Dual-graft adult living donor liver transplantation with ABO-incompatible graft: short-term and long-term outcomes

ABO-incompatible (ABOi) dual-graft (DG) adult living donor liver transplantation (ALDLT) is not commonly performed due to its inherently intricate surgical technique and immunological complexity. Therefore, data are lacking on the short- and long-term clinical outcomes of ABOi DG ALDLT. We performed a retrospective study by reviewing the medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. Additionally, computed tomography volumetric analysis was conducted to assess the graft regeneration rate. The mean age of a total of 28 recipients was 50.2 ± 8.5 years, and the mean model for end-stage liver disease score was 12.2 ± 4.6. The 1-, 3-, and 5-year patient survival rate was 96.4% during the mean follow-up period of 57.0 ± 22.4 months. The 1-, 3-, and 5-year graft survival rate was 96.4%, 94.2%, and 92.0%, respectively, and no significant differences were observed between ABO-compatible (ABOc) and ABOi grafts (P = .145). The biliary complication rate showed no significant difference (P = .195) between ABOc and ABOi grafts. Regeneration rates of ABOi grafts were not significantly different from those of ABOc grafts. DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks.

Survival Benefit of Early Cancer Detection Through Regular Endoscopic Screening for De Novo Gastric and Colorectal Cancers in Korean Liver Transplant Recipients

BACKGROUND

De novo malignancy is not uncommon after liver transplantation (LT). Gastric cancer is one of the most common malignancies in both the Korean general population and LT recipients, and colorectal cancer prevalence is gradually increasing.

METHODS

Among 3690 adult recipients who underwent LT from January 1999 and December 2013, the screening patterns and prognosis of 26 cases of gastric cancer and 22 cases of colorectal cancer were analyzed.

RESULTS

For gastric cancer, the mean patient age was 54.6 ± 6.2 years at LT and 59.5 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 60.2 ± 29.8 months. Patients were divided into regular (n = 18) and non-regular (n = 8) screening groups, with early cancer found in 14 and 0 patients; their 2-year survival rates after cancer diagnosis were 93.1% and 33.3% (P = .006), respectively. Endoscopic resection was successfully performed in 8 patients, all in the regular screening group. For colorectal cancer, the mean patient age was 53.3 ± 6.1 years at LT and 58.1 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 54.3 ± 38.0 months. Patients were divided into regular (n = 19) and non-regular (n = 3) screening groups, with early cancer found in 12 and 0 patients; their 2-year survival rates after cancer diagnosis of 92.3% and 33.3% (P = .003), respectively. Endoscopic resection was successfully performed in 6 patients, all in the regular screening group.

CONCLUSIONS

LT recipients are strongly advised to undergo regular screening studies for various de novo malignancies, especially cancers common in the general population. Regular endoscopic screening contributes to the timely detection of gastric and colorectal cancers, improving post-treatment survival outcomes.

Donor Safety and Recipient Liver Function After Right-Lobe Liver Transplantation From Living Donors With Gilbert Syndrome

BACKGROUND

Donor safety is the most important aspect in living-donor liver transplantation (LDLT). Gilbert syndrome is an autosomal recessive condition that is a common cause of isolated unconjugated hyperbilirubinemia, and its prevalence is not negligibly low in the general population. This study intended to assess donor safety and recipient liver function after LDLT with the use of right liver grafts from living donors with Gilbert syndrome.

METHODS

Among 2,140 right liver transplantations performed from January 2002 to December 20113 at our institution, we identified 12 living donors (0.6%) who showed a preoperative serum total bilirubin level of ≥2 mg/dL. These donors were clinically diagnosed with Gilbert syndrome. The clinical outcomes of these donors and their recipients were analyzed retrospectively.

RESULTS

The mean donor age was 24.6 ± 7.1 years, and 11 donors were male. All subjects met the preoperative evaluation conditions for right liver donation except for the level of unconjugated hyperbilirubinemia. The mean serum total bilirubin level of the donors was 2.23 ± 0.20 mg/dL before and 1.79 ± 0.61 mg/dL 1 year after right liver donation. The preoperative donor direct bilirubin level was 0.43 ± 0.19 mg/dL. The preoperative indocyanine green retention rate at 15 minutes was 8.2 ± 2.8%. All donors and recipients recovered uneventfully and were alive at the time of writing. The recipient serum total bilirubin level was 1.29 ± 0.47 mg/dL 1 year after LDLT.

CONCLUSIONS

We suggest that LDLT with living donors with Gilbert syndrome can be safely performed, but that a meticulous preoperative evaluation is vital to maximize donor safety.

