and greater transplant center experience with performing dual organ transplants. Due to lack of standardization of the process, there remains significant center-based variability in patient selection, perioperative and long-term management of these patients. RECENT FINDINGS Overall posttransplant outcomes for DOT have been acceptable with some immunological advantages because of partial tolerance offered by the second organ. These achievements should, however, be balanced with the ethical implications of bypassing the patients who are listed for single organ transplantation because of the preferential allocation of organs for DOT. SUMMARY The field of DOT is expanding rapidly, with good long-term outcomes. There is an urgent need for guidelines to standardize the process of patient selection and listing dual organ transplantation.
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Affiliation(s)
- Abdulelah Nuqali
- Division of Cardiology, Department of Medicine Yale University School of Medicine, New Haven, Connecticut, USA
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Shamsaeefar A, Kazemi K, Nikoupour H, Moosavi SA, Mashhadiagha A, Sayadi M, Gholami S, Motazedian N, Nikeghbalian S, Malekhosseini SA. Prope tolerance after pediatric liver transplantation: Experience at Shiraz Organ Transplant Center. Transpl Immunol 2023; 78:101827. [PMID: 37003498 DOI: 10.1016/j.trim.2023.101827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/18/2023] [Accepted: 03/19/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Children receive transplants at a younger age, and the period of immunosuppression therapy may extend over decades. However, immunosuppression seems to be responsible for long-term mortality and morbidity. Pediatric liver transplant recipients can benefit from achieving immune tolerance and the opportunity of freedom from lifelong immunosuppression. This study aimed to investigate the frequency of prope tolerance among pediatric liver transplant recipients and the characteristics of these patients. METHODS In this retrospective cohort study of pediatric liver transplant recipients, the medical records of transplant recipients treated at Shiraz Organ Transplant Center between 1994 and 2017 were reviewed. Prope tolerance was defined as normal laboratory values and stable clinical status on low-dose monotherapy. Children treated with low-dose monotherapy were categorized as the prope tolerant group. We compared the characteristics of prope tolerant recipients on low-dose monotherapy with patients on standard immunosuppression, i.e. full-dose tacrolimus plus steroids and mycophenolate mofetil. The data were analyzed with the t-test, chi-squared test, and a Cox proportional hazard model at a 5% significance level in SPSS software version 16. RESULTS A total of 585 children with a mean age of 8.32 ± 5.23 years were enrolled. 341 patients were categorized as prope tolerant and 244 comprised the full immunosuppression regimen group. Mean age at transplantation and rejection frequency were lower in the prope tolerant group (p < 0.001, p < 0.001). Based on the underlying diseases, metabolic/genetic, biliary tract, and cryptogenic liver diseases were significantly more prevalent in the prope tolerant group (p < 0.001). However, autoimmune liver disease was found to be more prevalent in the full immunosuppression regimen group. Also, those who received living organs (p = 0.001) and recipients of organs from female donors had a greater likelihood of achieving prope tolerant. According to the multiple Cox regression results, age at transplantation (p = 0.022), rejection frequency (p < 0.001), and autoimmune liver diseases (p = 0.028) had a prognostic effect on prope tolerance. CONCLUSION Factors as underlying disease, age at transplantation, and rejection frequency were factors that were predictive of prope tolerance in this sample of children. However, the risk of rejection should be considered during the tapering period.
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Affiliation(s)
- Alireza Shamsaeefar
- Abu Ali Sina Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kourosh Kazemi
- Abu Ali Sina Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamed Nikoupour
- Abu Ali Sina Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ali Moosavi
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirali Mashhadiagha
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrab Sayadi
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sivash Gholami
- Abu Ali Sina Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasrin Motazedian
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Saman Nikeghbalian
- Abu Ali Sina Organ Transplant Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Steiner R, Pilat N. The potential for Treg-enhancing therapies in transplantation. Clin Exp Immunol 2023; 211:122-137. [PMID: 36562079 PMCID: PMC10019131 DOI: 10.1093/cei/uxac118] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/21/2022] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
Since the discovery of regulatory T cells (Tregs) as crucial regulators of immune tolerance against self-antigens, these cells have become a promising tool for the induction of donor-specific tolerance in transplantation medicine. The therapeutic potential of increasing in vivoTreg numbers for a favorable Treg to Teff cell ratio has already been demonstrated in several sophisticated pre-clinical models and clinical pilot trials. In addition to improving cell quantity, enhancing Treg function utilizing engineering techniques led to encouraging results in models of autoimmunity and transplantation. Here we aim to discuss the most promising approaches for Treg-enhancing therapies, starting with adoptive transfer approaches and ex vivoexpansion cultures (polyclonal vs. antigen specific), followed by selective in vivostimulation methods. Furthermore, we address next generation concepts for Treg function enhancement (CARs, TRUCKs, BARs) as well as the advantages and caveats inherit to each approach. Finally, this review will discuss the clinical experience with Treg therapy in ongoing and already published clinical trials; however, data on long-term results and efficacy are still very limited and many questions that might complicate clinical translation remain open. Here, we discuss the hurdles for clinical translation and elaborate on current Treg-based therapeutic options as well as their potencies for improving long-term graft survival in transplantation.
