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Vinson AJ, Zhang X, Dahhou M, Süsal C, Döhler B, Sapir-Pichhadze R, Cardinal H, Melk A, Wong G, Francis A, Pilmore H, Foster BJ. Age-dependent Sex Differences in Graft Loss After Kidney Transplantation. Transplantation 2022; 106:1473-1484. [PMID: 34974454 DOI: 10.1097/tp.0000000000004026] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sex differences in kidney graft loss rates were reported in the United States. Whether these differences are present in other countries is unknown. METHODS We estimated the association between recipient sex and death-censored graft loss in patients of all ages recorded in the Scientific Registry of Transplant Recipients, Australia and New Zealand Dialysis and Transplant Registry, and Collaborative Transplant Study registries who received a first deceased donor kidney transplant (1988-2019). We used multivariable Cox regression models, accounting for the modifying effects of donor sex and recipient age, in each registry separately; results were combined using individual patient data meta-analysis. RESULTS We analyzed 438 585 patients. Young female patients 13-24 y old had the highest crude graft loss rates (female donor: 5.66; male donor: 5.50 per 100 person-years). Among young recipients of male donors, females showed higher graft loss risks than males (0-12 y: adjusted hazard ratio [aHR] 1.42, (95% confidence interval [CI], 1.17-1.73); 13-24 y: 1.24 (1.17-1.32); 25-44 y: 1.09 (1.06-1.13)). When the donor was female, there were no significant differences by recipient sex among those of age <45 y; however, the aHR for females was 0.93 (0.89-0.98) in 45-59 y-old and 0.89 (0.86-0.93) in ≥ 60 y-old recipients. Findings were similar for all 3 registries in most age intervals; statistically significant heterogeneity was seen only among 13-24-y-old recipients of a female donor (I2 = 71.5%, P = 0.03). CONCLUSIONS There is an association between recipient sex and kidney transplantation survival that is modified by recipient age and donor sex.
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Affiliation(s)
- Amanda J Vinson
- Nephrology Division, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Xun Zhang
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Mourad Dahhou
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Caner Süsal
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Bernd Döhler
- Institute of Immunology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ruth Sapir-Pichhadze
- Department of Medicine, Division of Experimental Medicine, McGill University, QC, Canada
| | - Heloise Cardinal
- Department of Medicine, Division of Nephrology, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Anette Melk
- Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Germaine Wong
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Anna Francis
- School of Clinical Medicine, University of Queensland, QLD, Australia
- Department of Nephrology, Queensland Children's Hospital, Brisbane, Australia
| | - Helen Pilmore
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Bethany J Foster
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Department of Pediatrics, Division of Nephrology, McGill University Faculty of Medicine, QC, Canada
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2
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Pan F, Cao S, Li XL, Jia YN, Wang RL, He Q, Zhu JQ. The Model for End-Stage Liver Disease Score and the Follow-Up Period Can Cause the Shift of Circulating Lymphocyte Subsets in Liver Transplant Recipients. Front Med (Lausanne) 2022; 8:779443. [PMID: 35047528 PMCID: PMC8761724 DOI: 10.3389/fmed.2021.779443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Little is known about the shift of lymphocytes under the condition of the model for end-stage liver disease score and the follow-up period. Then, we detected the peripheral blood from liver transplant recipients by flow cytometry and compared the results. The model for end-stage liver disease score affected the percentages of T-cell subsets and B cells during the short-term follow-up period, but failed to influence the lymphocyte subsets during the long-term follow-up period. In contrast, the follow-up period not only affected the absolute counts of T-cell subsets and natural killer (NK) cells in patients with the low model for end-stage liver disease scores, but also influenced the percentages and absolute counts of T-cell subsets in patients with the high model for end-stage liver disease scores. In the two-way ANOVA, we further revealed that the model for end-stage liver disease score was associated with the percentages of T cells and CD4+ T cells and the absolute numbers of T-cell subsets and B cells, while the follow-up period was associated with the percentages of T-cell subsets and the absolute numbers of lymphocyte subsets. Therefore, patients with either the low model for end-stage liver disease scores or the long-term follow-up period are in a relatively activated immune condition.
