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Abbassi F, Gero D, Muller X, Bueno A, Figiel W, Robin F, Laroche S, Picard B, Shankar S, Ivanics T, van Reeven M, van Leeuwen OB, Braun HJ, Monbaliu D, Breton A, Vachharajani N, Bonaccorsi Riani E, Nowak G, McMillan RR, Abu-Gazala S, Nair A, Bruballa R, Paterno F, Weppler Sears D, Pinna AD, Guarrera JV, de Santibañes E, de Santibañes M, Hernandez-Aleja R, Olthoff K, Ghobrial RM, Ericzon BG, Ciccarelli O, Chapman WC, Mabrut JY, Pirenne J, Müllhaupt B, Ascher NL, Porte RJ, de Meier VE, Polak WG, Sapisochin G, Attia M, Weiss E, Adam RA, Cherqui D, Boudjema K, Zienewicz K, Jassem W, Puhan M, Dutkowski P, Clavien PA. Novel benchmark values for redo liver transplantation – does the outcome justify the effort? Br J Surg 2022. [DOI: 10.1093/bjs/znac178.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Objective
In the era of organ shortage, redo liver transplantation (reLT) is frequently discussed in terms of expected poor outcome, high cost and therefore wasteful resources. However, there is a lack of benchmark data to reliably assess outcomes after reLT. The aim of this study was to define the ideal reLT case, and to establish clinically relevant benchmark values for best achievable outcome in reLT.
Methods
We collected data on reLT between January 2010 and December 2018 from 22 high volume transplant centers on three continents. Benchmark cases were defined as recipients with model of end-stage liver disease score <=25, absence of portal vein thrombosis, no mechanical ventilation before surgery, receiving a graft from a donor after brain death. In addition, early reLT including those for primary non-function (PNF) were excluded. Clinically relevant endpoints covering intra- and postoperative course were selected and complications were graded by severity using the Clavien-Dindo classification and the comprehensive complication index (CCI). The benchmark cutoff for each outcome was derived from the 75th percentile of the median values of all benchmark centers, indicating the “best achievable” result. To assess the utility of the newly established benchmark values, we analyzed patients who received reLT for PNF (non-benchmark patients).
Results
Out of 1110 reLT 413 (37.2%) qualified as benchmark cases. Benchmark values included: Length of intensive care unit and hospital stay: <=6 and <=24 days, respectively; Clavien-Dindo grade >=3a complications and the CCI at 1 year: <=76% and <=72.2, respectively; in-hospital and 1-year mortality rates: <=14.0% and <=14.3%, respectively. The cutoffs for transplant-specific complications such as biliary complications at 1 year, outflow problems at 1 year and hepatic artery thrombosis at discharge were <=27.3%, <=2.5% and <=4.8%, respectively. Patients receiving a reLT for PNF showed mean outcome values all outside the reLT benchmark values. In-hospital mortality rate was 34.4% and the mean CCI at discharge 68.8.
Conclusion
ReLT remains associated with high morbidity and mortality. The availability of benchmark values for outcome parameters of reLT may serve for comparison in any future analyses of individuals, patient groups, or centers, but also in the evaluation of new therapeutic strategies and principles.
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Affiliation(s)
- F Abbassi
- Department of Surgery and Transplantation, University Hospital Zurich , Zurich, Switzerland
| | - D Gero
- Department of Surgery and Transplantation, University Hospital Zurich , Zurich, Switzerland
| | - X Muller
- Department of General, Abdominal and Transplant Surgery, Croix-Rousse Hospital , Lyon, France
| | - A Bueno
- Department of Liver Studies, Kings’ College Hospital , London, United Kingdom
| | - W Figiel
- Department of General, Abdominal and Transplant Surgery, Medical University of Warsaw , Warsaw, Poland
| | - F Robin
- Department of HPB Surgery and Transplantation, University Hospital Rennes , Rennes, France
| | - S Laroche
- Department of Surgery and Transplanation at the HPB Center, Paul Brousse Hospital , Villejuif, France
| | - B Picard
- Department of Anesthesiology and Critical Care, Beaujon Teaching Hospital , Clinchy, France
| | - S Shankar
- Department of Abdominal Transplant and Hepatobiliary Surgery, The Leeds Teaching Hospital trust , Leeds, United Kingdom
| | - T Ivanics
- University Health Network Toronto Multi-Organ Transplant Program, , Toronto, Canada
| | - M van Reeven
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - O B van Leeuwen
- Division of HPB Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen , Groningen, The Netherlands
| | - H J Braun
- Division of Transplant Surgery, University of California , San Francisco, USA
| | - D Monbaliu
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven , Leuven, Belgium
| | - A Breton
- Department of General, Abdominal and Transplant Surgery, Croix-Rousse Hospital , Lyon, France
| | - N Vachharajani
- Department of Surgery, Division of Abdominal Transplantation, Washington University in St. Louis School of Medicine , St. Louis, USA
| | - E Bonaccorsi Riani
- Department of Abdominal and Transplant Surgery, University Hospital St. Luc , Brussels, Belgium
| | - G Nowak
- Department of Transplantation Surgery, Karolinska University Hospital Huddinge , Stockholm, Sweden
| | - R R McMillan
- Weill Cornell Medical Center, Houston Methodist Hospital , Houston, USA
| | - S Abu-Gazala
- Department of Surgery, Penn Transplant Institute, Hospital of the University of Pennsylvania , Philadelphia, USA
| | - A Nair
- Division of Transplantation and Hepatobiliary Surgery, University of Rochester , Rochester, USA
| | - R Bruballa
- Hospital Italiano de Buenos Aires HPB and Liver Transplant Unit, , Buenos Aires, Brazil
| | - F Paterno
- Division of Liver Transplant, Rutgers New Jersey Medical School University Hospital , Newark, USA
| | - D Weppler Sears
- Department of Abdominal and Transplant Surgery , Cleveland Clinic Florida, Weston, USA
| | - A D Pinna
- Department of Abdominal and Transplant Surgery , Cleveland Clinic Florida, Weston, USA
| | - J V Guarrera
- Division of Liver Transplant, Rutgers New Jersey Medical School University Hospital , Newark, USA
| | - E de Santibañes
- Hospital Italiano de Buenos Aires HPB and Liver Transplant Unit, , Buenos Aires, Brazil
| | - M de Santibañes
- Hospital Italiano de Buenos Aires HPB and Liver Transplant Unit, , Buenos Aires, Brazil
| | - R Hernandez-Aleja
- Division of Transplantation and Hepatobiliary Surgery, University of Rochester , Rochester, USA
| | - K Olthoff
- Department of Surgery, Penn Transplant Institute, Hospital of the University of Pennsylvania , Philadelphia, USA
| | - R M Ghobrial
- Weill Cornell Medical Center, Houston Methodist Hospital , Houston, USA
| | - B-G Ericzon
- Department of Transplantation Surgery, Karolinska University Hospital Huddinge , Stockholm, Sweden
| | - O Ciccarelli
- Department of Abdominal and Transplant Surgery, University Hospital St. Luc , Brussels, Belgium
| | - W C Chapman
- Department of Surgery, Division of Abdominal Transplantation, Washington University in St. Louis School of Medicine , St. Louis, USA
| | - J-Y Mabrut
- Department of General, Abdominal and Transplant Surgery, Croix-Rousse Hospital , Lyon, France
| | - J Pirenne
- Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven , Leuven, Belgium
| | - B Müllhaupt
- Department of Gastroenterology and Hepatology, University Hospital Zurich , Zurich, Switzerland
| | - N L Ascher
- Division of Transplant Surgery, University of California , San Francisco, USA
| | - R J Porte
- Division of HPB Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen , Groningen, The Netherlands
| | - V E de Meier
- Division of HPB Surgery and Liver Transplantation, University of Groningen and University Medical Center Groningen , Groningen, The Netherlands
| | - W G Polak
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC Transplant Institute, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - G Sapisochin
- University Health Network Toronto Multi-Organ Transplant Program, , Toronto, Canada
| | - M Attia
- Department of Abdominal Transplant and Hepatobiliary Surgery, The Leeds Teaching Hospital trust , Leeds, United Kingdom
| | - E Weiss
- Department of Anesthesiology and Critical Care, Beaujon Teaching Hospital , Clinchy, France
| | - R A Adam
- Department of Surgery and Transplanation at the HPB Center, Paul Brousse Hospital , Villejuif, France
| | - D Cherqui
- Department of Surgery and Transplanation at the HPB Center, Paul Brousse Hospital , Villejuif, France
| | - K Boudjema
- Department of HPB Surgery and Transplantation, University Hospital Rennes , Rennes, France
| | - K Zienewicz
- Department of General, Abdominal and Transplant Surgery, Medical University of Warsaw , Warsaw, Poland
| | - W Jassem
- Department of Liver Studies, Kings’ College Hospital , London, United Kingdom
| | - M Puhan
- Department of Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University Hospital Zurich , Zurich, Switzerland
| | - P Dutkowski
- Department of Surgery and Transplantation, University Hospital Zurich , Zurich, Switzerland
| | - P-A Clavien
- Department of Surgery and Transplantation, University Hospital Zurich , Zurich, Switzerland
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Pruett TL, Vathsala A, Berney T, Lerut J, Odorico JS, Johnson M, Egawa H, Gonzalez-Martinez F, Haberal M, Ascher NL, Chandraker AK. Criminal Organ Retrieval: Unconscionable. Am J Transplant 2017; 17:577. [PMID: 27696661 DOI: 10.1111/ajt.14028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Roland ME, Barin B, Carlson L, Frassetto LA, Terrault NA, Hirose R, Freise CE, Benet LZ, Ascher NL, Roberts JP, Murphy B, Keller MJ, Olthoff KM, Blumberg EA, Brayman KL, Bartlett ST, Davis CE, McCune JM, Bredt BM, Stablein DM, Stock PG. HIV-infected liver and kidney transplant recipients: 1- and 3-year outcomes. Am J Transplant 2008; 8:355-65. [PMID: 18093266 DOI: 10.1111/j.1600-6143.2007.02061.x] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Improvements in human immunodeficiency virus (HIV)-associated mortality make it difficult to deny transplantation based upon futility. Outcomes in the current management era are unknown. This is a prospective series of liver or kidney transplant recipients with stable HIV disease. Eleven liver and 18 kidney transplant recipients were followed for a median of 3.4 years (IQR [interquartile range] 2.9-4.9). One- and 3-year liver recipients' survival was 91% and 64%, respectively; kidney recipients' survival was 94%. One- and 3-year liver graft survival was 82% and 64%, respectively; kidney graft survival was 83%. Kidney patient and graft survival were similar to the general transplant population, while liver survival was similar to the older population, based on 1999-2004 transplants in the national database. CD4+ T-cell counts and HIV RNA levels were stable; and there were two opportunistic infections (OI). The 1- and 3-year cumulative incidence (95% confidence intervals [CI]) of rejection episodes for kidney recipients was 52% (28-75%) and 70% (48-92%), respectively. Two-thirds of hepatitis C virus (HCV)-infected patients, but no patient with hepatitis B virus (HBV) infection, recurred. Good transplant and HIV-related outcomes among kidney transplant recipients, and reasonable outcomes among liver recipients suggest that transplantation is an option for selected HIV-infected patients cared for at centers with adequate expertise.