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Affiliation(s)
- Romy Steiner
- Department of General Surgery, Medical University of Vienna, Vienna, Austria
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Nina Pilat
- Correspondence: Nina Pilat, PhD, Department of Cardiac Surgery, Center for Biomedical Research, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Tang Y, Chen J, Chen B, Guo C. Clinical characteristics of immune tolerance after pediatric liver transplantation. BMC Surg 2022; 22:102. [PMID: 35305597 PMCID: PMC8933983 DOI: 10.1186/s12893-021-01402-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/10/2021] [Indexed: 12/13/2022] Open
Abstract
Abstract
Background
Clinical operational tolerance is the ultimate goal for liver transplantation. This study aimed to investigate the clinical characteristics of immune tolerance after pediatric liver transplantation and to identify the possible predictors.
Methods
The clinical data from 37 cases of pediatric patients 2 year later after liver transplantation surgery in the Children’s Hospital of Chongqing Medical University, China, were retrospectively analyzed. According to the status of the current immunosuppressant medications of the patients, they were divided into tolerance (n = 15) and Control (n = 22) groups. The current status regarding prope/operational tolerance was reviewed and screened based on the immunosuppressant medications.
Results
The patients in the tolerance group were younger than that of Controls (p < 0.001). The children in the tolerance group experienced no acute rejection episode and exhibited no obvious abnormalities in the liver function during the continuous follow-up period. The primary disease of the tolerance group were more often diagnosed with biliary atresia (p = 0.011), and received with a living donor liver graft (p = 0.005). There were less glomerular function, diabetes mellitus, arterial hypertension events presented in the tolerance group compared with the control group, indicating low toxicity profile.
Conclusion
In the current study, there were really certain quantity of recipients following liver transplantation attained long term immune tolerance, with low toxicity and satisfied liver graft function. The younger age of the recipient and maternal donor seems to promote long-term clinical immune tolerance. Further work in larger series should be required to describe the overall perspective of tolerance.
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Barjon C, Dahlqvist G, Ghazal K, Saliba F, Durand F, Duvoux C, Aoudjehane L, Conti F. Influence of everolimus-based treatment on circulating regulatory T cells after liver transplantation: Comparative study with tacrolimus-based therapy. Clin Res Hepatol Gastroenterol 2021; 45:101559. [PMID: 33191181 DOI: 10.1016/j.clinre.2020.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 02/04/2023]
Abstract
Liver transplantation remains the only treatment for terminal liver diseases. However, immunosuppressive drugs required for allograft acceptance are toxic and may be responsible for severe side effects. Modulating the immune system to induce tolerance is a promising approach to reduce immunosuppressive regimen. More particularly, promoting natural CD4+ CD25+ FoxP3+ Tregs could be crucial in achieving tolerance. Contrary to calcineurin inhibitors, reports indicate that mTOR inhibitors may have a positive impact on Tregs. Here we present the first randomized prospective clinical study where Tregs levels from liver transplanted patients receiving either tacrolimus or everolimus were monitored for 6 months, starting from the day of transplantation. A total of 30 patients from four centers were monitored. Blood samples were obtained at day 0, day 14, one month, three months and six months post-transplantation. Flow-cytometry immunophenotyping of Tregs (CD4+ CD25+ CD127- FoxP3+) and functional assays with Tregs were performed to assess their immunosuppressive capacity. Levels of Tregs were significantly reduced after one month of standard tacrolimus-based immunosuppressive regimen (p<0.05). Four months after conversion, levels of Tregs from patients treated with everolimus was significantly higher than patients under tacrolimus (p<0.02). Functional assays demonstrated that Tregs conserved their capacity to suppress the proliferation of activated PBMC.