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Affiliation(s)
- Fei Pan
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Medical Research Center, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Shuang Cao
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Medical Research Center, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xian-Liang Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Medical Research Center, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ya-Nan Jia
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Medical Research Center, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ruo-Lin Wang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Medical Research Center, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiang He
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Medical Research Center, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ji-Qiao Zhu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Medical Research Center, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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3
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Donato-Santana C, Theodoropoulos NM. Immunization of Solid Organ Transplant Candidates and Recipients: A 2018 Update. Infect Dis Clin North Am 2018; 32:517-533. [PMID: 30146021 DOI: 10.1016/j.idc.2018.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
This article discusses the recommended vaccines used before and after solid organ transplant period, including data regarding vaccine safety and efficacy and travel-related vaccines. Vaccination is an important part of the preparation for solid organ transplantation, because vaccine-preventable diseases contribute to the morbidity and mortality of these patients. A pretransplantation protocol should be encouraged in every transplant center. The main goal of vaccination is to provide seroprotection before transplantation, because iatrogenically immunosuppressed patients posttransplant have a lower seroresponse to vaccines.
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Affiliation(s)
- Christian Donato-Santana
- Division of Infectious Diseases & Immunology, University of Massachusetts Medical School, 55 Lake Avenue North, S7-715, Worcester, MA 01655, USA
| | - Nicole M Theodoropoulos
- Division of Infectious Diseases & Immunology, University of Massachusetts Medical School, 55 Lake Avenue North, S7-715, Worcester, MA 01655, USA.
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4
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Transcriptomic studies in tolerance: Lessons learned and the path forward. Hum Immunol 2018; 79:395-401. [PMID: 29481826 DOI: 10.1016/j.humimm.2018.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/12/2018] [Accepted: 02/21/2018] [Indexed: 11/21/2022]
Abstract
Immunosuppression after solid organ transplantation is a delicate balance of the immune response and is a complex phenomenon with many factors involved. Despite advances in the care of patients receiving organ transplants the adverse effects associated with immunosuppressive agents and the risks of long-term immunosuppression present a series of challenges and the need to weigh the risks and benefits of either over or under-immunosuppression. Ideally, if all transplant recipients could develop donor-specific immunological tolerance, it could drastically improve long-term graft survival without the need for immunosuppressive agents. In the absence of this ideal situation, the next best approach would be to develop tools to determine the adequacy of immunosuppression in each patient, in a manner that would individualize or personalize therapy. Despite current genomics-based studies of tolerance biomarkers in transplantation there are currently, no clinically validated tools to safely increase or decrease the level of IS that is beneficial to the patient. However, the successful identification of biomarkers and/or mechanisms of tolerance that have implications on long-term graft survival and outcomes depend on proper integration of study design, experimental protocols, and data-driven hypotheses. The objective of this article is to first, discuss the progress made on genomic biomarkers of immunological tolerance and the future avenues for the development of such biomarkers specifically in kidney transplantation. Secondly, we provide a set of guiding principles and identify the pitfalls, advantages, and drawbacks of studies that generate genomic data aimed at understanding transplant tolerance that is applicable to all solid transplants.
