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Meier D, Rumbo M, Gondolesi GE. Current Status of Allograft Tolerance in Intestinal Transplantation. Int Rev Immunol 2013; 33:245-60. [DOI: 10.3109/08830185.2013.829468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Abstract
Composite tissue allotransplantation holds a great potential for providing increased knowledge of anatomy and microsurgical experience for life-enhancing reconstructions. Many transplant cases around the world have made this a clinical reality at the present time. Composite tissue allotransplants contain multiple tissue types, including bone, muscle, vessels, nerves, skin, and immune cells and bear a huge antigenic load. Although immunosuppressive drugs are applied successfully to prevent allograft rejection, their side effects pose a barrier to worldwide use. Bone marrow therapy in many tolerance induction protocols, therefore, provides a guide to reaching the target of permanent immunotolerance. Multiple studies suggest that bone marrow is immunomodulatory and may facilitate allograft acceptance. In this review, bone marrow based therapy protocols of clinical and experimental models are presented in two major categories: solid organ and composite tissue transplantation.
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Affiliation(s)
- Maria Siemionow
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
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Tang Y, Li YP, Li JS, Zhang ZD, Han FH, Hu WM, Tian BL. Impact of Portal Versus Systemic Venous Drainage on Acute Rejection of Simultaneous Pancreas−Kidney Transplantation in Pig. Transplantation 2007; 84:629-33. [PMID: 17876276 DOI: 10.1097/01.tp.0000278179.78975.b1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The immunological benefits of portal venous drainage (PVD) in pancreas transplantation remain debated clinically. We established simultaneous pancreas-kidney transplantation (SPK) models with portal venous drainage and systemic venous drainage to compare the impact of venous drainage site on acute rejection in pig. METHODS Forty-eight nonrelated, first hybrid landrace pigs were divided into PE (portal-enteric drainage) and SE (systemic-enteric drainage) groups. Type I diabetes mellitus was induced by whole pancreatectomy, and right-side nephrectomy was also performed in the recipients. The donor portal vein was anastomosed to superior mesenteric vein of the recipients in PE group or to the inferior hepatic cava vena of the recipients in SE group. Graft tissue specimens were obtained with laparotomy on Day 3 and 7 after transplant, and the severity of acute rejection was scored according to Nakhleh and Banff criteria. RESULTS The cold ischemia time, fasting plasma glucose and urine creatinine of the 2 groups had no statistic difference between 2 groups at Day 1, 3, 5, and 7 after transplant (P>0.05). The occurrence of both pancreas and kidney acute rejections in PE group was significant later and slighter than SE group (P<0.05). CONCLUSION PVD, compared with SVD, could ameliorate and delay acute rejection in pig SPK. It might become a tolerance inducing method of pancreas transplantation, decrease the cost and improve the quality of SPK, if further confirmed by clinical trials.
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Affiliation(s)
- Yong Tang
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Abstract
Intestine transplant is indicated for patients with intestinal failure who are unable to be weaned from parenteral nutrition (PN). Long-term PN, although life sustaining in many patients, can be associated with life-threatening complications including PN-associated liver disease (PNALD). Most patients are not considered for intestine transplant until they have developed severe PNALD and also need a liver transplant. Overall outcomes with intestinal transplantation are steadily improving, and current 1-year patient survivals for intestine-only transplants are now similar to those for liver transplant. Intestinal transplantation should be considered earlier in intestinal failure patients who are at high risk for developing PNALD and other life-threatening complications.
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Affiliation(s)
- Jonathan P Fryer
- Division of Transplantation, Department of Surgery, Feinberg School of Medicine, Northwestern University, 675 North St. Clair Street, Galter, Pavilion Suite 17-200, Chicago, IL 60611-2923S, USA.