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Affiliation(s)
- Clément Barjon
- UMR_S 938, CDR Saint-Antoine, F-75012 Paris, France; De Duve Institute, UCLouvain, 1200 Brussels, Belgium
| | - Géraldine Dahlqvist
- UMR_S 938, CDR Saint-Antoine, F-75012 Paris, France; Hepatogastroenterology Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
| | | | - Faouzi Saliba
- Centre Hépato-Biliaire, Hôpital Paul Brousse, AP-HP, Villejuif, France
| | - François Durand
- Liver Intensive Care Unit, Hôpital Beaujon, Assistance Publique-Hopitaux de Paris and University of Paris, Paris, France
| | - Christophe Duvoux
- Department of Hepatology, Hôpital Henri Mondor, AP-HP, Créteil, France
| | | | - Filomena Conti
- UMR_S 938, CDR Saint-Antoine, F-75012 Paris, France; Liver Transplantation Unit, AP-HP, Hôpital de la Pitié-Salpêtrière, 75012 Paris, France
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Zhang W, Cao D, Wang M, Wu Y, Gong J, Li J, Liu Y. XBP1s repression regulates Kupffer cell polarization leading to immune suppressive effects protecting liver allograft in rats. Int Immunopharmacol 2021; 91:107294. [PMID: 33395585 DOI: 10.1016/j.intimp.2020.107294] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Polarized kupffer cells (KCs) influence the immune response after liver transplantation. We report an undiscovered immune regulatory role of X-box binding protein 1 (XBP1) on immune function of kupffer cells (KCs). METHODS Acute rejection model using rats. RESULTS We found that suppression of XBP1s in lipopolysaccharide (LPS) -activated KCs could increase the expression of arginase-1 (Arg-1) and CD204 but also decrease the expression levels of MHC-II and CD40 and shift the phenotype markers of KCs toward M2 via the janus kinase (JAK) 3- Signal Transducer And Activator Of Transcription (STAT) 6 pathway, presenting an immunosuppressive function by enhancing anti-inflammatory cytokine secretion and accelerating apoptosis of activated T cells. XBP1s over-expression in KCs shift the phenotype markers on KCs towards M1 via the JAK1-STAT1 pathway and have shown a strong pro-inflammatory property. Down-regulation of XBP1s in KCs changed the phenotype and cytokine secretion profile towards M2 and markedly protected the function and structure of allograft liver, prolonging the recipient's survival compared with control and normal saline groups in rats. CONCLUSIONS Our findings reveal a novel regulatory mechanism of XBP1 in an induced immuno-suppressive state to protect rat's liver allograft via JAK-STAT mediated KCs polarization.
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Affiliation(s)
- Weikang Zhang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ding Cao
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China.
| | - Menghao Wang
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Yakun Wu
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Jianping Gong
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Jingzheng Li
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China
| | - Yiming Liu
- Chongqing Key Laboratory of Hepatobiliary Surgery and Department of Hepatobiliary Surgery, Second Affiliated Hospital, Chongqing Medical University, Chongqing 400010, China.
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Hu ZQ, Lu Y, Cui D, Ma CY, Shao S, Chen P, Tao R, Wang JJ. MicroRNAs and long non-coding RNAs in liver surgery: Diagnostic and therapeutic merits. Hepatobiliary Pancreat Dis Int 2020; 19:218-228. [PMID: 32414577 DOI: 10.1016/j.hbpd.2020.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatectomy and liver transplantation (LT) are the two most commonly performed surgical procedures for various hepatic lesions. microRNA (miRNA) and long non-coding RNA (lncRNA) have been gradually unveiled their roles as either biomarkers for early diagnosis or potentially therapeutic tools to manipulate gene expression in many disease entities. This review aimed to discuss the effects of miRNA or lncRNA in the hepatectomy and LT fields. DATA SOURCES We did a literature search from 1990 through January 2018 to summarize the currently available evidence with respect to the effects of miRNA and lncRNA in liver regeneration after partial hepatectomy, as well as their involvement in several key issues related to LT, including ischemia-reperfusion injury, allograft rejection, tolerance, recurrence of original hepatic malignancies, etc. RESULTS: Certain miRNAs and lncRNAs are actively involved in the regulation of various aspects of liver resection and transplantation. During the process of liver regeneration after hepatectomy, the expression of miRNAs and lncRNAs shows dynamic changes. CONCLUSIONS It is now clear that miRNAs and lncRNAs orchestrate in various aspects of the pathophysiological process of LT and hepatectomy. Better understanding of the underlying mechanism and future clinical trials may strengthen their positions as either biomarkers or potential therapeutic targets in the management of complications after liver surgery.
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Affiliation(s)
- Zhi-Qiu Hu
- Department of Surgery, Minhang Hospital, Fudan University, Shanghai 201199, China; Department of Hepatobiliary-Pancreatic & Minimally Invasive Surgery, Affiliated Zhejiang Provincial People's Hospital, Hangzhou Medical School, Hangzhou 310014, China
| | - Yi Lu
- Department of Hepatobiliary-Pancreatic & Minimally Invasive Surgery, Affiliated Zhejiang Provincial People's Hospital, Hangzhou Medical School, Hangzhou 310014, China; Center for Clinical Medical Research, Affiliated Zhejiang Provincial People's Hospital, Hangzhou Medical School, Hangzhou 310014, China
| | - Di Cui
- Center for Clinical Medical Research, Affiliated Zhejiang Provincial People's Hospital, Hangzhou Medical School, Hangzhou 310014, China
| | - Chen-Yang Ma
- Center for Clinical Medical Research, Affiliated Zhejiang Provincial People's Hospital, Hangzhou Medical School, Hangzhou 310014, China
| | - Su Shao
- Department of General Surgery, Chun'an 1st People's Hospital, Hangzhou 311700, China
| | - Ping Chen
- Department of Obstetrics and Gynecology, Shaoxing 2nd Hospital, Shaoxing 312000, China
| | - Ran Tao
- Department of Hepatobiliary-Pancreatic & Minimally Invasive Surgery, Affiliated Zhejiang Provincial People's Hospital, Hangzhou Medical School, Hangzhou 310014, China; Center for Clinical Medical Research, Affiliated Zhejiang Provincial People's Hospital, Hangzhou Medical School, Hangzhou 310014, China
| | - Jian-Jun Wang
- Department of General Surgery, Chun'an 1st People's Hospital, Hangzhou 311700, China.
