Factors Affecting the Development of an Antibody Response to Hepatitis B Immunization in Children With Intestinal Failure: Before and After Small Bowel Transplantation (With and Without Liver Graft)

BACKGROUND

Small bowel transplant with or without a liver graft (SBTx ± LTx) for children with intestinal failure involves checking their immunity to a range of microorganisms, including hepatitis B virus (HBV), at the time of assessment. HBV vaccination in the United Kingdom is recommended for transplant candidates. The aim of this audit was to find out how many SBTx ± LTx candidates received HBV vaccination before transplantation and how the timing of vaccination influenced the development of immunity.

MATERIALS AND METHODS

Retrospective review of case notes and hospital microbiology database formed the basis of the study. Vaccination history and serology were available in 56 of 87 subjects who had SBTx ± LTx.

RESULTS

All patients were seronegative for HBV when assessed for transplant. HBV vaccination was started before transplant in 25 children and after transplant in 31. Eight children died posttransplant before their immunity could be checked, but of the 48 survivors, 20 children developed immunity, of whom 13 (65%) received at least 1 vaccination before SBTx ± LTx ( P = .008). Lack of response to HBV vaccine was significantly associated with isolated bowel transplantation and intensification of immune suppression. Of 11 children, 5 lost hepatitis B surface antibody (HbsAb), and 28 never made HBsAb, despite repeated vaccinations.

CONCLUSION

Our study clearly shows that HBV vaccine before transplant is more effective. In line with renal failure patients, we suggest that children with chronic intestinal failure receive HBV vaccine when clinically stable, before referral for transplant. Higher-dose vaccines, accelerated schedules, and more frequent booster vaccinations are also strategies that may improve HBsAb levels after transplant.

Pregnancy of a patient treated with clozapine

The authors describe the case of a patient with treatment-resistant schizophrenia who became pregnant after switching from conventional neuroleptic medications to clozapine, an atypical antipsychotic medication that does not cause hyperprolactinemia. Gestational diabetes, possibly exacerbated by clozapine, complicated management of her pregnancy. Comprehensive community support and psychiatric rehabilitation, combined with a positive response to clozapine, contributed to satisfying the patient's goal of having a healthy baby and being able to take the baby home to live with her and her husband.

Water permeability of human hematopoietic stem cells

It is currently impossible to isolate or identify human hematopoietic progenitor cells from the bone marrow, yet the biophysical properties of these cells are important for the development of techniques to isolate and preserve stem cells for transplantation. Osmotic permeability properties of human bone marrow stem cells were estimated from the kinetics of cell damage in a hypotonic solution measured using in vitro colony assays for multipotential (CFU-GEMM) and committed (BFU-E, CFU-GM) progenitor cells. Cells exposed to a hypotonic solution swell as a result of water influx, and the rate of change of volume is proportional to the hydraulic conductivity of the plasma membrane. Cell damage occurs when the cell volume exceeds the maximum tolerable volume, so the hydraulic conductivity can be estimated from the kinetics of cell damage. For all the progenitor cells studied, the mean value of the hydraulic conductivity was 0.283 micron3/micron2/min/atm at 20 degrees C, with an Arrhenius activation energy of 6.41 kcal/mole. No significant differences were observed in the osmotic properties of the various progenitor cells. These data were used to predict the osmotic responses of human bone marrow stem cells at subzero temperatures during freezing.

The Experimental Study of Flash Burns

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