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5
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Fadus MC, Lau C, Bikhchandani J, Lynch HT. Curcumin: An age-old anti-inflammatory and anti-neoplastic agent. J Tradit Complement Med 2017; 7:339-346. [PMID: 28725630 PMCID: PMC5506636 DOI: 10.1016/j.jtcme.2016.08.002] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/09/2016] [Indexed: 01/19/2023] Open
Abstract
Curcumin is a natural anti-inflammatory agent that has been used for treating medical conditions for many years. Several experimental and pharmacologic trials have demonstrated its efficacy in the role as an anti-inflammatory agent. Curcumin has been shown to be effective in treating chronic conditions like rheumatoid arthritis, inflammatory bowel disease, Alzheimer's and common malignancies like colon, stomach, lung, breast, and skin cancers. As treatments in medicine become more and more complex, the answer may be something simpler. This is a review article written with the objective to systematically analyze the wealth of information regarding the medical use of curcumin, the "curry spice", and to understand the existent gaps which have prevented its widespread application in the medical community.
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Affiliation(s)
- Matthew C. Fadus
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, United States
| | - Cecilia Lau
- Duke University, Department of Psychiatry, Durham, NC, United States
| | - Jai Bikhchandani
- Creighton University, Department of Preventive Medicine, Omaha, NE 68178, United States
| | - Henry T. Lynch
- Creighton University, Department of Preventive Medicine, Omaha, NE 68178, United States
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Abstract
Mesenchymal stem cells derived from adipose tissue (ASC) have immune regulatory function, which makes them interesting candidates for cellular therapy. ASC cultures are however heterogeneous in phenotype. It is unclear whether all ASC contribute equally to immunomodulatory processes. ASC are also responsive to cytokine stimulation, which may affect the ratio between more and less potent ASC populations. In the present study, we determined IL-6 receptor (CD126 and CD130 subunits) and IFN-γ receptor (CD119) expression on ASC by flow cytometry. The production of IL-6 and IFN-γ was measured by ELISA and the frequency of IL-6 and IFN-γ secreting cells by ELISPOT. The results showed that ASC did not express CD126, and only 10–20% of ASC expressed CD130 on their surface, whereas 18–31% of ASC expressed CD119. ASC produced high levels of IL-6 and 100% of ASC were capable of secreting IL-6. Stimulation by IFN-γ or TGF-β had no effect on IL-6 secretion by ASC. IFN-γ was produced by only 1.4% of ASC, and TGF-β significantly increased the frequency to 2.7%. These results demonstrate that ASC cultures are heterogeneous in their cytokine secretion and receptor expression profiles. This knowledge can be employed for selection of potent, cytokine-producing, or responsive ASC subsets for cellular immunotherapy.
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Trubiano JA, Johnson D, Sohail A, Torresi J. Travel vaccination recommendations and endemic infection risks in solid organ transplantation recipients. J Travel Med 2016; 23:taw058. [PMID: 27625399 DOI: 10.1093/jtm/taw058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/25/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are often heavily immunosuppressed and consequently at risk of serious illness from vaccine preventable viral and bacterial infections or with endemic fungal and parasitic infections. We review the literature to provide guidance regarding the timing and appropriateness of vaccination and pathogen avoidance related to the immunological status of SOT recipients. METHODS A PUBMED search ([Vaccination OR vaccine] AND/OR ["specific vaccine"] AND/OR [immunology OR immune response OR cytokine OR T lymphocyte] AND transplant was performed. A review of the literature was performed in order to develop recommendations on vaccination for SOT recipients travelling to high-risk destinations. RESULTS Whilst immunological failure of vaccination in SOT is primarily the result of impaired B-cell responses, the role of T-cells in vaccine failure and success remains unknown. Vaccination should be initiated at least 4 weeks prior to SOT or more than 6 months post-SOT. Avoidance of live vaccination is generally recommended, although some live vaccines may be considered in the specific situations (e.g. yellow fever). The practicing physician requires a detailed understanding of region-specific endemic pathogen risks. CONCLUSIONS We provide a vaccination and endemic pathogen guide for physicians and travel clinics involved in the care of SOT recipients. In addition, recommendations based on timing of anticipated immunological recovery and available evidence regarding vaccine immunogenicity in SOT recipients are provided to help guide pre-travel consultations.