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Affiliation(s)
- M E Roland
- University of California, San Francisco, CA, USA.
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Yao FY, Xiao L, Bass NM, Kerlan R, Ascher NL, Roberts JP. Liver transplantation for hepatocellular carcinoma: validation of the UCSF-expanded criteria based on preoperative imaging. Am J Transplant 2007; 7:2587-96. [PMID: 17868066 DOI: 10.1111/j.1600-6143.2007.01965.x] [Citation(s) in RCA: 399] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We previously suggested that in patients with heptocellular carcinoma (HCC), the conventional Milan criteria (T1/T2) for orthotopic liver transplantation (OLT) could be modestly expanded based on pathology (UCSF criteria). The present study was undertaken to prospectively validate the UCSF criteria based on pretransplant imaging. Over a 5-year period, the UCSF criteria were used as selection guidelines for OLT in 168 patients, including 38 patients exceeding Milan but meeting UCSF criteria (T3A). The 1- and 5-year recurrence-free probabilities were 95.9% and 90.9%, and the respective survivals without recurrence were 92.1% and 80.7%. Patients with preoperative T1/T2 HCC had 1- and 5-year recurrence-free probabilities of 95.7% and 90.1%, respectively, versus 96.9% and 93.6%, respectively, for preoperative T3A stage (p = 0.58). Under-staging was observed in 20% of T2 and 29% of T3A HCC (p = 0.26). When explant tumor exceeded UCSF criteria (15%), the 1- and 5-year recurrence-free probabilities were 80.4% and 59.5%, versus 98.6% and 96.7%, respectively, for those within UCSF criteria (p < 0.0001). In conclusion, our results validated the ability of the UCSF criteria to discriminate prognosis after OLT and to serve as selection criteria for OLT, with a similar risk of tumor recurrence and under-staging when compared to the Milan criteria.
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Affiliation(s)
- F Y Yao
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
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5
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Krasnoff JB, Vintro AQ, Ascher NL, Bass NM, Paul SM, Dodd MJ, Painter PL. A randomized trial of exercise and dietary counseling after liver transplantation. Am J Transplant 2006; 6:1896-905. [PMID: 16889545 DOI: 10.1111/j.1600-6143.2006.01391.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report results of a randomized clinical trial of a combined intervention of exercise and dietary counseling (ExD) after orthotopic liver transplantation (OLT). Of the 151 patients randomized into ExD or usual care (UC), 119 completed testing 2, 6 and 12 months post-OLT. Testing included assessment of exercise capacity (VO(2peak)), quadricep muscle strength, body composition (DXA), nutritional intake (Block 95) and health-related quality of life (SF-36). The intervention consisted of individualized counseling and follow-up to home-based exercise and dietary modification. Repeated measure ANOVA was performed to determine differences over time between ExD and UC with a secondary analysis to determine differences over time between adherers (Adh), nonadherers (Nadh) to the intervention and UC. The ExD group showed greater increases in VO(2peak) (p = 0.036), and self-reported general health (p = 0.038) compared to UC. Both groups demonstrated increases in muscle strength, body weight, body fat and other SF-36 scale scores. Adherence to the intervention was 37% with positive trends in VO(2peak) and body composition observed in Adh compared to Nadh and UC. These data suggest improvements in exercise capacity and body composition are achieved with nutrition and exercise behavior modifications initiated early after OLT and with regular follow-up.
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Affiliation(s)
- J B Krasnoff
- Department of Physiological Nursing, University of California, San Francisco, USA.
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6
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Bernat JL, D'Alessandro AM, Port FK, Bleck TP, Heard SO, Medina J, Rosenbaum SH, Devita MA, Gaston RS, Merion RM, Barr ML, Marks WH, Nathan H, O'connor K, Rudow DL, Leichtman AB, Schwab P, Ascher NL, Metzger RA, Mc Bride V, Graham W, Wagner D, Warren J, Delmonico FL. Report of a National Conference on Donation after cardiac death. Am J Transplant 2006; 6:281-91. [PMID: 16426312 DOI: 10.1111/j.1600-6143.2005.01194.x] [Citation(s) in RCA: 356] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.
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8
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Ascher NL. Analysis of research projects in living donor organ transplantation. Transplant Proc 2003; 35:907-8. [PMID: 12947794 DOI: 10.1016/s0041-1345(03)00158-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- N L Ascher
- University of California, UCSF, Department of Surgery, 505 Parnassus Avenue, M896, San Francisco, CA 94143-2722, USA
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Abstract
The aim of this retrospective analysis was to evaluate the growth of 96 pediatric liver transplant recipients from February 1988 to June 1999. Inclusion criteria were the following: age younger than 18 years, follow-up longer than 1 year, transplantation for a nontumor indication, and no retransplantation. Linear height and growth velocity SD scores were correlated to age, sex, indication for transplantation, immunosuppression, and graft type. Transplant recipients of all ages and indications and both sexes were growth retarded at transplantation. Recipients aged younger than 24 months showed growth within the first year to achieve a height distribution equal to that of an age-matched population. Posttransplantation growth inversely correlated with height standard score at transplantation. Children older than 2 years at transplantation established new growth curves, but remained growth retarded. As children approached the prepubertal growth acceleration, growth deficits frequently were erased. Transplant recipients with biliary atresia and alpha(1)-antitrypsin deficiency showed increased growth performance compared with those who underwent transplantation for chronic hepatitis or fulminant hepatic failure. Boys were less growth retarded at transplantation and showed improved posttransplantation growth performance versus girls. No correlation to immunosuppression or graft type was identified. We conclude that early transplantation of children who show growth retardation is optimal for restoration of growth potential, whereas delaying transplantation in older children impedes potential growth.
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Affiliation(s)
- J F Renz
- Department of Surgery, University of California, San Francisco, USA.
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Foster RD, Ascher NL, McCalmont TH, Neipp M, Anthony JP, Mathes SJ. Mixed allogeneic chimerism as a reliable model for composite tissue allograft tolerance induction across major and minor histocompatibility barriers. Transplantation 2001; 72:791-7. [PMID: 11571439 DOI: 10.1097/00007890-200109150-00009] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although prolonged composite tissue allograft (CTA) survival is achievable in animals using immunosuppressive drugs, long-term immunosuppression of CTAs in the clinical setting may be unacceptable for most patients. The purpose of this study was to develop a model for reliable CTA tolerance induction in the adult rat across a major MHC mismatch without the need for long-term immunosuppression. METHODS Mixed allogeneic chimeras were prepared by using rat strains with strong MHC incompatibility [WF (RT1Au), ACI (RT1Aa)] WF + ACI-->WF, n=23. The bone marrow (BM) of recipient animals was pretreated with low-dose irradiation (500-700 cGy), followed by reconstitution with a mixture of T cell-depleted syngeneic (WF) and allogeneic (ACI) cells. Additionally, the recipient animals received a single dose of anti-lymphocyte serum (10 mg) 5 days before bone marrow transplantation (BMT) and tacrolimus (1 mg/kg/day) from the day before BMT to 10 days post-BMT. Hindlimb transplants were performed 12 months after BMT. Five animals received a limb allograft irradiated (1000 cGy) just before transplantation. Rat chimeras were characterized (percentage of donor cells present within the bloodstream) by flow cytometry at 3 and 12 months after BM reconstitution and after hindlimb transplantation. RESULTS Peripheral blood lymphocyte chimerism (WF/ACI) remained stable >12 months after BM reconstitution in 18/23 animals. Multi-lineage chimerism of both lymphoid and myeloid lineages was present, suggesting that engraftment of the pluripotent rat stem cell had occurred. In animals with donor chimerism >60% (n=18) no sign of limb rejection was present for the duration of the study. All animals with chimerism <20% (n=5) developed moderate signs of rejection clinically and histologically. Gross motor and sensory reinnervation (weight bearing, toe spread) developed at >60 days in 14/21 rats. Postoperative flow cytometry studies demonstrated stable chimerism in all animals studied (n=10). Five out of five animals with irradiated limb transplants showed no sign of GVHD at >100 days. CONCLUSIONS Stable mixed allogeneic chimerism can be achieved in a rat hindlimb model of composite tissue allotransplantation. Hindlimb allografts to mixed allogeneic chimeras exhibit prolonged, rejection-free survival. Partial functional return should be expected. The BM transplanted as part of the hindlimb allograft plays a role in the etiology of GVHD. Manipulating that BM before transplantation may influence the incidence of GVHD. This represents the first reliable rat hindlimb model demonstrating rejection-free CTA survival in an adult animal across a major MHC mismatch without the long-term need for immunosuppressive agents.