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Why some organ allografts are tolerated better than others: new insights for an old question. Curr Opin Organ Transplant 2020; 24:49-57. [PMID: 30516578 DOI: 10.1097/mot.0000000000000594] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW There is great variability in how different organ allografts respond to the same tolerance induction protocol. Well known examples of this phenomenon include the protolerogenic nature of kidney and liver allografts as opposed to the tolerance-resistance of heart and lung allografts. This suggests there are organ-specific factors which differentially drive the immune response following transplantation. RECENT FINDINGS The specific cells or cell products that make one organ allograft more likely to be accepted off immunosuppression than another are largely unknown. However, new insights have been made in this area recently. SUMMARY The current review will focus on the organ-intrinsic factors that contribute to the organ-specific differences observed in tolerance induction with a view to developing therapeutic strategies to better prevent organ rejection and promote tolerance induction of all organs.
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10
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Graves SS, Mathes DW, Storb R. Induction of Tolerance Towards Solid Organ Allografts Using Hematopoietic Cell Transplantation in Large Animal Models. ACTA ACUST UNITED AC 2019; 3. [PMID: 32944710 DOI: 10.21926/obm.transplant.1903080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The application of hematopoietic cell transplantation for induction of immune tolerance has been limited by toxicities associated with conditioning regimens and to graft-versus-host disease (GVHD). Decades of animal studies have culminated into sufficient control of these two problems, making immune tolerance a viable alternative to life-long application of immunosuppressive drugs to prevent allograft rejection. Methods Studies in mice have paved the way for the application of HCT with limited toxicity in large animal models. Resultant studies in the pig, dog, and ultimately the nonhuman primate have led to appropriate methods for achieving nonmyeloablative irradiation protocols, dose, and timing of post-grafting immunosuppressive drugs, monoclonal antibody therapy, and biologicals for costimulatory molecule blockade. The genetics field has been extensively evaluated in appreciation of the ultimate need to obtain organs from MHC-mismatched unrelated donors. Results Nonmyeloablative conditioning regimens have been shown to be successful in inducing immune tolerance across all three animal models. Postgrafting immunosuppression is also important in assuring sustained donor hematopoiesis for tolerance. Donor chimerism need not be permanent to establish stable engraftment of donor organs, thereby essentially eliminating the risk of GVHD. Using nonmyeloablative HCT with monoclonal antibody immunosuppression, the kidney has been successfully transplanted in MHC-mismatched nonhuman primates. Conclusions Nonmyeloablative HCT for the establishment of temporary mixed chimerism has led to the establishment of stable tolerance against solid organ allografts in large animal models. The kidney, considered a tolerogenic organ, has been successfully transplanted in the clinic. Other organs such as heart, lung, and vascularized composite allografts (face and hands), remain distant possibilities. Further study in large animal models will be required to improve tolerance against these organs before success can be attained in the clinic.
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Affiliation(s)
- Scott S Graves
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, D1-100, Seattle, WA, U.S.A
| | - David W Mathes
- Department of Plastic Surgery, University of Colorado, Aurora, CO.,Plastic Surgery Service VA, Eastern Care System, Denver, CO
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, D1-100, Seattle, WA, U.S.A.,University of Washington School of Medicine, Seattle, WA, U.S.A
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Toniutto P, Bitetto D, Fornasiere E, Fumolo E. Challenges and future developments in liver transplantation. MINERVA GASTROENTERO 2018; 65:136-152. [PMID: 30303340 DOI: 10.23736/s1121-421x.18.02529-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Liver transplantation (LT) has become the treatment of choice for a wide range of liver diseases in both adult and pediatric patients. Until recently, the largest proportion of LT in adults, were performed in patients with hepatitis C (HCV) related cirrhosis. The recent availability of safe and effective direct antiviral agents to cure HCV infection in almost all patients whatever the HCV genotype and severity of liver disease, will reduce the need for LT in this category of recipients. Thus, it is presumed that in the next 1 to 2 decades HCV related liver disease will diminish substantially, whereas non-alcoholic steato-hepatitis (NASH) will correspondingly escalate as an indication for LT. The greatest challenges facing LT remain the limited supply of donor organs, and the need for chronic immunosuppression, which represent the true obstacles to the greater application and durable success of the LT procedure. This review aimed to highlight, in different sections, the main open issues and future developments in LT. These will be focused to explore current and future strategies to maximize the use of limited organs, to offer an update on potential new approaches to immunosuppression and to imagine new indications for LT when the number of patients awaiting transplants for HCV related liver disease is reduced.