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Abstract
Transplantation is standard therapy for many patients suffering from kidney, liver, or heart failure. In contrast, transplantation of the intestine remains a high-risk procedure, which is performed in a minority of patients with short bowel syndrome. The difficulty is the strong alloimmune response caused by intestinal grafts and the complications of the profound immunosuppression. We tested a new clinical immunomodulatory protocol using donor-specific blood transfusion, a strategy that was popular before the introduction of cyclosporine and was recently shown to promote development of regulatory cells. Low-dose steroids and low-dose tacrolimus were administered based on previous observations that tolerance requires an intact immune system, that over-immunosuppression is counterproductive, and that high doses of calcineurin inhibitors block development of regulatory cells whereas low doses promote it. Finally, inflammation within the intestinal graft was minimized to reduce the additional stimulants that the innate immunity of the transplanted intestine exert on the adaptive immune response. Under this protocol, freedom from rejection was achieved in four consecutive intestinal transplant recipients using extremely low immunosuppression.
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Affiliation(s)
- J Pirenne
- Abdominal Transplant Surgery Department, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Gorczynski RM. Regulation of transplantation tolerance by antigen-presenting cells. Transplant Rev (Orlando) 2005. [DOI: 10.1016/j.trre.2005.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Levay-Young B, Shearer JD, Gruessner AC, Kim SC, Nahkleh RE, Gruessner RWG. Intestinal graft versus native liver cytokine expression in a rat model of intestinal transplantation: effect of donor-specific cell augmentation. Transplant Proc 2004; 36:399-400. [PMID: 15050172 DOI: 10.1016/j.transproceed.2004.01.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Immunomodulation by portal vein delivery of donor antigen reduces intestinal graft rejection. We investigated the impact of portal venous donor-specific cell augmentation (blood versus bone marrow) on cytokine expression in intestinal grafts versus native livers. METHODS Ten groups of intestinal transplants (brown Norway male to Lewis female rats) varied by (1). the type of donor-specific cell augmentation and (2). the use and dose of tacrolimus-based immunosuppression. Tissue samples for histologic analysis and cytokine mRNA analysis were obtained at designated time points. RESULTS Without immunosuppression, no type of cell augmentation reduced the rate of rejection. With immunosuppression, outcome was significantly better after portal donor-specific blood transfusion (versus bone marrow infusion). Irrespective of the type of cell augmentation, severe rejection caused strong intragraft expression of IL-1alpha, IL-1beta, IFN-gamma, and TNF-alpha; liver expression mainly involved TNF-alpha. Of note, nonimmunosuppressed, cell-augmented rats showed hardly any differences in cytokine expression in their grafts versus significant increases in their native livers. With immunosuppression, bone marrow infusion (versus blood transfusion) increased intragraft cytokine expression of IL-1alpha, IL-1beta, IFN-gamma, as well as TNF-alpha, and liver expression of IL-1beta. CONCLUSIONS (1). Rejection and donor-specific cell augmentation independently caused differences in intragraft versus native liver cytokine expression after intestinal transplants. (2). Portal donor-specific blood transfusion (versus bone marrow infusion) lowered the incidence of rejection and diminished intragraft cytokine up-regulation. (3). In our study, TNF-alpha appeared to be the cytokine most strongly associated with rejection.
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Affiliation(s)
- B Levay-Young
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Mitsuoka N, Iwagaki H, Ozaki M, Sheng SD, Sadamori H, Matsukawa H, Morimoto Y, Matsuoka J, Tanaka N, Yagi T. The impact of portal infusion with donor-derived bone marrow cells and intracellular cytokine expression of graft-infiltrating lymphocytes on the graft survival in rat small bowel transplant model. Transpl Immunol 2004; 13:155-60. [PMID: 15381197 DOI: 10.1016/j.trim.2004.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2004] [Revised: 06/14/2004] [Accepted: 06/28/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intraportal administration of alloantigen is reported to reduce antigen-specific immune responses, although the underlying mechanisms for the reduced immunological reactions, especially those of the graft, are poorly understood. We examined intracellular cytokine production by graft-infiltrating lymphocytes (GILs) and peripheral blood lymphocytes (PBLs) to elucidate the underlying mechanisms of beneficial effects on intraportal infusion of donor cells in rat small bowel transplantation (SBT). METHODS Recipient rats (Lewis) were transplanted with small bowel from ACI rats. Tacrolimus (Tac) was injected daily from days 0 to 4. Bone marrow cells of ACI rats were infused via the portal or tail vein on the day of surgery. On day 5, both GILs and PBLs collected from SBT graft and peripheral blood, respectively, were analyzed for intracellular cytokine production of recipient-derived alphabeta-T cells. The Th1/Th2 balance in each group was designated as the ratio of the percentage of GILs or PBLs staining positive for intracellular IL-4 or IFN-gamma, respectively. The total cell numbers of GILs from SBT graft were also counted. RESULTS Survival of recipients was markedly prolonged by the combination of Tac and donor-specific bone marrow infusion via the portal vein (DSBMI-PV-Tac) compared with the untreated control, Tac alone, or DSBMI tail vein plus Tac. DSBMI-PV-Tac significantly decreased the total cell numbers of GILs and also induced remarkable Th2-type response in GILs. CONCLUSIONS Our results indicate that DSBMI-PV-Tac decreased GILs and enhanced Th2-type response in SBT graft, both of which are associated with a significant prolongation of graft survival in SBT.