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Affiliation(s)
- R D Foster
- University of California, San Francisco, Division of Plastic and Reconstructive Surgery, 533 Parnassus Avenue, U-147, San Francisco, CA 94143-0718, USA.
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11
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Yao FY, Ferrell L, Bass NM, Watson JJ, Bacchetti P, Venook A, Ascher NL, Roberts JP. Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival. Hepatology 2001; 33:1394-403. [PMID: 11391528 DOI: 10.1053/jhep.2001.24563] [Citation(s) in RCA: 1588] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
The precise staging of hepatocellular carcinoma (HCC) based on the size and number of lesions that predict recurrence after orthotopic liver transplantation (OLT) has not been clearly established. We therefore analyzed the outcome of 70 consecutive patients with cirrhosis and HCC who underwent OLT over a 12-year period at our institution. Pathologic tumor staging of the explanted liver was based on the American Tumor Study Group modified Tumor-Node-Metastases (TNM) Staging Classification. Tumor recurrence occurred in 11.4% of patients after OLT. The Kaplan-Meier survival rates at 1 and 5 years were 91.3% and 72.4%, respectively, for patients with pT1 or pT2 HCC; and 82.4% and 74.1%, respectively, for pT3 tumors (P =.87). Patients with pT4 tumors, however, had a significantly worse 1-year survival of 33.3% (P =.0001). An alpha-fetoprotein (AFP) level > 1,000 ng/mL, total tumor diameter > 8 cm, age > or = 55 years and poorly differentiated histologic grade were also significant predictors for reduced survival in univariate analysis. Only pT4 stage and total tumor diameter remained statistically significant in multivariate analysis. Patients with HCC meeting the following criteria: solitary tumor < or = 6.5 cm, or < or = 3 nodules with the largest lesion < or = 4.5 cm and total tumor diameter < or = 8 cm, had survival rates of 90% and 75.2%, at 1 and 5 years, respectively, after OLT versus a 50% 1-year survival for patients with tumors exceeding these limits (P =.0005). We conclude that the current criteria for OLT based on tumor size may be modestly expanded while still preserving excellent survival after OLT.
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Affiliation(s)
- F Y Yao
- Department of Medicine, University of California, San Francisco 94143-0538, USA.
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12
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Abstract
The US Surgeon General's Report on Physical Activity and Health recommends that people of all ages engage in regular physical activity, and that significant health benefits can be obtained through a moderate amount of physical activity. Physical activity appears to improve health-related quality of life (HRQOL) by enhancing physical functioning in persons compromised by poor health. The Medical Outcomes Study Short Form-36 (SF-36) Health Status Questionnaire was sent to all patients who were 5 years or more post-liver transplantation at the University of California at San Francisco. Additional questions related to coexisting medical conditions and participation in regular physical activity were included. SF-36 scale scores were compared between active and inactive patients. Regression analysis was also performed to determine the contributions of coexisting medical conditions and physical activity to the physical scales of the SF-36 questionnaire. Patients who participated in regular physical activity had significantly higher scores on all physical scales and the physical component scale (PCS). The regression model, which included age, sex, time posttransplantation, retransplantation, recurrence of hepatitis C, number of comorbid conditions, and physical activity participation showed that both the number of comorbid conditions and participation in physical activity were significant independent contributors to the physical functioning scale and PCS. This study indicates that physical activity is related to HRQOL after liver transplantation independent of other coexisting medical conditions.
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Affiliation(s)
- P Painter
- Department of Physiological Nursing, Box 0610, University of California at San Francisco, San Francisco, CA 94143, USA.
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13
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Koh BY, Rosenthal P, Medeiros LJ, Osorio RW, Roberts JP, Ascher NL, Gelb AB. Posttransplantation lymphoproliferative disorders in pediatric patients undergoing liver transplantation. Arch Pathol Lab Med 2001; 125:337-43. [PMID: 11231479 DOI: 10.5858/2001-125-0337-pldipp] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To study the clinicopathologic and molecular genetic findings in posttransplantation lymphoproliferative disorders (PTLDs) following pediatric liver transplantation and to determine the applicability of a recently proposed consensus classification system. DESIGN The clinical, pathologic, and molecular genetic findings of 11 PTLDs that occurred in 10 patients are presented. These 10 patients were derived from a group of 121 pediatric patients who underwent liver transplantation at the University of California, San Francisco. The PTLDs were classified using the proposed Society for Hematopathology scheme. Clonality was determined by immunohistochemical detection of monotypic immunoglobulin or by using polymerase chain reaction-based methods to detect monoclonal immunoglobulin heavy-chain gene rearrangements. Epstein-Barr virus (EBV) was detected by immunohistochemistry, in situ hybridization, or polymerase chain reaction. Epstein-Barr virus typing and the presence of LMP1 gene deletions were also analyzed by polymerase chain reaction. RESULTS There were 3 early lesions, 4 polymorphic PTLDs, and 4 monomorphic PTLDs. Monoclonality was demonstrated in 8 of 9 cases assessed. Epstein-Barr virus was present in all cases; of 9 cases assessed by polymerase chain reaction, the virus was type A in 8 and type B in 1. No EBV LMP1 gene deletions were identified. The corresponding liver explants were negative for EBV in 8 cases and positive in 1 case. Greater than 3 foci of disease and monomorphic PTLD were associated with decreased actuarial survival (P <.05). CONCLUSIONS The prognosis of pediatric patients with PTLD is favorable for early lesions and polymorphous PTLD, particularly in patients with localized disease. Multifocal disease and monomorphic PTLD are associated with an unfavorable prognosis.
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14
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Affiliation(s)
- N L Ascher
- Department of Surgery, University of California, San Francisco 94143, USA.
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15
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Chang GJ, Mahanty HD, Vincenti F, Freise CE, Roberts JP, Ascher NL, Stock PG, Hirose R. A calcineurin inhibitor-sparing regimen with sirolimus, mycophenolate mofetil, and anti-CD25 mAb provides effective immunosuppression in kidney transplant recipients with delayed or impaired graft function. Clin Transplant 2000; 14:550-4. [PMID: 11127307 DOI: 10.1034/j.1399-0012.2000.140606.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Delayed graft function (DGF) after renal transplantation is a significant risk factor for early acute rejection and graft loss. Sirolimus (SRL) can be administered in the setting of DGF without exacerbating the impaired renal function after transplantation. We examined a calcineurin-sparing regimen using SRL during the early post-operative period in renal transplant patients with delayed or impaired graft function. A retrospective review of 14 consecutive kidney transplant recipients with delayed or impaired graft function who received SRL was performed. The immunosuppressive regimen consisted of daclizumab induction (2 mg/kg), SRL (5-15 mg load followed by 2 5 mg daily maintenance therapy), corticosteroids, and mycophenolate mofetil (MMF, 1.5-3 g/d). Patients were monitored for allograft function, acute rejection, graft survival, thrombocytopenia, and leukopenia. Serum levels of SRL were determined by high-performance liquid chromatography performed at an independent commercial laboratory. Donors were cadaveric in 13 cases and living related in one. The duration of follow-up was 0.5-5.2 months. Nine patients required hemodialysis after transplantation. The mean time to initiation of calcineurin inhibitors was 21 +/- 13 d. Average serum creatinine levels at the initiation of SRL and at 1 month after transplantation were 8.4 +/- 2.7 and 2.1 +/- 1.2 mg/dL, respectively. There were 2 patients (14%) who experienced acute rejection within the first month after transplantation -1 with type I (steroid therapy) and 1 with type II (anti-thymocyte therapy). Serum levels of SRL were initially undetectable in the 2 patients with acute rejection. No grafts were lost during the period of follow-up. Three patients developed thrombocytopenia (platelets < 100 x 10(9)) and no patients developed leukopenia. The combination of SRL with anti-CD25 mAb, MMF, and corticosteroids appears to provide effective non-nephrotoxic immunosuppression for kidney transplantation without the need for a lymphocyte-depleting regimen. However, it is important to monitor serum SRL levels to determine the optimal dosing regimen. Furthermore, long-term follow-up of these patients will be helpful to determine whether improved immunosuppression can be achieved with a fully calcineurin-sparing regimen using SRL.
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Affiliation(s)
- G J Chang
- Department of Surgery, University of California, San Francisco 94143-0780, USA
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16
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Reichert PR, Renz JF, D'Albuquerque LA, Rosenthal P, Lim RC, Roberts JP, Ascher NL, Emond JC. Surgical anatomy of the left lateral segment as applied to living-donor and split-liver transplantation: a clinicopathologic study. Ann Surg 2000; 232:658-64. [PMID: 11066137 PMCID: PMC1421220 DOI: 10.1097/00000658-200011000-00007] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate intrahepatic vascular and biliary anatomy of the left lateral segment (LLS) as applied to living-donor and split-liver transplantation. SUMMARY BACKGROUND DATA Living-donor and split-liver transplantation are innovative surgical techniques that have expanded the donor pool. Fundamental to the application of these techniques is an understanding of intrahepatic vascular and biliary anatomy. METHODS Pathologic data obtained from cadaveric liver corrosion casts and liver dissections were clinically correlated with the anatomical findings obtained during split-liver, living-donor, and reduced-liver transplants. RESULTS The anatomical relation of the left bile duct system with respect to the left portal venous system was constant, with the left bile duct superior to the extrahepatic transverse portion of the left portal vein. Four specific patterns of left biliary anatomy and three patterns of left hepatic venous drainage were identified and described. CONCLUSIONS Although highly variable, the biliary and hepatic venous anatomy of the LLS can be broadly categorized into distinct patterns. The identification of the LLS duct origin lateral to the umbilical fissure in segment 4 in 50% of cast specimens is significant in the performance of split-liver and living-donor transplantation, because dissection of the graft pedicle at the level of the round ligament will result in separate ducts from segments 2 and 3 in most patients, with the further possibility of an anterior segment 4 duct. A connective tissue bile duct plate, which can be clinically identified, is described to guide dissection of the segment 2 and 3 biliary radicles.