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Affiliation(s)
- Pierluigi Toniutto
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy -
| | - Davide Bitetto
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Ezio Fornasiere
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Elisa Fumolo
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
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Huo Q, Zhou M, Cooper DKC, Dai Y, Xie N, Mou L. Circulating miRNA or circulating DNA-Potential biomarkers for organ transplant rejection. Xenotransplantation 2018. [DOI: 10.1111/xen.12444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Qin Huo
- College of Life Science and Oceanography; Shenzhen University; Shenzhen Guangdong China
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center; Institute of Translational Medicine; Shenzhen Second People's Hospital; First Affiliated Hospital of Shenzhen University; Shenzhen Guangdong China
| | - Ming Zhou
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center; Institute of Translational Medicine; Shenzhen Second People's Hospital; First Affiliated Hospital of Shenzhen University; Shenzhen Guangdong China
| | - David K. C. Cooper
- Xenotransplantation Program; Department of Surgery; The University of Alabama at Birmingham; Birmingham Alabama
| | - Yifan Dai
- Jiangsu Key Laboratory of Xenotransplantation; Nanjing Medical University; Nanjing Jiangsu China
| | - Ni Xie
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center; Institute of Translational Medicine; Shenzhen Second People's Hospital; First Affiliated Hospital of Shenzhen University; Shenzhen Guangdong China
| | - Lisha Mou
- Shenzhen Xenotransplantation Medical Engineering Research and Development Center; Institute of Translational Medicine; Shenzhen Second People's Hospital; First Affiliated Hospital of Shenzhen University; Shenzhen Guangdong China
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Abstract
Immunosuppressive therapy is arguably the most important component of medical care after lung transplantation. The goal of immunosuppression is to prevent acute and chronic rejection while maximizing patient survival and long-term allograft function. However, the benefits of immunosuppressive therapy must be balanced against the side effects and major toxicities of these medications. Immunosuppressive agents can be classified as induction agents, maintenance therapies, treatments for acute rejection and chronic rejection and antibody directed therapies. Although induction therapy remains an area of controversy in lung transplantation, it is still used in the majority of transplant centers. On the other hand, maintenance immunosuppression is less contentious; but, unfortunately, since the creation of three-drug combination therapy, including a glucocorticoid, calcineurin inhibitor and anti-metabolite, there have been relatively modest improvements in chronic maintenance immunosuppressive regimens. The presence of HLA antibodies in transplant candidates and development of de novo antibodies after transplantation remain a major therapeutic challenge before and after lung transplantation. In this chapter we review the medications used for induction and maintenance immunosuppression along with their efficacy and side effect profiles. We also review strategies and evidence for HLA desensitization prior to lung transplantation and management of de novo antibody formation after transplant. Finally, we review immune tolerance and the future of lung transplantation to limit the toxicities of conventional immunosuppressive therapy.
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Affiliation(s)
- Luke J Benvenuto
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Michaela R Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
| | - Selim M Arcasoy
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, USA
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Safinia N, Grageda N, Scottà C, Thirkell S, Fry LJ, Vaikunthanathan T, Lechler RI, Lombardi G. Cell Therapy in Organ Transplantation: Our Experience on the Clinical Translation of Regulatory T Cells. Front Immunol 2018. [PMID: 29535728 PMCID: PMC5834909 DOI: 10.3389/fimmu.2018.00354] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Solid organ transplantation is the treatment of choice for patients with end-stage organ dysfunction. Despite improvements in short-term outcome, long-term outcome is suboptimal due to the increased morbidity and mortality associated with the toxicity of immunosuppressive regimens and chronic rejection (1–5). As such, the attention of the transplant community has focused on the development of novel therapeutic strategies to achieve allograft tolerance, a state whereby the immune system of the recipient can be re-educated to accept the allograft, averting the need for long-term immunosuppression. Indeed, reports of “operational” tolerance, whereby the recipient is off all immunosuppressive drugs and maintaining good graft function, is well documented in the literature for both liver and kidney transplantations (6–8). However, this phenomenon is rare and in the setting of liver transplantation has been shown to occur late after transplantation, with the majority of patients maintained on life-long immunosupression to prevent allograft rejection (9). As such, significant research has focused on immune regulation in the context of organ transplantation with regulatory T cells (Tregs) identified as cells holding considerable promise in this endeavor. This review will provide a brief introduction to human Tregs, their phenotypic and functional characterization and focuses on our experience to date at the clinical translation of Treg immunotherapy in the setting of solid organ transplantation.
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Affiliation(s)
- Niloufar Safinia
- Department of Immunoregulation and Immune Intervention, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom.,Faculty of Medicine, Division of Digestive Disease, Imperial College London, London, United Kingdom
| | - Nathali Grageda
- Department of Immunoregulation and Immune Intervention, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Cristiano Scottà
- Department of Immunoregulation and Immune Intervention, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Sarah Thirkell
- Department of Immunoregulation and Immune Intervention, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Laura J Fry
- Clinical Research Facility GMP Unit, NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Trishan Vaikunthanathan
- The Blizard Institute of Cell and Molecular Science, Queen Mary University of London, London, United Kingdom
| | - Robert I Lechler
- Department of Immunoregulation and Immune Intervention, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Giovanna Lombardi
- Department of Immunoregulation and Immune Intervention, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
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15
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Vaikunthanathan T, Safinia N, Boardman D, Lechler RI, Lombardi G. Regulatory T cells: tolerance induction in solid organ transplantation. Clin Exp Immunol 2017; 189:197-210. [PMID: 28422316 DOI: 10.1111/cei.12978] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2017] [Indexed: 02/06/2023] Open
Abstract
The concept of regulatory T cell (Treg ) therapy in transplantation is now a reality. Significant advances in science and technology have enabled us to isolate human Tregs , expand them to clinically relevant numbers and infuse them into human transplant recipients. With several Phase I/II trials under way investigating Treg safety and efficacy it is now more crucial than ever to understand their complex biology. However, our journey is by no means complete; results from these trials will undoubtedly provoke both further knowledge and enquiry which, alongside evolving science, will continue to drive the optimization of Treg therapy in the pursuit of transplantation tolerance. In this review we will summarize current knowledge of Treg biology, explore novel technologies in the setting of Treg immunotherapy and address key prerequisites surrounding the clinical application of Tregs in transplantation.