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Affiliation(s)
- Naoshi Mitsuoka
- Department of Gastroenterological Surgery, Transplant and Surgical Oncology, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata, 700-8558, Japan
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Pirenne J, Kawai M. Tolerogenic protocols for intestinal transplantation. Transpl Immunol 2004; 13:131-7. [PMID: 15380543 DOI: 10.1016/j.trim.2004.05.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2004] [Accepted: 05/21/2004] [Indexed: 11/22/2022]
Abstract
The intestine has long been considered as a "forbidden" organ to transplant [Ann. Surg. 216 (1992) 223-33]. This is due to the particularly challenging nature of the immunological conflict that an intestinal graft may cause: a particularly vigorous rejection response, in addition to the capacity to mount a graft-versus-host disease (GVHD) [Transplantation 37 (1984) 429]. Currently, the short-term success of intestinal transplantation (Itx) depends upon the chronic delivery of profound immunosuppression but this causes infection, malignancies--in particular posttransplant lymphoproliferative disorder (PTLD)--and direct drug toxicity. For these reasons, the results of Itx remain inferior to those of other solid organ transplants in the middle and in the long term (Intestinal Transplant Registry: www.small-bowel-transplant.org). Improved results and wider application of Itx requires the development of protocols that would facilitate acceptance of the new intestine thereby allowing to reduce the need for immunosuppression with its attending complications. Relevant experimental data and the recent evolution in the clinical strategies used to promote acceptance of intestinal grafts are reviewed.
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Affiliation(s)
- Jacques Pirenne
- Abdominal Transplant Surgery Department, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.
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Gruessner RWG, Levay-Young BK, Nakhleh RE, Shearer JD, Dunning M, Nelson CM, Gruessner AC. PORTAL DONOR-SPECIFIC BLOOD TRANSFUSION AND MYCOPHENOLATE MOFETIL ALLOW STEROID AVOIDANCE AND TACROLIMUS DOSE REDUCTION WITH SUSTAINED LEVELS OF CHIMERISM IN A PIG MODEL OF INTESTINAL TRANSPLANTATION. Transplantation 2004; 77:1500-6. [PMID: 15239611 DOI: 10.1097/01.tp.0000128298.12937.b2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In a pig model of intestinal transplantation, we previously showed that hepatic conditioning through portal donor-specific blood transfusion (pDSBT), high-dose tacrolimus (TAC), and steroids prevented rejection and increased survival Our current study tests a protocol of pDSBT, short-term mycophenolate mofetil (MMF), and low-dose TAC to eliminate the use of steroids, reduce TAC dosage, and increase the level of chimerism in the peripheral blood. MATERIALS AND METHODS Four groups of outbred, mixed lymphocyte culture (MLC)-reactive pigs underwent bowel transplants and pDSBT. Immunosuppression (group 1, high-dose TAC and steroids; group 2, low-dose TAC and MMF; group 3, low-dose TAC, MMF, and aminoguanidine; group 4, low-dose TAC, MMF, and arginine) was discontinued after 28 days. RNA was extracted from intestinal graft and native liver biopsies for cytokine measurements. Chimerism levels were determined using a Q-PCR analysis. RESULTS Pig survival and death rates due to rejection did not significantly differ between the four groups. Chimerism levels determined by Q-PCR analysis were not different until day 28. After discontinuation of immunosuppression, we noted a trend (P = 0.15) toward higher mean chimerism levels on day 60 for groups 2, 3, and 4 (9%) vs. group 1 (0.5%). Tissue cytokine and serum nitrate levels did not significantly differ between the four groups. Attempts to modify nitric oxide synthase activity offered no added benefit. CONCLUSIONS The combination of pDSBT, MMF, and low-dose TAC (vs. high-dose TAC and steroids) allowed sustained levels of mixed chimerism to develop after discontinuation of immunosuppression.