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Affiliation(s)
- P R Reichert
- Department of Anatomy, Universidade de Passo Fundo, and the Disciplina de Cirurgia do Aparelho Digestivo da Universidade de São Paulo, São Paulo, Brazil
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17
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Chang GJ, Mahanty HD, Quan D, Freise CE, Ascher NL, Roberts JP, Stock PG, Hirose R. Experience with the use of sirolimus in liver transplantation--use in patients for whom calcineurin inhibitors are contraindicated. Liver Transpl 2000; 6:734-40. [PMID: 11084060 DOI: 10.1053/jlts.2000.19023] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Sirolimus (SRL) provides effective immunosuppression for kidney transplantation and may be useful in patients with delayed allograft function after kidney transplantation. We review our experience with SRL in liver transplant recipients for whom calcineurin inhibitors are undesirable. Fourteen patients with renal insufficiency or acute mental status impairment were administered SRL after liver transplantation (5- to 10-mg load, 1 to 4 mg/d). Immunosuppression also consisted of mycophenolate mofetil and corticosteroids. On resolution of neurological or renal dysfunction (return to baseline mental status or serum creatinine level), tacrolimus (TAC) therapy was initiated. Twelve patients received primary transplants, 1 patient received a combined liver-kidney transplant, and 1 patient received a third transplant. Follow-up was 2 to 7 months. Calcineurin inhibitors were initially withheld in 9 patients, and therapy was aborted because of toxicity in the remaining 5 patients. Mean times to the initiation of SRL and TAC therapy were 5.4 +/- 4.6 and 26.8 +/- 24.4 days, respectively. Serum trough levels of SRL did not correlate with dose or other patient variables. Two patients died after prolonged pretransplantation hospital courses in the intensive care unit. Six patients experienced acute rejection, but only 1 patient required antilymphocyte therapy. Serum creatinine levels at the start of SRL therapy were 2.2 +/- 1.1 and 1.2 +/- 0.6 mg/dL at 3 months. All 3 patients with neurological indications for SRL had a return to their baseline mental status. All patients had improved liver function chemistry test results and prothrombin times. No patients developed leukopenia or thrombocytopenia. SRL is safe after liver transplantation in patients with acute neurological or renal impairment. SRL is an attractive alternative when calcineurin inhibitors are undesirable, but serum trough levels of SRL should be monitored. A prospective randomized study of an SRL-based calcineurin inhibitor-avoiding regimen compared with standard therapy in patients with renal insufficiency will further evaluate the role for SRL in liver transplantation.
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Affiliation(s)
- G J Chang
- Department of Surgery, Division of Transplantation, University of California, San Francisco, CA 94143-0780, USA
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18
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Lee CM, Carter JT, Alfrey EJ, Ascher NL, Roberts JP, Freise CE. Prolonged cold ischemia time obviates the benefits of 0 HLA mismatches in renal transplantation. Arch Surg 2000; 135:1016-9; discussion 1019-20. [PMID: 10982503 DOI: 10.1001/archsurg.135.9.1016] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS Recipients of 0 HLA mismatch kidneys with prolonged cold ischemia times of longer than 36 hours do not have superior outcomes compared with recipients of kidneys with 1 or more mismatches. DESIGN Retrospective review. SETTING Transplanation centers. PATIENTS AND METHODS A total of 63,688 recipients who underwent transplantation between January 1, 1990, and July 31, 1998. MAIN OUTCOME MEASURES Delayed graft function, serum creatinine level, and patient and renal graft survival. RESULTS Recipients of 0 HLA mismatch kidneys with fewer than 36 hours of cold ischemia time had better 5-year graft survival (75%) when compared with recipients with 1 or more mismatches (67%) (P<.001). However, recipients of 0 HLA mismatch kidneys with longer than 36 hours of cold ischemia time did not have any graft survival advantage (71% in 0 HLA mismatch kidneys vs 72% in 1 or more mismatches, P =.24). CONCLUSIONS Cold ischemia times of longer than 36 hours obviate the benefits of better graft survival conferred by better matching.
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Affiliation(s)
- C M Lee
- Division of Transplantation, Department of Surgery, Box 0780, University of California-San Francisco, 513 Parnasus Ave, San Francisco, CA 94143-0780, USA.
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19
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Kang SM, Braat D, Schneider DB, O'Rourke RW, Lin Z, Ascher NL, Dichek DA, Baekkeskov S, Stock PG. A non-cleavable mutant of Fas ligand does not prevent neutrophilic destruction of islet transplants. Transplantation 2000; 69:1813-7. [PMID: 10830216 DOI: 10.1097/00007890-200005150-00014] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fas ligand (FasL) mediates apoptosis of susceptible Fas-expressing lymphocytes, and may contribute to the maintenance of peripheral tolerance. In transplantation models, however, artificial expression of FasL on cellular as well as islet transplants results in accelerated rejection by neutrophils. The mechanism of the neutrophilic response to FasL expression is unknown. FasL, like other members of the tumor necrosis factor family, is cleaved to a soluble form by metalloproteases. We tested the hypothesis that soluble FasL (sFasL) was responsible for neutrophil migration by creating a non-cleavable mutant of FasL. METHODS Three mutants of FasL with serial deletions in the putative proteolytic cleavage site of human FasL were made using inverse polymerase chain reaction. The relative fractions of sFasL and membrane-bound FasL were assessed by Western blot and immunoprecipitation, as well as by cytotoxicity assay using Fas-expressing target cells. The fully non-cleavable mutant was transduced into murine islets as well as myoblasts and tumor cell lines, and tested in a murine transplantation model. RESULTS Serial deletions in the putative metalloprotease site of FasL resulted in a fully non-cleavable mutant of FasL (ncFasL). Expression of ncFasL in tumor lines induced higher levels of apoptosis in Fas bearing targets than wild-type FasL. Transplantation of ncFasL-expressing islets under the kidney capsule of allogenic mice resulted in accelerated rejection identical to that seen with wild-type Fas ligand-expressing islets. Myoblasts and tumor cell lines expressing ncFasL also induced neutrophil infiltration. CONCLUSIONS Membrane-bound Fas ligand is fully capable of inducing a neutrophilic response to transplants, suggesting an activation by Fas ligand of neutrophil chemotactic factors.
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Affiliation(s)
- S M Kang
- Department of Surgery, Hormone Research Institute, and University of California, San Francisco 94143, USA
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20
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O'Rourke RW, Kang SM, Lower JA, Feng S, Ascher NL, Baekkeskov S, Stock PG. A dendritic cell line genetically modified to express CTLA4-IG as a means to prolong islet allograft survival. Transplantation 2000; 69:1440-6. [PMID: 10798768 DOI: 10.1097/00007890-200004150-00039] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dendritic cells are potent antigen-presenting cells that bind allogeneic T cells. They are thus candidates for targeting immunoregulatory molecules to the alloreactive T cell compartment and suppressing the alloimmune response. METHOD A dendritic cell line derived from the BALB/c mouse (H2d) was genetically modified to express the immunoregulatory molecule CTLA4-Ig. The ability of these dendritic cell transfectants to downregulate the alloimmune response was tested in an islet transplant model. Allogeneic C57Bl/6 (H2b) mice were rendered diabetic with streptozocin, and they received BALB/c islet (H2d) transplants. Mice were administered 25 million untransfected or CTLA4-Ig-transfected D2SC/1 cells i.v. on the day of islet transplantation and 6 days later[fnc]. RESULT Mice treated with CTLA4-Ig-transfected D2SC/1 cells demonstrated prolonged allograft survival (mean = 20 days, median = 17 days, SD = 9.39) compared with mice treated with untransfected D2SC/1 cells (mean = 12 days, median = 11 days, SD=2.74) or untreated control mice (mean = 11 days, median = 11 days SD = 1.41). Third party allograft survival was not prolonged in mice receiving similar treatment. CONCLUSIONS These results demonstrate that a genetically modified dendritic cell line can suppress the alloimmune response and prolong islet allograft survival in an allospecific manner. The findings also suggest that genetically modified dendritic cells may be useful in targeting alloreactive T cells and prolonging allograft survival.
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Affiliation(s)
- R W O'Rourke
- Transplantation Laboratory, and Hormone Research Institute, University of California, San Francisco 94143-0780, USA
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21
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O'Rourke RW, Osorio RW, Freise CE, Lou CD, Garovoy MR, Bacchetti P, Ascher NL, Melzer JS, Roberts JP, Stock PG. Flow cytometry crossmatching as a predictor of acute rejection in sensitized recipients of cadaveric renal transplants. Clin Transplant 2000; 14:167-73. [PMID: 10770424 DOI: 10.1034/j.1399-0012.2000.140212.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Flow cytometry crossmatching (FCXM) was developed as a more sensitive assay than the standard complement-dependent cytotoxicity crossmatch (CDCXM) for the detection of anti-donor antibodies, that mediate hyperacute rejection and graft loss in the early post-transplant period in renal transplant recipients. The role of FCXM in predicting long-term clinical outcome in renal allograft recipients is unclear. This study examines the role of FCXM in predicting long-term clinical outcome in highly sensitized recipients of cadaveric renal transplants. All patients (n = 100) with peak panel reactive antibody (PRA) levels > 30%, who received cadaveric renal transplants between 1/1/'90 and 12/31/'95 at our institution, were divided into FCXM + and FCXM - groups. The incidence of acute rejection was determined for each group during the first yr after transplant. Graft survival rates at 1, 2, and 3 yr, and creatinine levels were also compared between groups. FCXM + patients experienced a higher incidence of acute rejection during the first yr after transplant (69 vs. 45%), and a higher percentage of FCXM + patients had more than one episode of acute rejection during the first yr after transplant (34 vs. 8%) when compared to FCXM - patients. There was no statistically significant difference in 1-, 2-, or 3-yr graft survival between FCXM + and FCXM - patients (76 vs. 83, 62 vs. 80, 62 vs. 72%, respectively). These results suggest that sensitized FCXM + cadaveric renal transplant recipients have a higher incidence of acute rejection episodes in the first yr after transplant. Given the association of multiple rejection episodes with poor long-term allograft survival, FCXM may be a useful predictor of long-term clinical outcome in this sub-group of renal transplant recipients.