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Affiliation(s)
- T Vaikunthanathan
- MRC Centre for Transplantation, Division of Transplantation Immunology and Mucosal Biology, King's College London, London, UK
| | - N Safinia
- MRC Centre for Transplantation, Division of Transplantation Immunology and Mucosal Biology, King's College London, London, UK
| | - D Boardman
- MRC Centre for Transplantation, Division of Transplantation Immunology and Mucosal Biology, King's College London, London, UK
| | - R I Lechler
- MRC Centre for Transplantation, Division of Transplantation Immunology and Mucosal Biology, King's College London, London, UK
| | - G Lombardi
- MRC Centre for Transplantation, Division of Transplantation Immunology and Mucosal Biology, King's College London, London, UK
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Toniutto P, Zanetto A, Ferrarese A, Burra P. Current challenges and future directions for liver transplantation. Liver Int 2017; 37:317-327. [PMID: 27634369 DOI: 10.1111/liv.13255] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 09/08/2016] [Indexed: 12/14/2022]
Abstract
Liver transplantation is an effective and widely used therapy for several patients with acute and chronic liver diseases. The discrepancy between the number of patients on the waiting list and available donors remains the key issue and is responsible for the high rate of waiting list mortality. The recent news is that the majority of patients with hepatitis C virus related liver disease will be cured by new antivirals therefore we should expect soon a reduction in the need of liver transplantation for these recipients. This review aims to highlight, in two different sections, the main open issues of liver transplantation concerning the current and future strategies to the best use of limited number of organs. The first section cover the strategies to increase the donor pool, discussing the use of older donors, split grafts, living donation and donation after cardiac death and mechanical perfusion systems to improve the preservation of organs before liver transplantation. Challenges in immunosuppressive therapy and operational tolerance induction will be evaluated as potential tools to increase the survival in liver transplant recipients and to reducing the need of re-transplantation. The second section is devoted to the evaluation of possible new indications to liver transplantation, where the availability of organs by implementing the strategies mentioned in the first section and the reduction in the number of waiting transplants for HCV disease is realized. Among these new potential indications for transplantation, the expansion of the Milan criteria for hepatocellular cancer is certainly the most open to question.
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Affiliation(s)
- Pierluigi Toniutto
- Department of Clinical Sciences Experimental and Clinical, Medical Liver Transplant Section, University of Udine, Udine, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padova, Italy
| | - Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padova, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padova, Italy
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Madariaga MLL, Spencer PJ, Michel SG, La Muraglia GM, O’Neil MJ, Mannon EC, Leblang C, Rosales IA, Colvin RB, Sachs DH, Allan JS, Madsen JC. Effects of Lung Cotransplantation on Cardiac Allograft Tolerance Across a Full Major Histocompatibility Complex Barrier in Miniature Swine. Am J Transplant 2016; 16:979-86. [PMID: 26469344 PMCID: PMC5010442 DOI: 10.1111/ajt.13489] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/10/2015] [Accepted: 08/09/2015] [Indexed: 01/25/2023]
Abstract
A 12-day course of high-dose tacrolimus induces tolerance of major histocompatibility complex-mismatched lung allografts in miniature swine but does not induce tolerance of heart allografts unless a kidney is cotransplanted. To determine whether lungs share with kidneys the ability to induce cardiac allograft tolerance, we investigated heart-lung cotransplantation using the same induction protocol. Hearts (n = 3), heart-kidneys (n = 3), lungs (n = 6), and hearts-lungs (n = 3) were transplanted into fully major histocompatibility complex-mismatched recipients treated with high-dose tacrolimus for 12 days. Serial biopsy samples were used to evaluate rejection, and in vitro assays were used to detect donor responsiveness. All heart-kidney recipients and five of six lung recipients demonstrated long-term graft survival for longer than 272 days, while all heart recipients rejected their allografts within 35 days. Tolerant recipients remained free of alloantibody and showed persistent donor-specific unresponsiveness by cell-mediated lympholysis/mixed-lymphocyte reaction. In contrast, heart-lung recipients demonstrated rejection of both allografts (days 47, 55, and 202) and antidonor responsiveness in vitro. In contrast to kidneys, lung cotransplantation leads to rejection of both heart and lung allografts, indicating that lungs do not have the same tolerogenic capacity as kidneys. We conclude that cells or cell products present in kidney, but not heart or lung allografts, have a unique capacity to confer unresponsiveness on cotransplanted organs, most likely by amplifying host regulatory mechanisms.