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Affiliation(s)
- Rainer W G Gruessner
- Department of Surgery, University of Minnesota, MMC 90, 420 Delaware St. SE, Minneapolis, MN 55455, USA.
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Troppmann C, Gjertson DW, Cecka JM, McVicar JP, Perez RV. Impact of portal venous pancreas graft drainage on kidney graft outcome in simultaneous pancreas-kidney recipients reported to UNOS. Am J Transplant 2004; 4:544-53. [PMID: 15023146 DOI: 10.1111/j.1600-6143.2004.00378.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Clinical data on the potential immunologic impact of portal (PD) vs. systemic (SD) venous pancreas graft drainage on outcome remains controversial. We reviewed the UNOS database to study the effect of PD vs. SD on the incidence of kidney graft rejection and survival in first cadaveric simultaneous pancreas-kidney (SPK) recipients transplanted 1994-2001. We studied three groups: all SPK (n=6629, 13% PD) (group I), SPK on tacrolimus (n=3563, 17% PD) (group II), and SPK on tacrolimus performed at centers with significant PD experience (n=948, 46% PD) (group III). The cumulative kidney graft rejection incidence for PD vs. SD was only significantly different in group I (for PD vs. SD, respectively: at 6 months, 31% vs. 36% [p=0.015]; at 1 year, 37% vs. 43% [p=0.006]). Kidney graft survival was similar in all groups for PD vs. SD. Multivariate analysis of group III showed only transplantation during the earlier era (1994-96), but not SD, to be an independent risk factor for kidney graft rejection. Portal venous pancreas graft drainage does not affect kidney graft rejection and survival in SPK recipients on tacrolimus. Our data suggests that the efficacy of current immunosuppressive protocols and increasing center experience are clinically much more relevant than any potential immunologic advantage of portal venous drainage in SPK recipients.
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Affiliation(s)
- Christoph Troppmann
- Department of Surgery, University of California, Davis, Medical Center, Sacramento, CA, USA.
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Jiang F, Yin ZY, Ni XD, Li YS, Li N, Li JS. Modifications in combined liver-small bowel transplantation in pigs. World J Gastroenterol 2003; 9:2125-7. [PMID: 12970921 PMCID: PMC4656689 DOI: 10.3748/wjg.v9.i9.2125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To introduce combined liver-small bowel transplantation in pigs.
METHODS: Eighteen transplantations in 36 large white pigs were performed. Three modifications in combined liver-small bowel transplantation model were applied: Veno-venous bypass was not used. Preservation of the donor duodenum and head of pancreas in continuity with the combined graft to avoid biliary reconstruction. The splenic vein of donor was anastomosed end-to-end with the portal vein of recipients by the formation of a “cuff”.
RESULTS: Without immunosuppressive therapy, 72-hour survival rate of the transplanted animals was 72% (13/18). Five of 18 pigs operated died of respiratory failure (3 cases) and bleeding during hepatectomy (2 cases). The longest survival time of animals was 6 days.
CONCLUSION: Our surgical modifications are feasible and reliable, which have made the transplantation in pigs simpler and less aggressive, and thus these can be used for preclinical study.
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Affiliation(s)
- Feng Jiang
- Medical School of Nanjing University, Nanjing 210093, Jiangsu Province, China.