Liver transplantation in Korea: past, present, and future

PURPOSE

This study reviewed the past and present status of liver transplantation (LT) and outlooks for the future of LT in Korea.

METHOD

The first LT in Korea was successfully performed using a deceased donor graft in 1988. Pediatric and adult living donor liver transplantations (LDLTs) were initiated in 1994 and 1997, respectively. From 1988 to 2013, 10,581 LTs were performed at 40 centers, whereas LDLT accounted for 76.5% of all LTs.

RESULTS

In the early 1990s, the deceased organ donation rate was less than 1.5 per million population (PMP) per year, but it increased to 5 PMP beginning in 2008. Despite the increasing number of deceased donor liver transplantations (DDLTs), high prevalence of hepatitis B virus (HBV)-induced cirrhosis and hepatocellular carcinoma (HCC) has provoked persistent performance of adult LDLT with technical advancement including middle hepatic vein (MHV) reconstruction of right lobe graft and dual graft LDLT with 1 nationwide donor mortality.

CONCLUSION

The number of LTs in Korea in 2010 was 23.2 PMP (1042 LTs/45 million population), lower than 23.5 PMP of Spain, but higher than 20 PMP of the United States. However, future LT numbers may decrease because of lowering the HBV carrier rate (neonatal HBV universal vaccination began in 1992), new potent anti-HBV agents, and lowest birth rate (1.22 children per family) with a decrease of potential live donors.

Expression pattern analysis of hepatocellular carcinoma tumor markers in viral hepatitis B and C patients undergoing liver transplantation and resection

BACKGROUND

This study was conducted to compare the expression patterns of serum alpha-fetoprotein (AFP) and proteins induced by vitamin K absence or antagonist-II (PIVKA-II) in hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT) and resection at a high-volume single institution.

METHODS

First, 663 liver transplant recipients with HCC were selected. They were divided into hepatitis B virus (HBV) (n = 628) and hepatitis C virus (HCV) groups (n = 35). Their medical records were retrospectively reviewed. Second, another cohort of 2709 patients who underwent HCC resection included 2258 HBV, 143 HCV, and 308 non-HBV non-HCV (NBNC) patients.

RESULTS

In the transplantation group, pretransplantation AFP level >20 ng/mL was observed in 42.5% of HBV patients and 60% of HCV patients (P = .042). PIVKA-II level >40 mAU/mL was observed in 30.6% of HBV patients and 42.9% of HCV patients (P = .127). In the resection group, a preoperative AFP level >20 ng/mL was observed in 51.7% of HBV patients and 43.3% of HCV patients (P = .052). PIVKA-II level >40 mAU/mL was observed in 59.7% of HBV patients and 56.6% of HCV patients (P = .47). Preoperative AFP level >20 ng/mL and PIVKA-II level >40 mAU/mL were observed in 35.7% and 61% of NBNC patients, respectively. Receiver-operator characteristic curve analyses revealed that the expression pattern of PIVKA-II in patients with elevated AFP level was not predictable and vice versa, regardless of background liver diseases.

CONCLUSIONS

This study indicates that serum AFP and PIVKA-II may be expressed variably regardless of the types of background liver disease. Further large-volume multicenter studies are needed to evaluate the possibility of the etiology-dependent expression of tumor markers.

A pilot study on the safety and efficacy of generic mycophenolate agent as conversion maintenance therapy in stable liver transplant recipients

PURPOSE

The patent covering mycophenolate mofetil (MMF) in Korea has expired and, thus, several generic MMF agents are now commercially available. The supply of Cellcept (Roche Korea) was interrupted at the end of 2011, so it was inevitable that a generic MMF would be used instead. During this period, we performed a prospective pilot study to examine the safety and efficacy of a generic mycophenolate agent (Myconol: Hanmi Pharmaceutical, Seoul Korea) for use as conversion maintenance therapy in stable liver transplantation (OLT) recipients.

METHODS

OLT recipients, who were treated with MMF on an outpatient basis from January 2012 to March 2012, attended follow-up interviews conducted. The patients had undergone OLT ≥ 2 years before the study, had tolerated Cellcept, and showed stable liver function. Fifty-three patients were followed up for more than 3 months after conversion to the same dose of Myconol.