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Affiliation(s)
- R W O'Rourke
- Department of Transplantation Surgery, University of California, San Francisco 94143, USA
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22
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Hirose R, Roberts JP, Quan D, Osorio RW, Freise C, Ascher NL, Stock PG. Experience with daclizumab in liver transplantation: renal transplant dosing without calcineurin inhibitors is insufficient to prevent acute rejection in liver transplantation. Transplantation 2000; 69:307-11. [PMID: 10670644 DOI: 10.1097/00007890-200001270-00019] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Daclizumab is a monoclonal antibody directed against the alpha chain of the interleukin 2 receptor. We review our experience with the use of daclizumab in liver transplant recipients. METHODS Thirty-two patients were given daclizumab as induction therapy in the setting of hepatic transplantation. Seven of these patients were enrolled in a pilot study to determine the efficacy of daclizumab in conjunction with corticosteroids and mycophenolate mofetil without the initial use of calcineurin inhibitors (CI). The remaining 25 patients received daclizumab, mycophenolate mofetil, and steroids, with the institution of CI generally within the first postoperative week. The majority of these patients (n = 17) had some degree of renal insufficiency. RESULTS The pilot study was halted after the first seven patients were enrolled because of an unacceptably high rate of rejection (7/7 = 100%). The patients outside of this pilot study, however, had a much lower rate of rejection (36%). The incidence and severity of rejection correlated with the delay in institution of CI. The described dosing schedule resulted in subtherapeutic daclizumab levels in liver transplant recipients. CONCLUSIONS Daclizumab used in liver transplant recipients without any CI was ineffective and can potentially lead to steroid-resistant rejection. The dosing regimen used in renal transplant recipients is most likely insufficient for liver transplant patients. However, daclizumab can be used safely in patients with preexisting or postoperative renal dysfunction in conjunction with low doses of CI given within the first week postoperatively.
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Affiliation(s)
- R Hirose
- Department of Surgery, University of California, San Francisco 94143, USA
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23
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Narumi S, Hakamada K, Sasaki M, Freise CE, Stock PG, Roberts JP, Ascher NL. Liver transplantation for autoimmune hepatitis: rejection and recurrence. Transplant Proc 1999; 31:1955-6. [PMID: 10455934 DOI: 10.1016/s0041-1345(99)00227-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- S Narumi
- Department of Surgery, Hirosaki University School of Medicine, Aomori, Japan
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24
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Hebert MF, Ascher NL, Lake JR, Emond J, Nikolai B, Linna TJ, Roberts JP. Four-year follow-up of mycophenolate mofetil for graft rescue in liver allograft recipients. Transplantation 1999; 67:707-12. [PMID: 10096526 DOI: 10.1097/00007890-199903150-00011] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) has been shown to have promise in short-term liver transplantation graft rescue studies. The purpose of this study was to evaluate the long-term efficacy and safety of MMF in liver transplant patients who had failed cyclosporine (CsA)-based conventional immunosuppression. METHODS Nineteen orthotopic liver allograft recipients were converted from azathioprine to MMF in combination with CsA and prednisone in this prospective, open-labeled, single-center, graft rescue, pilot study. Six patients were taken off CsA when MMF was initiated. A 4-year patient follow-up is reported here. Patients were considered to have failed CsA-based immunosuppression either for refractory rejection, chronic rejection, or severe CsA neurologic toxicity. RESULTS Twelve patients had complete histologic resolution, two had partial resolution, and three had worsening of their rejection. Thirteen patients had a complete biochemical response; one had a partial response and four had worsening of their rejection. Two patients had no histologic and one no biochemical follow-up. Of the six patients treated with MMF and prednisone alone, four had complete resolution of rejection without recurrence. The majority of adverse reactions were gastrointestinal [nausea and/or vomiting (n=5); diarrhea (n=8); gastritis, duodenitis, or esophagitis (n=4); and ulcers (n=2)] or bone marrow suppressive [leukopenia (n=9), anemia (n=6), and thrombocytopenia (n=5)]. CONCLUSIONS MMF seems to be an effective alternative immunosuppressive in patients failing CsA-based conventional therapy. MMF may be of particular benefit in patients who do not tolerate CsA or tacrolimus. The long-term safety profile is similar to that of other immunosuppressives.
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Affiliation(s)
- M F Hebert
- Department of Pharmacy, University of Washington, Seattle 98195-7630, USA
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25
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Renz JF, Lightdale J, Mudge C, Bacchetti P, Watson J, Ascher NL, Emond JC, Rosenthal P, Roberts JP. Mycophenolate mofetil, microemulsion cyclosporine, and prednisone as primary immunosuppression for pediatric liver transplant recipients. Liver Transpl Surg 1999; 5:136-43. [PMID: 10071353 DOI: 10.1002/lt.500050208] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Triple immunosuppressive therapy using mycophenolate mofetil (MMF), microemulsion cyclosporine (me-CsA), and prednisone offers the potential for potent immunosuppression without intravenous drug therapy or anti-T-cell antibody induction therapy. This report describes the application of an immunosuppressive protocol (CNp) using MMF, me-CsA, and prednisone as primary immunosuppression for pediatric liver transplant recipients at the University of California at San Francisco. From August 1995 through December 1996, 26 children (17 boys, 9 girls) aged 1 month to 16 years (mean +/- standard deviation, 58 +/- 62 months; median, 31 months) underwent liver transplantation at our institution, receiving CNp as primary immunosuppression. Posttransplantation renal function, incidence of leukopenia, and drug tolerance within the group receiving CNp as primary immunosuppression were compared with those of 19 children who received primary immunosuppression consisting of azathioprine, oil-based gel-encapsulated cyclosporine, and prednisone with anti-T-cell antibody induction therapy at the same institution from October 1993 through July 1995. No significant difference was observed between immunosuppressive protocols in serum creatinine level or incidence of leukopenia requiring medical therapy during the first year posttransplantation. Whereas gastrointestinal symptoms were observed in approximately 30% of CNp recipients during initial immunotherapy, tolerance of CNp primary immunotherapy was routinely achieved by the dose reduction of MMF. At 1 year posttransplantation, 20 children (77%) remained on CNp primary immunotherapy, 5 children (19%) were receiving tacrolimus-based immunotherapy secondary to rejection, and 1 patient (4%) converted to tacrolimus-based immunotherapy secondary to persistent gastrointestinal intolerance. In conclusion, CNp provides an alternative immunosuppressive protocol that eliminates the necessity of intravenous and induction immunosuppressive therapy with no increased incidence of posttransplantation renal dysfunction or leukopenia and is well tolerated in children.
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Affiliation(s)
- J F Renz
- Department of Surgery, Division of Transplantation, University of California, San Francisco, CA, USA
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26
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Freise CE, Ferrell L, Liu T, Ascher NL, Roberts JP. Effect of systemic cyclosporine on tumor recurrence after liver transplantation in a model of hepatocellular carcinoma. Transplantation 1999; 67:510-3. [PMID: 10071018 DOI: 10.1097/00007890-199902270-00003] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Long-term results after liver transplantation for hepatocellular carcinoma have been disappointing, largely because of the high recurrence rate. It is controversial whether the immunosuppressed state of the recipient contributes to this recurrence rate. We have developed a model in the rat system to examine the effect of immunosuppression on tumor recurrence after transplantation, as well as to evaluate other treatment strategies to decrease the recurrence rate. METHODS A 2-mm3 nodule of Morris hepatoma 3924a was implanted intrahepatically at day 0. At postimplant day 16, the animals underwent syngeneic orthotopic liver transplantation. Two treatment groups were established. Group I received saline injections subcutaneously for 2 weeks, while group II received subcutaneous cyclosporine injections at 3 mg/kg/day for 14 days. Animal survival, tumor recurrence rate, and sites of recurrence and number of pulmonary nodules were recorded. RESULTS Overall survival rate was reduced in animals receiving cyclosporine. The mean survival time was 74.4 days (SEM 6.39 days) in saline-treated animals and 50.4 days (SEM 7.63 days) in the cyclosporine-treated animals. The proportion surviving in group 1 was 47% and in group 2 was 18%. This difference in survival was statistically significant (P=0.025). The incidence of pulmonary nodules was increased in the cyclosporine-treated animals, and tumor recurrence in extrapulmonary sites was seen only in the cyclosporine-treated animals. CONCLUSION Results from this study suggest that cyclosporine has an adverse effect on tumor recurrence after transplantation. This model will be useful to further examine treatment strategies to improve the outcome of transplantation for hepatocellular carcinoma.
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Affiliation(s)
- C E Freise
- Department of Surgery, University of California, San Francisco 94143-0780, USA
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Narumi S, Osorio RW, Freise CE, Stock PG, Roberts JP, Ascher NL. Hepatic artery pseudoaneurysm with hemobilia following angioplasty after liver transplantation. Clin Transplant 1998; 12:508-10. [PMID: 9850442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
A 58-yr-old female with primary biliary cirrhosis underwent an uncomplicated orthotopic liver transplantation. Elevated liver function tests 2 months post-transplantation were evaluated with Doppler ultrasound and a hepatic artery stricture was documented. The hepatic artery stenosis was treated with angioplasty. She developed hemobilia 1 d after the procedure, which was confirmed by angiography. Emergent exploratory laparotomy revealed a pseudoaneurysm at the hepatic artery anastomosis. The pseudoaneurysm was resected and the proper hepatic artery of the graft was anastomosed to the splenic artery of the host using preserved homograft. Her post-operative course was uneventful and liver function tests returned to normal quickly after the surgery. This report will discuss the unusual nature of this complication, and review the problem of hemobilia and pseudoaneurysms in liver transplant recipients.