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Iwanami K, Ishikawa T, Nalesnik MA, Okuda T, Neto JS, Zhu Y, Türler A, Moore BA, Bauer AJ, Venkataramanan R, Murase N. Long-term function and morphology of intestinal autografts and allografts in outbred dogs. Am J Transplant 2003; 3:1083-90. [PMID: 12919087 DOI: 10.1034/j.1600-6143.2003.00161.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Although small bowel transplantation (SBTx) has become a clinical option, there have been few studies of long-term function and histopathology of intestinal grafts. Unrelated mongrel dogs received autologous (n = 4) or allogeneic (n = 11) orthotopic SBTx under oral cyclosporine. Intestinal graft function and routine/immunohistopathology of full-thickness intestine were studied. Six allograft and all isograft recipients had comparable body weight gain and are currently alive (> 420 days). Five allograft recipients were sacrificed because of significant body weight loss and malnutrition at a median of 119 days. Analyses of intestinal function in long-surviving recipients revealed marginal reduction of D-xylose/cyclosporine absorption, intestinal transit time, in vitro muscle contractility, and mucosal enzyme activity compared with normal dogs. However, these changes were insignificant and no statistical difference was seen between auto and long-surviving allografts. In histopathological analysis, long-surviving allografts had normal mucosa with submucosal, muscularis propria, and perineural (Auerbach's plexus) inflammation. Five allorecipients with malnutrition had mucosal atrophy/erosion and significantly reduced intestinal absorption and motility. Thus, denervated intestinal allografts are able to efficiently digest and absorb nutrients to support life. Results also indicate that these allografts experienced low-grade chronic rejection as evidenced in the submucosa and muscle layers, despite the lack of clinical symptoms.
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MESH Headings
- Animals
- Body Weight
- Cyclosporine/therapeutic use
- Dogs
- Female
- Gastrointestinal Transit
- Graft Survival/physiology
- Immunosuppressive Agents/therapeutic use
- Intestinal Absorption
- Intestine, Small/pathology
- Intestine, Small/physiology
- Intestine, Small/transplantation
- Male
- Muscle, Smooth/pathology
- Muscle, Smooth/physiology
- Muscle, Smooth/transplantation
- Time Factors
- Transplantation, Autologous/pathology
- Transplantation, Autologous/physiology
- Transplantation, Homologous/pathology
- Transplantation, Homologous/physiology
- Xylose/pharmacokinetics
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Affiliation(s)
- Kotaro Iwanami
- Department of Surgery, Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Levay-Young B, Gruessner SE, Shearer JD, Cheol Kim S, Nahkleh RE, Gruessner RWG. Intestinal graft versus native liver cytokine expression in a rat model of intestinal transplantation with and without donor-specific cell augmentation. J Surg Res 2003; 114:78-89. [PMID: 13678702 DOI: 10.1016/s0022-4804(03)00211-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Immunomodulatory strategies such as donor-specific bone marrow or blood transfusions have been used to promote engraftment after intestinal transplants. We previously showed that delivery of donor antigen via the portal vein can effectively reduce the rate of intestinal graft rejection. The purpose of our current study was to investigate the impact of donor-specific cell augmentation (blood versus bone marrow) via the portal vein on cytokine expression in intestinal grafts versus native livers. MATERIAL AND METHODS We performed heterotopic small intestinal transplants between male Brown-Norway (donor) and female Lewis (recipient) rats. We studied 10 groups according to the type of donor-specific cell augmentation and the use and dose of immunosuppressive therapy. For cell augmentation, donor-specific blood or bone marrow was transfused via the donor portal vein immediately before graft implantation. For immunosuppression, tacrolimus was used post-transplant at a high or low dose. Control rats received neither immunosuppression nor cell augmentation. Tissue samples for histological assessment were obtained at designated time points. RNA was extracted from intestinal graft and native liver biopsies for cytokine measurements (IL-1 alpha, IL-1 beta, IL-2, IL-4, IL-5, IL-6, IFN-gamma, TNF-alpha, and TNF-beta). Chimerism levels were determined using Q-PCR analysis. RESULTS