RESULTS

After conversion to Myconol, 6 patients (11.3%) experienced new side effects, which disappeared when they reverted to Cellcept (n = 5) or stopped taking Myconol medication (n = 1). The side effects associated with Myconol included gastrointestinal symptoms (indigestion and diarrhea; n = 3), skin eruptions (n = 1), pruritus (n = 1), and insomnia (n = 1). The mean mycophenolic acid levels were 1.71 ± 0.88 μg/mL for Cellcept and 1.83 ± 0.91 μg/mL for Myconol, which showed a strong correlation (r(2) = 0.92, P < .001).

CONCLUSIONS

Myconol showed similar pharmacokinetics to those of Celcept, but a small proportion of patients experienced agent-specific side effects; therefore, patients should be closely monitored when taking Myconol. Also, further studies, with a greater number of patients, are required to identify the full spectrum of drug-associated side effects.

Toward more than 400 liver transplantations a year at a single center

BACKGROUND

For the first time at Asan Medical Center (AMC) we performed more than 400 liver transplantations (LTs) per year in 2011, despite same number of living donor liver transplantations (LDLTs).

METHODS

Our OLT program was started in 1992, but not activated well due to the scarcity of deceased donor organs. Since adult LDLTs using a left lobe and then a right lobe were successfully performed in 1997, we have developed several innovative techniques and approaches for adult LDLT, for example, modified right-lobe graft reconstructing middle hepatic branches in 1998, dual graft LDLT using 2 left lobes in 2000; new criteria for hepatocellular carcinoma (HCC); as well as ABO-incompatible LDLT, the first in the world. As a result, the number of LDLTs has increased rapidly but reached a plateau recently. Nationwide efforts to promote deceased donation increased the number of deceased donor liver transplantation (DDLT).

RESULTS

We have performed 317 LDLTs per year in 2010 and 2011, respectively. The number of LTs reached 403 in 2011. This large number was possible due to a remarkable increase of DDLTs from 50 in 2010 to 86 in 2011. Seventy-nine patients (68.1%) among 116 patients (28.8%) required an urgent LT receiving a DDLT. LT for HCC or ABO-mismatch comprised 50.3% (n = 150) or 8.7% (n = 35), respectively. In-hospital mortality rate in 2011 was 4.7%.

CONCLUSIONS

The increased LTs number at AMC was aided by the nationwide campaign.

Standardization of modified right lobe grafts to minimize vascular outflow complications for adult living donor liver transplantation

BACKGROUND

After >2000 adult living donor liver transplants (LDLTs), we observed minimization of the complication rate using case-by-case modification of venous outflow reconstruction in right liver graft (RLG), standardization seeking intend to provide a hemodynamic- based, regeneration-compliant hepatic outflow reconstruction.

METHODS

We retrospectively examined 100 consecutive adult LDLT using modified RLG before and after application of RLG standardization to compare the 6-month incidences of vascular outflow complications.

RESULT

The right hepatic vein stenting rate for first 6 months was 5% in the customized group and 1% in the standardized group (P=.212). The middle hepatic vein stenting rate for first 6 months was 9% in the customized group and 4% in the standardized group (P=.373). The inferior right hepatic vein stenting rate for first 6 months was 12.8% in the customized group and 7.1% in the standardized group (P=.472). The overall 6-month patient survival rate was 94% in the customized group and 95% in the standardized group (P=.867). The overall incidence of significant RLG venous outflow complications was 19% in the customized group and 8% in the standardized group (P=.023).

CONCLUSION

Standardization as a universal graft model seemed to be more effective and feasible than conventional graft customization requiring individualized case-by-case modification.

De novo malignancies after liver transplantation: incidence comparison with the Korean cancer registry

PURPOSE

De novo malignancy is not uncommon after liver transplantation (OLT). We have compared the incidence of novo malignancy following OLT with those among the general Korean population.

METHODS

Between January 1998 and December 2008, 1952 adult OLT were performed, including 1714 living donor and 238 deceased donor grafts whose medical records were retrospectively reviewed.

RESULTS

Among the 1952 patients, 44 (2.3%) showed de novo malignancies after a mean posttransplant period of 41 months. Among the 14 types of malignancy the most frequent was stomach cancer (n = 11; 25.0%), colorectal cancer (n = 9; 20.5%), breast cancer (n = 4; 9.1%), and thyroid cancer (n = 3; 6.8%). These patients underwent aggressive treatment, including surgery, chemotherapy, and radiotherapy, except for one patient with an aggressive primary liver cancer. Over a mean follow-up of 45 months after diagnosis of de novo malignancy, 13 patients (29.5%) died; the overall 3-year patient survival rate was 67.5%. The relative risk of malignancy following OLT was 7.7-fold higher in men and 7.3-fold higher in women than the Korean general population.