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Affiliation(s)
- Jason A Trubiano
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia Department of Infectious Diseases, Peter MaCallum Cancer Centre, Melbourne, VIC, Australia Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Douglas Johnson
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia Department of Medicine, University of Melbourne, Parkville, VIC, Australia Department of General Medicine, Austin Health, Heidelberg, VIC, Australia
| | - Asma Sohail
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia
| | - Joseph Torresi
- Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia Department of Microbiology and Immunology, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia Eastern Infectious Diseases and Travel medicine, Knox Private Hospital, Boronia, VIC, Australia
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Leventhal J, Mathew J, Salomon D, Kurian S, Friedewald J, Gallon L, Konieczna I, Tambur A, charette J, Levitsky J, Jie C, Kanwar YS, Abecassis MM, Miller J. Nonchimeric HLA-Identical Renal Transplant Tolerance: Regulatory Immunophenotypic/Genomic Biomarkers. Am J Transplant 2016; 16:221-34. [PMID: 26227106 PMCID: PMC4718825 DOI: 10.1111/ajt.13416] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/14/2015] [Accepted: 06/02/2015] [Indexed: 01/25/2023]
Abstract
We previously described early results of a nonchimeric operational tolerance protocol in human leukocyte antigen (HLA)-identical living donor renal transplants and now update these results. Recipients given alemtuzumab, tacrolimus/MPA with early sirolimus conversion were multiply infused with donor hematopoietic CD34(+) stem cells. Immunosuppression was withdrawn by 24 months. Twelve months later, operational tolerance was confirmed by rejection-free transplant biopsies. Five of the first eight enrollees were initially tolerant 1 year off immunosuppression. Biopsies of three others after total withdrawal showed Banff 1A acute cellular rejection without renal dysfunction. With longer follow-up including 5-year posttransplant biopsies, four of the five tolerant recipients remain without rejection while one developed Banff 1A without renal dysfunction. We now add seven new subjects (two operationally tolerant), and demonstrate time-dependent increases of circulating CD4(+) CD25(+++) CD127(-) FOXP3(+) Tregs versus losses of Tregs in nontolerant subjects (p < 0.001). Gene expression signatures, developed using global RNA expression profiling of sequential whole blood and protocol biopsy samples, were highly associative with operational tolerance as early as 1 year posttransplant. The blood signature was validated by an external Immune Tolerance Network data set. Our approach to nonchimeric operational HLA-identical tolerance reveals association with Treg immunophenotypes and serial gene expression profiles.
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Affiliation(s)
- J.R. Leventhal
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Surgery- Transplantation; Northwestern University, Chicago, Illinois, U.S.A
| | - J.M. Mathew
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Surgery- Transplantation; Northwestern University, Chicago, Illinois, U.S.A,Department of Microbiology-Immunology; Northwestern University, Chicago, Illinois, U.S.A
| | - D.R. Salomon
- Department of Molecular and Experimental Medicine; The Scripps Research Institute, La Jolla, California, U.S.A
| | - S.M. Kurian
- Department of Molecular and Experimental Medicine; The Scripps Research Institute, La Jolla, California, U.S.A
| | - J.J. Friedewald
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Medicine-Nephrology; Northwestern University, Chicago, Illinois, U.S.A
| | - L. Gallon
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Medicine-Nephrology; Northwestern University, Chicago, Illinois, U.S.A
| | - I. Konieczna
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A
| | - A.R. Tambur
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Surgery- Transplantation; Northwestern University, Chicago, Illinois, U.S.A
| | - j. charette
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Surgery- Transplantation; Northwestern University, Chicago, Illinois, U.S.A
| | - J. Levitsky
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Medicine-Hepatology; Northwestern University, Chicago, Illinois, U.S.A
| | - C. Jie
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A