Without concurrent immunosuppression, neither portal donor-specific blood nor bone marrow transfusion reduced the rate of rejection. With immunosuppression, outcome was significantly better after portal donor-specific blood (versus bone marrow) transfusion. Irrespective of the type of donor-specific cell augmentation, severe rejection caused strong cytokine expression in the grafts of IL-1 alpha, IL-1 beta, IFN-gamma, and TNF-alpha; in the native livers, mainly of TNF-alpha (with IFN-gamma showing hardly any increase). In general, rejection caused stronger cytokine expression in the grafts than in the native livers. Mild rejection correlated well with strong intragraft expression of IL-6, TNF-alpha, and TNF-beta (early rejection markers); severe rejection with IL-1 alpha, IL-1 beta, IFN-gamma, and TNF-alpha (late rejection markers). In addition to cell augmentation per se, the type of cell augmentation also had an impact on cytokine expression in both grafts and native livers. Cell-augmented (versus tacrolimus-treated) rats showed hardly any differences in intragraft cytokine expression, but the expression of almost all cytokines was significantly stronger in the native livers. With immunosuppression, bone marrow infusion increased intragraft cytokine expression of IL-1 alpha, IL-1 beta, IFN-gamma, and TNF alpha, as well as liver cytokine expression of IL-1 beta, compared to blood transfusion. This finding reflected the more advanced rejection stages in the bone marrow infused group; different types of donor-specific cell augmentation had similar effects on liver cytokine expression. In the absence of myoablative therapy, chimerism levels were low, in both cell-augmented and non-cell-augmented groups. CONCLUSIONS Rejection and donor-specific cell augmentation independently causes differences in intragraft versus native liver cytokine expression after intestinal transplants. Portal donor-specific blood transfusion, as compared with donor-specific bone marrow infusion, lowered the incidence of rejection and diminished intragraft cytokine up-regulation.
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Affiliation(s)
- Brett Levay-Young
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Gorczynski RM, Hu J, Chen Z, Kai Y, Lei J. A CD200FC immunoadhesin prolongs rat islet xenograft survival in mice. Transplantation 2002; 73:1948-53. [PMID: 12131694 DOI: 10.1097/00007890-200206270-00018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A solubilized form of the CD200 molecule, CD200Fc, has been shown to suppress allograft rejection and development of collagen-induced arthritis in mice. We investigated whether the same molecule could prolong survival of rat islet xenografts. METHODS Streptozocin-treated mice, receiving injections with anti-asialo-GM1 antibody, received rat islets ( approximately 400/mouse) under the kidney capsule or injected into the portal vein, along with rapamycin treatment. Thereafter mice received injections of CD200Fc (10 microg/mouse/injection) or control mouse IgG2. Blood glucose was monitored daily. Some mice received additional injections of anti-CD200/-CD200R monoclonal antibodies. RESULTS Portal vein delivery of islets led to more extended resolution of diabetes than did transplantation under the kidney capsule. CD200Fc further prolonged survival in either case, an effect abolished by anti-CD200 or F(ab')2 anti-CD200R mAbs, but not by whole anti-CD200R (anti-CD200R Ig). Spleen cells taken from CD200Fc-treated mice showed polarization to type-2 cytokine production (interleukin-4, interleukin-10) on restimulation with rat splenocytes in culture, in comparison to cells from control mice (type-1 cytokines, interlulin-2, interferon-gamma). CONCLUSION CD200:CD200R interactions are important in regulating rat islet xenograft survival.
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Affiliation(s)
- R M Gorczynski
- The Toronto Hospital, University Health Network and Department of Surgery, University of Toronto, Toronto, Canada M5G2C4