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Affiliation(s)
- M. L. L. Madariaga
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - P. J. Spencer
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - S. G. Michel
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - G. M. La Muraglia
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - M. J. O’Neil
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - E. C. Mannon
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - C. Leblang
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - I. A. Rosales
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - R. B. Colvin
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - D. H. Sachs
- Center for Transplantation Science, Department of Surgery, Massachusetts General Hospital, Boston, MA
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Jwa E, Hwang S, Kwon YJ, Kim N, Song GW, Jung DH, Ahn CS, Tak E, Moon DB, Kim KH, Ha TY, Park GC, Lee SG. In vitro immune cell monitoring as a guide for long-term immunosuppression in adult liver transplant recipients. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2015; 19:139-48. [PMID: 26693232 PMCID: PMC4683916 DOI: 10.14701/kjhbps.2015.19.4.139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 10/25/2015] [Accepted: 11/05/2015] [Indexed: 01/12/2023]
Abstract
Backgrounds/Aims We evaluated the clinical usability of immune cell monitoring in adult liver transplantation (LT) recipients. Methods This study was composed of two parts as using calcineurin phosphatase (CNP) activity assay and ImmuKnow assay independently as in vitro monitoring tools of immune cell function in adult LT recipients. Results There was a rough correlation between CNP activity and tacrolimus concentration in 33 patients. This association was evident in patients who were only administered tacrolimus, but disappeared after the co-administration of mycophenolate. In 118 healthy individuals, the mean proportion of helper T-cells was 37.4±8.1%. According to ImmuKnow assay, their immune responses were strong in 12 patients (10.2%), moderate in 92 patients (78.0%), and low in 14 patients (11.9%). In 85 patients waiting for LT, there was a rough correlation between the ImmuKnow ATP level and age. Their immune responses were strong in 0 patients (0%), moderate in 8 patients (9.4%), and low in 77 patients (90.6%). There was a difference in the ImmuKnow ATP levels between healthy individuals and patients with liver disease. In 137 LT recipients, there was no correlation between the ImmuKnow ATP levels and tacrolimus concentration. This trend did not change after grouping the patients according to co-administration with mycophenolate. Eight recipients experienced acute rejection, but none showed strong immune response. Conclusions We think that both CNP activity assay and ImmuKnow assay are too limited to objectively determine the level of immunosuppression. Further studies should be performed to identify other methods for immune function monitoring.
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Affiliation(s)
- Eunkyoung Jwa
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Jae Kwon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nayoung Kim
- Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eunyoung Tak
- Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
PURPOSE OF REVIEW When it comes to tolerance induction, kidney allografts behave differently from heart allografts that behave differently from lung allografts. Here, we examine how and why different organ allografts respond differently to the same tolerance induction protocol. RECENT FINDINGS Allograft tolerance has been achieved in experimental and clinical kidney transplantation. Inducing tolerance in experimental recipients of heart and lung allografts has, however, proven to be more challenging. New protocols being developed in nonhuman primates based on mixed chimerism and cotransplantation of tolerogenic organs may provide mechanistic insights to help overcome these challenges. SUMMARY Tolerance induction protocols that are successful in patients transplanted with 'tolerance-prone' organs such as kidneys and livers will most likely not succeed in recipients of 'tolerance-resistant' organs such as hearts and lungs. Separate clinical trials using more robust tolerance protocols will be required to achieve tolerance in heart and lung recipients.
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Zhang CX, Wen PH, Sun YL. Withdrawal of immunosuppression in liver transplantation and the mechanism of tolerance. Hepatobiliary Pancreat Dis Int 2015; 14:470-6. [PMID: 26459722 DOI: 10.1016/s1499-3872(15)60411-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Immunosuppression reagents have side effects and cause considerable long-term morbidity and mortality in patients after liver transplantation. Sufficient evidences showed that minimization or withdrawal of immunosuppression reagents does not deteriorate the recipient's immune response and physiological function and therefore, is feasible in some recipients of liver transplantation. However, the mechanisms are not clear. The present review was to update the current status of immunosuppression in liver transplantation and the mechanism of minimization or withdrawal of immunosuppression in liver recipients. DATA SOURCES We searched articles in English on minimization or withdrawal of immunosuppression in liver transplantation in PubMed. We focused on the basic mechanisms of immune tolerance in liver transplantation. Studies on immunosuppression minimization or withdrawal protocols and biomarker in tolerant recipients were also analyzed. RESULTS Minimization or withdrawal of immunosuppression can be achieved by the induction of immune tolerance, which may not be permanent and can be affected by various factors. However, accurately evaluating immune status post-transplant is a prerequisite to achieve individualized immunosuppression. Numerous mechanisms for immune tolerance have been found, including immunophenotypic shift of memory CD8+ T cells and CD4+ T cell subsets. Activation of the inflammasome through apoptosis-associated speck-like protein containing a C-terminal caspase recruitment domain (ASC) in dendritic cells is associated with rejection after liver transplantation. CONCLUSIONS Minimization or withdrawal of immunosuppression can be achieved by the induction of immune tolerance via different mechanisms. This process could be affected by immunophenotypic shift of memory CD8+ T cells and CD4+ T cell subsets, which may be correlated with activation of the inflammasome through ASC in dendritic cells.