| | - Y. S. Kanwar
- Department of Pathology; Northwestern University, Chicago, Illinois, U.S.A
| | - M. M. Abecassis
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Surgery- Transplantation; Northwestern University, Chicago, Illinois, U.S.A,Department of Microbiology-Immunology; Northwestern University, Chicago, Illinois, U.S.A
| | - J. Miller
- Comprehensive Transplant Center; Northwestern University, Chicago, Illinois, U.S.A,Department of Surgery- Transplantation; Northwestern University, Chicago, Illinois, U.S.A
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Leventhal JR, Mathew JM, Salomon DR, Kurian SM, Suthanthiran M, Tambur A, Friedewald J, Gallon L, Charette J, Levitsky J, Kanwar Y, Abecassis M, Miller J. Genomic biomarkers correlate with HLA-identical renal transplant tolerance. J Am Soc Nephrol 2013; 24:1376-85. [PMID: 23787913 DOI: 10.1681/asn.2013010068] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
The ability to achieve immunologic tolerance after transplantation is a therapeutic goal. Here, we report interim results from an ongoing trial of tolerance in HLA-identical sibling renal transplantation. The immunosuppressive regimen included alemtuzumab induction, donor hematopoietic stem cells, tacrolimus/mycophenolate immunosuppression converted to sirolimus, and complete drug withdrawal by 24 months post-transplantation. Recipients were considered tolerant if they had normal biopsies and renal function after an additional 12 months without immunosuppression. Of the 20 recipients enrolled, 10 had at least 36 months of follow-up after transplantation. Five of these 10 recipients had immunosuppression successfully withdrawn for 16-36 months (tolerant), 2 had disease recurrence, and 3 had subclinical rejection in protocol biopsies (nontolerant). Microchimerism disappeared after 1 year, and CD4(+)CD25(high)CD127(-)FOXP3(+) regulatory T cells and CD19(+)IgD/M(+)CD27(-) B cells were increased through 5 years post-transplantation in both tolerant and nontolerant recipients. Immune/inflammatory gene expression pathways in the peripheral blood and urine, however, were differentially downregulated between tolerant and nontolerant recipients. In summary, interim results from this trial of tolerance in HLA-identical renal transplantation suggest that predictive genomic biomarkers, but not immunoregulatory phenotyping, may be able to discriminate tolerant from nontolerant patients.
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Affiliation(s)
- Joseph R Leventhal
- Comprehensive Transplant Center, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Hüser N, Matevossian E, Schmidbauer P, Assfalg V, Scherberich JE, Stangl M, Holzmann B, Friess H, Laschinger M. Calculated withdrawal of low-dose immunosuppression based on a detailed immunological monitoring after kidney transplantation between monocygotic twins. Transpl Immunol 2009; 22:38-43. [PMID: 19766188 DOI: 10.1016/j.trim.2009.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 08/29/2009] [Accepted: 09/01/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pretransplant screening in living donor kidney transplantation includes human leukocyte antigen matching, and panel reactive antibody analysis, whereas T cell mediated anti-donor reactivity is not assessed routinely. We investigated T cell reactivity after living related kidney transplantation between two monocygotic twins and in consequence correlated the withdrawal of individual immunosuppressive medication with immunological findings. METHODS Immunosuppression consisted of mycophenolate mofetil, glucocorticoid single shot, and induction therapy with antithymocyte immunoglobulin. RESULTS FACS analysis of recipient peripheral blood cells revealed a normal haemogram after transplantation, showing non-activated CD4 and CD8 cells. Mixed lymphocyte reaction did not reveal donor-specific T cell activity. IFN-gamma and IL-10 ELISA of supernatants of recipient cells cocultivated with donor cells support the lack of Th1 and Th2 cell differentiation. CONCLUSION Based on immunological findings on days 5 and 20 MMF-therapy was reduced and stopped. Immunological monitoring on day 90 confirmed the absence of immune reactions directed against donor tissue.
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Affiliation(s)
- Norbert Hüser
- Department of Surgery, Technische Universität München, D-81675 Munich, Germany.
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