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Pirenne J, Koshiba T, Geboes K, Emonds MP, Ferdinande P, Hiele M, Nevens F, Waer M. Complete freedom from rejection after intestinal transplantation using a new tolerogenic protocol combined with low immunosuppression. Transplantation 2002; 73:966-8. [PMID: 11923701 DOI: 10.1097/00007890-200203270-00024] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intestinal transplantation (Itx) remains the most difficult form of transplantation. This is due to the high immunogenicity of the bowel that currently obligates Itx patients to heavy immunosuppression, which causes infection, posttransplant lymphoproliferative disease (PTLD), and drug toxicity. Wider application of Itx depends on the development of tolerogenic strategies to promote engraftment while reducing the need for immunosuppression. We applied a strategy to clinical Itx that combines intraportal donor-specific blood transfusion with a deliberately low immunosuppression protocol (no high-dose steroids; lower tacrolimus level). METHODS A 55-year-old patient received a combined liver/Itx. Donor-specific whole blood was taken from the donor during procurement and transfused in the recipient portal vein after graft reperfusion. For induction immunosuppression, no intravenous bolus of steroids was given; only two doses of anti-interleukin 2 receptor antibody were administered. The patient received posttransplantation maintenance immunosuppression with lower tacrolimus levels than average (15 ng/ml first month; 5-10 ng/ml thereafter), low-dose azathioprine (1 mg/kg first to third months; 0.5 mg/kg thereafter), and low-dose steroids (Medrol 8 mg twice daily first and second months; 4 mg twice thereafter). The patient was monitored for rejection, graft-versus-host disease, infection, and PTLD. Protocol biopsy specimens were taken from the distal ileum (2 per week). RESULTS Clinical, endoscopic, and histologic signs of rejection did not develop. Chimerism was identified at day 28. Graft-versus-host disease was absent clinically. Chimerism was self-limiting and disappeared without modifying baseline immunosuppression and without observing a change in graft function. The patient remained free of systemic opportunistic infections, PTLD, and drug toxicity. Total parenteral nutrition was stopped at 7 weeks after transplantation. The patient remains free of total parenteral nutrition and free of rejection at 14 months after transplantation. CONCLUSIONS We describe an Itx patient who remained rejection free despite receiving significantly lower immunosuppression than average. We hypothesize that intraoperative immunomodulation via intraportal donor-specific blood transfusion in the absence of nonspecific overimmunosuppression promoted Itx acceptance.
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Affiliation(s)
- Jacques Pirenne
- Catholic University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium. Jacques.Pirenne@ uz.kuleuven.ac.be
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Pirenne J, Koshiba T, Coosemans W, Herman J, Van Damme-Lombaerts R. Recent advances and future prospects in intestinal and multi-visceral transplantation. Pediatr Transplant 2001; 5:452-6. [PMID: 11737771 DOI: 10.1034/j.1399-3046.2001.t01-2-00025.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
From an experimental procedure, intestinal transplantation (ITx) has evolved over the last 10 yr into a treatment option for patients suffering from short bowel syndrome and who develop life-threatening complications from total parenteral nutrition (TPN) (e.g. liver dysfunction, line sepsis, shortage of venous access, etc.). One-year survival rates are approximately 70% and thus similar to lung Tx. However, the intestine remains the most challenging abdominal organ to transplant. This is because of the severe immune response (mostly rejection) that is produced, and therefore the need for profound immunosuppression with its attendant complications (sepsis, lymphoma, direct drug toxicity). Unlike other organs, graft loss as a result of acute rejection can occur late after transplantation (more than 1 yr post-transplant). With regard to the actual immunosuppressive regimens, considerable experience in patient management is required to optimize outcome of those complex transplants, which are permanently at risk of rejection and infection. ITx remains an unfinished product, and the application of ITx to patients doing well on TPN warrants further research in the understanding of the rejection process, in the development of less toxic and more efficient immunosuppressive protocols, and in the development of immunomodulatory strategies, to better control rejection and thereby reduce the need for immunosuppression.
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Affiliation(s)
- J Pirenne
- Abdominal Transplant Surgery and Pediatric Transplantation, University Hospitals Gasthuisberg, Catholic University Leuven, Leuven, Belgium.