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Affiliation(s)
- S Narumi
- Department of Surgery, University of California, San Francisco, USA.
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28
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Pessoa MG, Terrault NA, Ferrell LD, Detmer J, Kolberg J, Collins ML, Viele M, Lake JR, Roberts JP, Ascher NL, Wright TL. Hepatitis after liver transplantation: the role of the known and unknown viruses. Liver Transpl Surg 1998; 4:461-8. [PMID: 9791156 DOI: 10.1002/lt.500040603] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study was designed to determine the cause of posttransplantation hepatitis in patients undergoing transplantation for liver disease of nonviral cause; the role of acquired hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis G virus (HGV) in posttransplantation hepatitis; and the course of posttransplantation hepatitis of unknown cause. Two hundred forty-three patients underwent transplantation for nonviral liver diseases (mean age, 48 years; 103 men, 140 women). Serological and virological assays for HBV and HCV were performed pretransplantation to exclude preexisting infection and posttransplantation to investigate the cause of posttransplantation hepatitis. Histology was graded on all available biopsy specimens; posttransplantation hepatitis was assessable in 150 patients. Posttransplantation hepatitis was present in 29% (44 of 150) of the patients after a median follow-up of 47 months (range, 1 to 101 months). Actuarial survival was significantly lower in patients with posttransplantation hepatitis compared with patients without (71% v 89% at 5-year follow-up; P = .03). HCV and HBV were identified posttransplantation in 14% and 9% of patients with hepatitis, respectively. After the exclusion of HCV and HBV infection, 22% (33 of 150) of the patients had posttransplantation hepatitis of unknown cause. HGV was present in 58% of these patients, but HGV was equally prevalent in patients without posttransplantation hepatitis. When patients with HBV and HCV were excluded, there was no difference in survival between patients with posttransplantation hepatitis compared with patients without (P = .08, log-rank test). Posttransplantation hepatitis was present in approximately 30% of the patients undergoing transplantation for nonviral diseases, with a median follow-up of 47 months. Known hepatitis viruses (HBV, HCV) were present in one fourth of the patients with posttransplantation hepatitis; 22% (33 of 150) of the patients had hepatitis of unknown cause, suggesting that other, as yet undiscovered, hepatitis viruses may exist.
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Affiliation(s)
- M G Pessoa
- Departments of Medicine, University of California, San Francisco, USA
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Kita Y, Lake JR, Ferrell LD, Mori M, Roberts JP, Kakizoe S, Kiyosawa K, Tanaka E, Shiga J, Takikawa H, Inoue Y, Ohtake T, Ohtomo K, Yotsuyanagi H, Oka T, Harihara Y, Takayama T, Kubota K, Kawarasaki H, Hashikura Y, Kawasaki S, Ascher NL, Makuuchi M. Possible recurrence of primary sclerosing cholangitis following living-related liver transplantation: report of a case. Transplant Proc 1998; 30:3321-3. [PMID: 9838468 DOI: 10.1016/s0041-1345(98)01047-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Y Kita
- Liver Transplant Team, Faculty of Medicine, University of Tokyo, Japan
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Reichert PR, Renz JF, Rosenthal P, Bacchetti P, Lim RC, Roberts JP, Ascher NL, Emond JC. Biliary complications of reduced-organ liver transplantation. Liver Transpl Surg 1998; 4:343-9. [PMID: 9724470 DOI: 10.1002/lt.500040517] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Reduced-organ liver transplantation for children is effective in lowering pretransplantation morbidity and mortality. Improvements in surgical technique have reduced vascular complications; however, biliary complications continue to account for significant posttransplantation morbidity. This investigation chronicles the incidence and type of biliary complications encountered with reduced-organ liver transplantation. Retrospective review of reduced-organ liver recipients over a 59-month period was performed, and biliary complications were classified as (1) missed biliary radicle, (2) anastomotic leak requiring revision, and (3) biliary stricture. From July 1992 to May 1997, 42 children received reduced-organ grafts: 32 living-donor, 8 cadaveric-reduced, 1 split-liver, and 1 auxiliary orthotopic liver transplant. Of the 42 grafts, 41 were Couinaud segments II/III and 1 was segments II/III/IV. Ten biliary complications were identified in 9 recipients (24%). Biliary complications included parenchymal radicle leaks, 5 (50%); biliary strictures, 3 (30%); and anastomotic leaks, 2 (20%). Although technical advances have reduced the incidence of biliary complications secondary to organ ischemia, parenchymal radicle leaks continue to be a source of morbidity for reduced-organ recipients. Planned exploration on posttransplantation day 7 was performed on the most recent 26 of the 42 total reduced-organ procedures as a mechanism to identify and treat early technical complications. Planned exploration as a routine component of reduced-organ transplantation has yielded a 15% incidence of discovered parenchymal leaks and a 5% incidence of discovered anastomotic leaks. This series underscores the necessity for improved anatomical studies to correctly identify duct territories and the development of accurate noninvasive methods to assess the biliary system preoperatively and intraoperatively in the application of reduced-organ liver transplantation.
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Lightdale JR, Mudge CL, Ascher NL, Rosenthal P. The role of pediatricians in the care of children with liver transplants. Arch Pediatr Adolesc Med 1998; 152:797-802. [PMID: 9701141 DOI: 10.1001/archpedi.152.8.797] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To examine the role of pediatricians in posttransplantation care of pediatric liver transplant recipients. DESIGN Written survey of parents and pediatricians of children enrolled in a pediatric liver transplant program. SETTING Questionnaires were mailed from a liver transplant center (LTC), set in a university-affiliated, tertiary-care medical center, to the homes of families and the offices of pediatricians in a variety of urban, suburban, and rural locales worldwide. STUDY POPULATION Eighty-four percent of families and 81% of pediatricians who met study criteria participated. RESULTS Only 8.9% of all pediatricians reported feeling comfortable providing all care for their liver transplant patients, while 82.2% were most comfortable sharing responsibility for care with the LTC. The remaining 8.9% of pediatricians were most comfortable with the LTC providing care. The more comfort pediatricians reported in providing care, the more likely parents were to report contacting pediatricians for medical problems. The more comfort pediatricians reported, the more parents perceived that (1) pediatricians and the LTC work well together (P<.03); (2) the LTC is informed about their child (P<.001); and (3) pediatricians are similarly up-to-date (P<.001). Furthermore, the more comfort pediatricians felt, the more parents believed that the liver transplant improved their child's health (P<.03) and that their child enjoys school (P=.08). Of the pediatricians, 15.6% who reported attending a continuing medical education course were significantly more comfortable (P=.05). The 18.9% of participating pediatricians who reported receiving some training in pediatric gastroenterology were also significantly more comfortable caring for children with liver transplants (P<.05). CONCLUSION Increasing pediatrician comfort levels in providing posttransplantation care for children with liver transplants is critical to the continuing success of pediatric liver transplantation.
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Affiliation(s)
- J R Lightdale
- Department of Pediatrics, University of California, San Francisco 94143-0136, USA
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Terrault NA, Zhou S, McCory RW, Pruett TL, Lake JR, Roberts JP, Ascher NL, Wright TL. Incidence and clinical consequences of surface and polymerase gene mutations in liver transplant recipients on hepatitis B immunoglobulin. Hepatology 1998; 28:555-61. [PMID: 9696024 DOI: 10.1002/hep.510280237] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Mutations in the "a" determinant of the surface gene have been associated with failure of hepatitis B immunoglobulin (HBIg) prophylaxis. We compared sequences from the surface and polymerase regions of hepatitis B virus (HBV) from 4 patients who failed high-dose HBIg therapy with two control groups: HBIg-treated patients who remained hepatitis B surface antigen (HBsAg)-negative (n = 4) and HBV-infected transplant recipients who never received HBIg (n = 4). Mutations within the surface and overlapping polymerase region were more common in patients failing HBIg than controls (P = .03), and mutations in the region of the "a" determinant were present only in patients failing HBIg. To examine the relationship between HBIg failure and duration of therapy, five additional treatment failures from a second transplantation center were sequenced (total with HBIg failure = 9). Mutations in the "a" determinant developed in 1 of 3 patients receiving HBIg for less than 6 months compared with 5 of 6 patients failing HBIg after 6 months of therapy (P = .23). The most frequently identified amino acid substitution was glycine to arginine at position 145 (present in 4 of 6 patients who failed HBIg after at least 6 months of treatment). A unique mutation within the YMDD motif (methionine to leucine) was present in 1 patient who failed HBIg treatment and who received a short course of ganciclovir. We conclude that the emergence of mutations in the "a" determinant accounts for some, but not all, treatment failures in patients receiving HBIg prophylaxis. Mutations in other regions of the S gene were more common in patients failing HBIg than controls, suggesting that domains other than the "a" determinant may be important.