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Affiliation(s)
- Chi-Xian Zhang
- Institute of Hepatobiliary and Pancreatic Diseases, Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhengzhou University, School of Medicine, Zhengzhou 450052, China.
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21
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"Current state and prospects in managing liver transplanted children". Clin Res Hepatol Gastroenterol 2015; 39:292-5. [PMID: 25241997 DOI: 10.1016/j.clinre.2014.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 08/27/2014] [Accepted: 08/27/2014] [Indexed: 02/04/2023]
Abstract
Pediatric liver transplantation (LTx) has revolutionized life chances and perspectives of children with liver disease. Following rapid establishment of the therapeutic concept in the early years of pediatric transplant medicine, more aspects beyond plain survival become increasingly important. In addition to improving the short to medium-term survival rates, researchers are focusing on themes such as rehabilitation, adherence and quality of life, long-term graft fibrosis and dysfunction, as well as the consequences of long-term immunosuppression. Also, more protocol biopsy data are available to evaluate increasing graft fibrosis. To manage their conditions, patients will need access to highly experienced pediatric liver transplant centers where clinical research will examine modulators of renal disease, endocrine and cardiovascular comorbidity and the development of graft fibrosis and malignancies. Assessment and evaluation of health-related quality of life and factors which influence clinical tolerance, adherence and transition from child to adult care will also be investigated. The analysis of multi-national registry data and more than 40years of experience with large patient cohorts will provide important clues to treatment and will thus get increasing attention. In the future, longitudinal assessment of the outcome for pediatric LTx patients should include more functional aspects than plain survival rates or laboratory parameters.
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Calmus Y, Conti F. Is the liver a tolerogenic organ? Clin Res Hepatol Gastroenterol 2014; 38:655-8. [PMID: 25260569 DOI: 10.1016/j.clinre.2014.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/20/2014] [Indexed: 02/04/2023]
Affiliation(s)
- Yvon Calmus
- Centre de transplantation hépatique, hôpital Saint-Antoine, AP-HP, 75012 Paris, France.
| | - Filoména Conti
- France Sorbonne universités, UPMC université Paris 06, 75006 Paris, France
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23
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Abstract
Proteomics and biochemical profiling have emerged as exciting and powerful tools in clinical biomarker research. In the field of transplantation, proteomics aims not only at developing noninvasive means for immune monitoring but also to gain mechanistic insights into the pathophysiology of the alloimmune response and hence defining new therapeutic targets. This chapter provides an overview of proteomic biomarker-driven approaches and its underlying concepts and discusses the advantages, clinical implications, challenges, and limitations of this novel modality as it relates to solid organ transplantation.
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Affiliation(s)
- Katrin Kienzl-Wagner
- Center of Operative Medicine, Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Combined Heart and Liver Transplantation Can Be Safely Performed With Excellent Short- and Long-Term Results. Ann Thorac Surg 2014; 98:858-62. [DOI: 10.1016/j.athoracsur.2014.04.100] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/27/2014] [Accepted: 04/01/2014] [Indexed: 11/17/2022]
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Kornberg A. Liver Transplantation for Hepatocellular Carcinoma beyond Milan Criteria: Multidisciplinary Approach to Improve Outcome. ISRN HEPATOLOGY 2014; 2014:706945. [PMID: 27335840 PMCID: PMC4890913 DOI: 10.1155/2014/706945] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 01/03/2014] [Indexed: 12/12/2022]
Abstract
The implementation of the Milan criteria (MC) in 1996 has dramatically improved prognosis after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Liver transplantation has, thereby, become the standard therapy for patients with "early-stage" HCC on liver cirrhosis. The MC were consequently adopted by United Network of Organ Sharing (UNOS) and Eurotransplant for prioritization of patients with HCC. Recent advancements in the knowledge about tumor biology, radiographic imaging techniques, locoregional interventional treatments, and immunosuppressive medications have raised a critical discussion, if the MC might be too restrictive and unjustified keeping away many patients from potentially curative LT. Numerous transplant groups have, therefore, increasingly focussed on a stepwise expansion of selection criteria, mainly based on tumor macromorphology, such as size and number of HCC nodules. Against the background of a dramatic shortage of donor organs, however, simple expansion of tumor macromorphology may not be appropriate to create a safe extended criteria system. In contrast, rather the implementation of reliable prognostic parameters of tumor biology into selection process prior to LT is mandatory. Furthermore, a multidisciplinary approach of pre-, peri-, and posttransplant modulating of the tumor and/or the patient has to be established for improving prognosis in this special subset of patients.
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Affiliation(s)
- A. Kornberg
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaningerstraße 22, D-81675 Munich, Germany
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