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Nakao A, Yagi T, Matsukawa H, Endo A, Okada Y, Sun DS, Sadamori H, Inagaki M, Matsuno T, Tanaka N. Combined effect of donor-specific bone marrow transplantation via portal vein and FK506 on small bowel transplantation in the rat. Transplant Proc 2000; 32:2011-2. [PMID: 11120044 DOI: 10.1016/s0041-1345(00)01536-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- A Nakao
- First Department of Surgery, Okayama University Medical School, Okayama, Japan
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Cattral MS, Bigam DL, Hemming AW, Carpentier A, Greig PD, Wright E, Cole E, Donat D, Lewis GF. Portal venous and enteric exocrine drainage versus systemic venous and bladder exocrine drainage of pancreas grafts: clinical outcome of 40 consecutive transplant recipients. Ann Surg 2000; 232:688-95. [PMID: 11066141 PMCID: PMC1421223 DOI: 10.1097/00000658-200011000-00011] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test the hypothesis that pancreas transplantation using the more physiologic method of portal venous-enteric (PE) drainage could be performed without compromising patient and graft outcome, compared with the standard method of systemic venous-bladder (SB) drainage. METHODS Between November 1995 and November 1998, the authors prospectively followed up 20 consecutive patients with SB drainage followed by 20 consecutive patients with PE drainage. All patients underwent simultaneous pancreas-kidney transplantation, and all were immunosuppressed with antilymphocyte serum, cyclosporin, azathioprine, and steroids. RESULTS The actuarial patient survival rate at 1 year was 95% in the SB group and 100% in the PE group. Death-censored kidney graft survival was 100% in both groups; pancreas graft survival was 95% in the SB group and 100% in the PE group. The mean initial hospital stay was 15 days for both groups. However, during the first 6 months after transplantation, the SB group required more medical day-unit visits, mostly for treatment of metabolic acidosis and dehydration. The incidence of urinary tract infections was similar in both groups. The incidence of cytomegalovirus infections was significantly less in the PE group. The incidence of acute rejection was 37% in the SB group and 15% in the PE group. Mean serum creatinine levels 6 months after transplantation were significantly lower in the PE group than in the SB group. Glycemic control was excellent in both groups, but fasting serum insulin levels were significantly lower in the PE group. CONCLUSIONS The PE method of pancreas transplantation can be performed with excellent patient and graft outcomes.
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Affiliation(s)
- M S Cattral
- Multiorgan Transplantation Program, The Toronto General Hospital, University Health Network, and the Departments of Surgery and Medicine, University of Toronto, Toronto, Ontario, Canada.
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Yamamoto S, Sato Y, Suda T, Kurosaki I, Okamoto H, Sakai Y, Hatakeyama K. Can donor-specific transfusion via the portal vein under activated Kupffer cells enhance the beneficial effect of portal venous tolerance for rat small intestinal transplantation? Transplant Proc 2000; 32:2485. [PMID: 11120258 DOI: 10.1016/s0041-1345(00)01757-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- S Yamamoto
- First Department of Surgery, Niigata University School of Medicine, Niigata, Japan
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Fishbein TM, Bodian CA, Miller CM. National sharing of cadaveric isolated intestinal allografts for human transplantation: a feasibility study. Transplantation 2000; 69:859-63. [PMID: 10755540 DOI: 10.1097/00007890-200003150-00032] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Most isolated intestinal graft losses are immunological. We conducted a pilot study to evaluate the feasibility of national sharing of HLA no-mismatch allografts for cadaveric isolated intestinal transplantation. METHODS UNOS data were analyzed in a theoretical model. Part I: All solid organ donors between 1/95-8/97 who would have met criteria for bowel donation were considered potential donors for all recipients who actually received isolated intestinal transplants during this period. We then determined how many donor intestines could have been directed to no-mismatch candidates had national sharing been in place. Donor exclusion criteria were CMV+ donors to CMV- recipients, hemodynamic instability, age >50, size mismatch (donor weight greater than recipient), and obesity. Mean and median waits for transplants, as well as theoretical mean and median waits for transplants that would have occurred given national sharing, were calculated. Part II: We estimated, based on registry graft survival data, the number of intestinal transplants necessary to demonstrate a no-mismatch graft survival advantage at 2 years. RESULTS Part I: Although no actual cadaveric no-mismatch transplant was performed, 12-17% of patients could have received no-mismatch allografts had sharing been in place, using various donor acceptance criteria. The impact on waiting time was variable. Part II: Accepting a 15% rate of no-mismatch cases and a survival advantage of 10% at 2 years, 793 transplants would be required to prove an advantage to HLA matching at P<0.05. If the graft survival advantage were 20% at 2 years, the time to show significance would be approximately 5 years. Using early acute rejection as an endpoint could require fewer transplants (93), and only a few years to complete the study. CONCLUSIONS National sharing of cadaveric isolated intestinal allografts is feasible. Median waits would not be significantly increased. The time necessary to prove graft survival advantage would be considerable, but a difference in the rate of acute rejection could be seen within 2 years. Additionally, a national sharing arrangement might improve the overall outcome of isolated intestinal transplantation.
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Affiliation(s)
- T M Fishbein
- The Recanati/Miller Transplantation Institute, The Mount Sinai Medical Center, New York, New York 10029, USA
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