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Affiliation(s)
- N A Terrault
- Department of Medicine, Veteran's Administration Medical Center San Francisco and University of California, 94121, USA
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Affiliation(s)
- N L Ascher
- Liver Transplant Program, University of California, San Francisco, CA
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34
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Ascher NL. Expanded donor pool. Liver Transpl Surg 1998; 4:249-50. [PMID: 9563968 DOI: 10.1002/lt.500040311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
No Abstract Copyright
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Affiliation(s)
- NL Ascher
- Liver Transplant Program, University of California, San Francisco, CA
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Abstract
BACKGROUND Previous reports with short-term follow-up after renal transplantation for IgA nephropathy (IgAN) have suggested an incidence of recurrence up to 50%, an increased recurrence with living-related donors, and the rarity of graft loss due to recurrence. In this study, the long-term results of renal transplantation for IgAN were examined. METHODS Between June 1980 and December 1994, 54 patients (61 renal transplants) with end-stage renal disease due to IgA nephropathy were performed at the University of California San Francisco. Actuarial patient and graft survival were compared with a matched reference group. Correlates of recurrent disease (biopsy confirmed) and graft loss were determined. RESULTS Patient and graft survival for IgA patients were good (100% and 75%, respectively, at 5 years after transplant). Graft survival was lower in IgA recipients with living-related compared with cadaveric renal allografts (P<0.09) and also with renal allografts well matched at HLA-AB (< or =2 AB mismatches) (P<0.09) or HLA-DR (< or =1 mismatch) (P<0.01). Recurrence was not correlated with donor status, recipient age, race, gender, or immunosuppression. Recurrence (18 of 61) resulted in substantial graft loss (6 of 18) or deteriorating renal function (4 of 18) at a mean follow-up of 61 months. Mean time to diagnosis of recurrence and subsequent graft loss was 31 and 63 months, respectively. Despite re-recurrence of IgAN in three of five patients who were retransplanted, all have good long-term renal function. CONCLUSIONS Substantial graft loss due to recurrent disease after renal transplantation for IgAN occurs with long-term follow-up. Living-related transplantation and HLA matching do not appear to confer an advantage for graft survival in patients with IgAN. Despite the potential for recurrence, IgAN patients enjoy good long-term graft survival.
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Affiliation(s)
- G L Bumgardner
- Department of Surgery, The Ohio State University, Columbus 43210, USA
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Freise CE, Galbraith CA, Nikolai BJ, Ascher NL, Lake JR, Stock PG, Roberts JP. Risks associated with conversion of stable patients after liver transplantation to the microemulsion formulation of cyclosporine. Transplantation 1998; 65:995-7. [PMID: 9565107 DOI: 10.1097/00007890-199804150-00022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoral is a microemulsion formulation of cyclosporine that has a better pharmacokinetic profile than the standard formulation (Sandimmune). To prove the safety of converting stable liver transplant patients from Sandimmune to Neoral, we conducted a prospective trial involving 54 patients. METHOD The average time from transplantation to conversion was 48.5+/-21.6 months. Thirty of 54 patients (55%) required a dose reduction during the study for various reasons. Five of 30 patients had the first dose reduction because of increased levels of cyclosporine. Seven patients required more than one dose reduction. RESULTS Sixteen patients suffered serious adverse events. Six patients had a biopsy-proven rejection. Four of 6 patients had trough cyclosporine levels within 20% of baseline value immediately before developing rejection. CONCLUSION Converting patients from the standard formulation to the microemulsion formulation of cyclosporine seems to expose stable patients to unnecessary risks.
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Affiliation(s)
- C E Freise
- Department of Surgery, University of California, San Francisco 94143, USA
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37
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Affiliation(s)
- N L Ascher
- Liver Transplant Program, University of California, San Francisco, 94143-0780, USA
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38
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Affiliation(s)
- S M Kang
- Department of Surgery, University of California at San Francisco, USA
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39
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Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is a highly effective but costly therapy for end-stage liver disease. However, there are limited data on the demographic and clinical variables that affect cost. We undertook a preliminary study using multiple regression techniques to analyze factors that influence the cost of OLT. METHODS Patient and demographic data, including laboratory values and charges for all liver transplantations performed between June 1992 and June 1993 were analyzed (n = 111). Linear regression with standard and log-transformed values was performed by using STATA software (Stata Corporation College Station, TX). Independent variables included in the analyses were age, sex, United Network for Organ Sharing (UNOS) status, primary versus retransplantation, liver-kidney transplantation, and laboratory parameters of both liver (aspartate aminotransferase, AST; alkaline phosphatase; bilirubin; albumin; and prothrombin time) and kidney (blood urea nitrogen, BUN; creatinine) function. An F-to-remove strategy was employed with a significance level set at P = .05. RESULTS The full model with 12 variables explained 37% of the total variation in charges. When one excludes variables that did not have a significant impact on cost, the remaining significant variables were BUN and UNOS status 1. The final model was Charges (US$) = 3,407 x BUN + 74,474 x status 1 + 102,662. This model accounted for 29% of the total variability with BUN accounting for the vast majority (26%). CONCLUSIONS Renal function is the most important predictor of cost of OLT (P < .001). UNOS status 1 further increases cost, but other hospitalized patients have similar costs when one controls for other clinical variables. The degree of liver impairment is less important in predicting cost.
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Affiliation(s)
- R S Brown
- Department of Medicine, University of North Carolina at Chapel Hill, 27599-7080, USA
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40
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Kaufman DB, Ascher NL. Quo vadis, my transplant fellow: a discussion of transplant surgery fellowship training activity in the United States and Canada: 1991-1997. Education Committee of the American Society of Transplant Surgeons. Transplantation 1998; 65:269-72. [PMID: 9458028 DOI: 10.1097/00007890-199801270-00023] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This is a discussion of transplant surgery fellowship training issues that pertain to educational quality guidelines of fellowship programs, the number of fellows being trained, and the individual's fate in securing transplant surgery positions after training. In 1995, the Council of the American Society of Transplant Surgeons (ASTS) revised the academic guidelines to enhance the educational standards of programs seeking ASTS approval as a transplant surgery fellowship training program. The criteria for accrediting training programs in kidney and liver transplant surgery were redefined, and new criteria for pancreas transplant surgery training were developed. Regarding the number of transplant surgery fellows being trained per year, during the period from 1991 to 1997, a total of 327 transplant surgery fellows completed training at ASTS-accredited transplant surgery fellowship training programs. The annual number of transplant surgery fellowship graduates has remained nearly constant at approximately 45 per year. However, the proportion of transplant surgery trainees who are foreign medical graduates has increased annually since 1995. Currently, 49% of the trainees are foreign medical graduates. Regarding the individual's fates in securing transplant surgery positions after training, the proportion of U.S./Canadian medical graduates who received transplant surgery training during the last year but are practicing in surgical disciplines other than transplant surgery appears to be increasing. Before 1996, it was rare for transplant surgery trainees to pursue surgical practice activities that did not include transplantation. Among the current group of 28 U.S./Canadian medical graduates who completed transplant surgery training between January 1997 and July 1997, six did not secure an acceptable position in transplantation. Instead, they are practicing in either general surgery or vascular surgery, or obtaining additional transplant training. These changes in the demographics and dynamics of transplant surgery fellowship training activity provoke important concerns.
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Affiliation(s)
- D B Kaufman
- Department of Surgery, Northwestern University Medical School, Chicago, Illinois, USA
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41
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Affiliation(s)
- N L Ascher
- Liver Transplant Program, University of California, San Francisco 94143-0780, USA
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42
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Brown RS, Ascher NL, Lake JR, Emond JC, Bacchetti P, Randall HB, Roberts JP. The impact of surgical complications after liver transplantation on resource utilization. Arch Surg 1997; 132:1098-103. [PMID: 9336508 DOI: 10.1001/archsurg.1997.01430340052008] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the impact of surgical complications on length of stay and hospital charges after liver transplantation. DESIGN A retrospective economic evaluation of the outcomes during initial hospitalization after liver transplantation. SETTING University hospital treating referred patients. PATIENTS The study population was 109 patients undergoing 111 liver transplantations during fiscal year 1993. MAIN OUTCOME MEASURES Hospital charges and length of stay during the initial hospitalization after liver transplantation. Multivariate regression methods were used to analyze the impact of surgical complications on costs. RESULTS Of the 111 transplantations, 30 (27%) had a surgical complication that required a return to the operating room during the initial hospitalization. The effect of a surgical complication was to increase the mean hospital charges (excluding physician charges) from $150,092 to $347,728 (difference of mean, $197,636; confidence interval of difference, $114,153 to $319,326). The median length of stay was 16 days for patients without complications and 45 days for those with complications. Univariate and multivariate models suggested that surgical complications had the greatest effect on length of stay and hospital charges among the factors studied. Complications tended to occur more frequently among patients with United Network for Organ Sharing (UNOS) status 1 (42% vs 22%), but this did not reach statistical significance (P = .09). CONCLUSIONS Surgical complications after liver transplantation have a marked impact on the cost of the procedure. The magnitude of this effect is greater than that of UNOS status, presence of rejection, or other demographic or clinical factors studied. Complications tend to occur in the most ill patients. Identifying strategies to reduce the risk of complications, particularly in patients with UNOS status 1, likely can reduce the cost of transplantation.
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Affiliation(s)
- R S Brown
- Department of Medicine, University of North Carolina at Chapel Hill, USA
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43
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Renz JF, Rosenthal P, Roberts JP, Ascher NL, Emond JC. Planned exploration of pediatric liver transplant recipients reduces posttransplant morbidity and lowers length of hospitalization. Arch Surg 1997; 132:950-5; discussion 955-6. [PMID: 9301606 DOI: 10.1001/archsurg.1997.01430330016002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pediatric liver transplantation (eg, orthotopic liver transplantation) has been associated with decreased graft survival compared with adult transplantation; this has been attributed to the increased difficulty of the procedure in small children and the increased number of technical variants that have been used to increase the supply of small livers. OBJECTIVES To adopt a policy of planned exploration (PLANEX) of children on the seventh day after orthotopic liver transplantation, to obtain a liver biopsy specimen, to identify and treat potential technical problems at that time, and to evaluate the effect of this strategy on the length of hospitalization and morbidity rate in 60 children who underwent orthotopic liver transplantation. DESIGN The PLANEX was adopted progressively during a 3-year period. A retrospective study was conducted that compared outcomes between patients who did and did not undergo PLANEX. Data were collected from chart review with a complete follow-up of patients. SETTING A university medical center at which 130 liver transplantations are performed annually in adults and children. PATIENTS Sixty children who received primary transplants between October 1992 and December 1996 were studied. INTERVENTIONS Standard, partial, and living-donor transplantations were performed. Routine procedures performed at PLANEX included hematoma evacuation, tissue culture, inspection of all anastomoses, intraoperative ultrasonographic verification of vessel patency, open liver biopsy, and definitive abdominal closure. MAIN OUTCOME MEASURES The duration of the primary hospitalization was the main outcome measure. Surgical complications and graft and patient survival rates were also analyzed. RESULTS The mean +/- SD length of hospitalization for 24 recipients who underwent PLANEX was 16.5 +/- 5.7 days compared with 19.2 +/- 4.7 days for 6 patients (25%) who had significant findings at exploration (P = .34). In the 36 patients who did not undergo PLANEX, 10 patients (28%) required unplanned explorations (on median posttransplant day 13) that identified the following 13 complications: biliary (n = 4), undiscovered enterotomy (n = 6), hemoperitoneum (n = 2), and partial vascular thrombosis (n = 1). The mean length of hospitalization for recipients who did not require exploration was 19.3 +/- 3.9 days (PLANEX, P = .28); however, in patients who required unplanned exploration, the mean length of hospitalization increased to 41.2 +/- 15.5 days (median, 43 days). The mean length of hospitalization of recipients who underwent unplanned exploration was significantly increased compared with recipients who underwent PLANEX with significant intraoperative findings (P = .02). CONCLUSIONS In this series, early identification and repair of surgical problems in asymptomatic patients on day 7 significantly decreased the hospital stay and morbid consequences of surgical problems. This aggressive approach may improve overall graft and patient survival.
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Affiliation(s)
- J F Renz
- Department of Surgery, University of California-San Francisco, USA
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Abstract
Fulminant hepatic failure (FHF) is defined as a syndrome of acute liver failure with the development of hepatic encephalopathy and severe hypoprothrombinemia occurring within 2 months of the onset of symptoms or jaundice in a person without preexisting liver disease. Total orthotopic liver transplantation (OLTX) is a lifesaving therapeutic option for patients with FHF, but currently requires lifelong immunosuppression to maintain the graft. Auxiliary partial orthotopic liver transplantation (A-OLTX) is a procedure whereby only a portion of the native liver is removed, and the remainder of the native liver is left in situ. A-OLTX provides temporary support until the native liver recovers and immunosuppression can be withdrawn. We describe the successful application of emergency A-OLTX in a young girl who accidentally ingested Amanita phalloides mushrooms and developed FHF.
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Affiliation(s)
- P Rosenthal
- Pediatric Liver Transplant Program University of California, San Francisco Medical Center, San Francisco, CA 94143, USA
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Abstract
The relationship between liver regeneration and the induction of the immune response is uncertain. We hypothesize that the altered environment of the regenerating liver allograft increases the immune response to the allograft. In DA (RT1a) to LEW (RT1I) rats, hepatectomized, small-for-size and whole, normal-for-size liver transplants were performed. Naive and 70% hepatectomized LEW served as controls. Animals were assessed for survival, mass restoration, and host alloresponses. Although 30% partial allografts regenerated well to achieve a volume nearly equal to that of recipient's native liver in 7 days, survival was significantly shorter than that of the recipients of whole grafts (8.8 +/- 0.4 vs 10.3 +/- 1.2 days, n = 6, P < 0.02). When compared on Day 4 after transplantation, histologic examination revealed a more vigorous cellular infiltration in the sinusoidal area in the partial liver transplant group. Phenotypic analysis of thymocytes showed a predominance of more mature phenotypes in the partial group, including more prominent decrease in the frequency of CD4, CD8-double-positive cells and increase in that of alpha beta TCRhigh cells. Proliferative activity of thymocytes in response to Con A was higher in the partial group than in the whole group. MLR of splenocytes against donor-type antigens was higher in the partial group, whereas reactivity against third party was the same as in other groups. These data suggest that host cellular responses to the allograft are enhanced in the regenerating, small-for-size liver graft. These findings have implications in the clinical management of liver recipients with damaged or small for size livers.
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Affiliation(s)
- T Omura
- Department of Surgery, University of California, San Francisco 94143, USA
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46
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Pessoa MG, Terrault NA, Ferrell LD, Kim JP, Kolberg J, Detmer J, Collins ML, Yun AJ, Viele M, Lake JR, Roberts JP, Ascher NL, Wright TL. Hepatitis G virus in patients with cryptogenic liver disease undergoing liver transplantation. Hepatology 1997; 25:1266-70. [PMID: 9141450 DOI: 10.1002/hep.510250535] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To examine the prevalence of hepatitis G virus (HGV) in end-stage liver disease of unknown cause and the role of HGV infection in posttransplantation hepatitis, we studied 46 patients undergoing liver transplantation (mean age, 50 years; M:F, 18:28) with cryptogenic cirrhosis. HGV RNA was detected by polymerase chain reaction (PCR) and was quantified by a branched DNA (bDNA) assay. The prevalence of HGV RNA was determined in samples collected before and after liver transplantation and was found to be 22% and 67%, respectively. We evaluated the prevalence of posttransplantation hepatitis in 25 patients, 16 of whom were HGV-positive and 9 were HGV-negative. The proportion of patients with hepatitis was not significantly different in the two groups (38% in HGV-positive and 22% in HGV-negative patients). The median histological scores were significantly higher in liver biopsies from patients with HGV infection than in those without HGV infection (2 [range, 0-14] and 1 [range, 0-3]; P = .01), but the histological scores were low overall. The duration of follow-up was similar in the two groups. HGV RNA levels were not correlated with the severity of liver disease based on histological score (r = -.08). Graft survival and patient survival were not significantly different. We concluded that liver disease was frequent (32%) after transplantation in patients with a pretransplantation diagnosis of cryptogenic cirrhosis, although the disease was generally mild. Although HGV RNA was demonstrable in the majority (67%) of patients after transplantation, there was no relationship between the presence of HGV RNA and the presence of posttransplantation liver disease. The finding of posttransplantation hepatitis in the absence of known viruses (A-G), suggests that other, as-yet-unidentified viruses may be important.
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Affiliation(s)
- M G Pessoa
- Department of Medicine, Department of Veterans Affairs Medical Center and University of California, San Francisco 94121, USA
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47
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Somberg KA, Lombardero MS, Lawlor SM, Ascher NL, Lake JR, Wiesner RH, Zetterman RK. A controlled analysis of the transjugular intrahepatic portosystemic shunt in liver transplant recipients. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database. Transplantation 1997; 63:1074-9. [PMID: 9133467 DOI: 10.1097/00007890-199704270-00005] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The transjugular intrahepatic portosystemic shunt (TIPS) is an important treatment for complications of portal hypertension. As some authors have suggested that TIPS may facilitate liver transplantation technically, the objective of this study was to determine the impact of TIPS on the liver transplant operation and its outcome. METHODS The analysis was designed as a retrospective cohort study using a multicenter database. Fifty-five patients with TIPS were matched with 55 controls on the basis of 10 pretransplant laboratory, clinical, and demographic features. TIPS patients and control patients were compared with regard to duration of surgery, intraoperative blood product usage, liver and renal function, volume of ascites, survival, and hospital stay. For confirmatory purposes, a parallel analysis using linear regression methods was performed. RESULTS By matched analysis, TIPS patients had less ascites at surgery (mean 0.9+/-0.20 vs. 2.2+/-0.37 L, P=0.005) and a slightly shorter time from incision to cross-clamp (mean 2.1+/-0.10 vs. 2.5+/-0.15 hr, P=0.03). However, there were not significant differences for total operative time (mean 6.0+/-0.17 vs. 6.3+/-0.25 hr, P=1.00), blood product usage, or any other outcome variable. Regression analysis confirmed these results. CONCLUSIONS TIPS does not significantly impact the course of liver transplantation surgery. Therefore, preoperative portal decompression solely to facilitate liver transplantation is not an appropriate indication for TIPS.
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Affiliation(s)
- K A Somberg
- Department of Medicine, University of California, San Francisco 94143, USA
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48
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Affiliation(s)
- N L Ascher
- Liver Transplant Program, University of California, San Francisco 94143-0780, USA
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49
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Reiser M, Terrault N, Nelson DR, Mizokami M, Ferrell L, Lake JR, Roberts JP, Ascher NL, Wright TL, Lau JY. Antibody to the host cellular gene-derived epitope GOR-1 in liver transplant recipients with hepatitis C virus infection. Transplantation 1997; 63:609-12. [PMID: 9047160 DOI: 10.1097/00007890-199702270-00022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The presence of anti-GOR was determined in paired pre-orthotopic liver transplantation (pre-OLT) and post-OLT sera from 87 OLT patients with hepatitis C virus infection. Before OLT, 48/87 patients were seropositive for anti-GOR, but this marker had no relationship with the clinical and biochemical parameters, or viremia level. Anti-GOR was less commonly detected in patients infected with genotype 3a, compared with genotypes 1 and 2, which might be related to the less conserved nature of the proposed shared epitope (amino acid sequence 9-18) in genotype 3a isolates. After OLT (median follow-up 16 months), anti-GOR was detected in 31/87 patients and it had no correlation with the clinical and biochemical parameters, viremia level, histologic disease activity, and clinical outcome. Changes in anti-GOR status (before OLT versus after OLT) were also not related to any of the clinical parameters. Although anti-GOR is commonly detected in OLT patients infected with hepatitis C virus genotypes 1 and 2, it has no clinical or prognostic significance.
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Affiliation(s)
- M Reiser
- Department of Medicine, University of Florida, Gainesville 32610, USA
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Orloff SL, Hirose R, Lin Z, Narumi S, Stock PG, Ascher NL. Clonal deletion is one mechanism responsible for tolerance in mixed hematopoietic chimeras. Transplant Proc 1997; 29:1198-200. [PMID: 9123270 DOI: 10.1016/s0041-1345(96)00545-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- S L Orloff
- Department of Surgery, University of California, San Francisco, USA
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