CONCLUSIONS

OLT recipients must be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population.

Peritransplant monitoring of immune cell function in adult living donor liver transplantation

PURPOSE

We evaluated the clinical utility of peritransplant in vitro assays of immune cell function in adult living donor liver transplant (LDLT) recipients.

METHODS

In particular, we measured immune cell function, using the ImmuKnow assay, in 107 adult LDLT recipients and 200 potential living liver donors (control group) admitted to our center between July 2008 and January 2009.

RESULTS

In the control group, the mean proportion of T-helper/inducer cells was 36.8% ± 8.2%. The degree of immune response was strong in 12%, moderate in 77%, and low in 11%. In the study group, the degree of immune response within the first month was strong in 4.6%, moderate in 38.2%, and low in 57.2%, thus significantly lower than in the control group (P < .001). ImmuKnow results and tacrolimus levels did not show a significant correlation (r(2) = .002, P = .392). Although six patients showed biopsy-proven acute cellular rejection, none showed a strong immune response. Patients with overt infection showed a lower immune response.

CONCLUSIONS

These results indicate that peritransplant assessment of immune response using the ImmuKnow assay does not reliably predict the occurrence of acute rejection. Additional studies are necessary to accurately assess the clinical utility of immune response monitoring.

Small-sized liver graft does not increase the risk of hepatocellular carcinoma recurrence after living donor liver transplantation

PURPOSE

Following implantation into adult recipients, living donor liver grafts usually undergo liver regeneration. This regeneration process may provoke the growth of occult hepatocellular carcinoma (HCC) cells in the recipient body. To assess the risk of HCC recurrence, we analyzed the influence of graft-recipient weight ratio (GRWR).

METHODS

The 181 recipients with HCC within the University of California at San Francisco (UCSF) criteria were divided into four groups according to GRWR: low GRWR (<0.8; n = 30), mid GRWR (0.8-1.0; n = 65), high GRWR (>1.0; n = 64), and whole liver graft group (>1.5; n = 22).

RESULTS

There were no differences in overall patient survival (P = .105) and recurrence-free survival (P = .406) among these four groups. GRWR <0.8 was not a significant risk factor for HCC recurrence. Similar outcomes were obtained in HCC patients who met the Milan criteria (n = 170).

CONCLUSIONS

We think that small living donor liver graft and subsequent liver regeneration do not increase the risk of posttransplant HCC recurrence when HCC is within the Milan or UCSF criteria.

Suitable whole blood levels 2 hours after neoral in liver transplant patients: experiences at a single center

Whole blood levels 2 hours after Neoral (C2) administration were observed to correlate better with area under the curve (AUC(0-4)) than trough levels (C0), suggesting that C2 may be the best single time point predictor of Neoral absorption. Owing to concerns about drug toxicity due to excessive immunosuppression, C2 adjustments to target blood levels may represent an advance. The present study measured C2 and levels to determine which correlated more closely with AUC(0-4).

METHODS

Between August 2003 and July 2004, 40 adult liver transplantations were performed in our center. All patients received Neoral twice daily. They were maintained at a C0 level of about 200 ng/mL. C0 levels were measured daily. C2 levels were estimated on postoperative days 3, 5, 7, 14, and 28. AUC(0-4) performed on postoperative days 3, 7, and 28 was calculated using the trapezoidal rule.

RESULTS

The mean AUC(0-4), C0, C1, C2, C3, and C4 were 1100.3 +/- 484.8 ng/mL, 197.1 +/- 84.7 ng/mL, 240.7 +/- 166.2 ng/mL, 307.8 +/- 162.6 ng/mL, 302.8 +/- 138.9 ng/mL, and 300.3 +/- 142.8 ng/mL, respectively. C2 correlated with AUC(0-4) (R2 = 0.868: P < .05) better than C0 (R2 = 0.245: P < .05), C1 (R2 = 0.604: P < .05), or C4 (R2 = 0.583: P < .05).

CONCLUSIONS

Neoral dose monitoring according to a mean C2 range of 307.8 +/- 162.6 ng/mL correlated better with AUC(0-4). Further studies are required to determine suitable C2 levels in liver transplant patients.

Reappraisal of seventh-day syndrome following living donor liver transplantation

Seventh-day syndrome (7DS) is characterized by sudden failure of a liver graft that had been working normally at about 1 week after transplantation, without an identifiable cause. A nonnegligible percentage of cadaveric liver transplants have shown this type of acute graft failure, whereas 7DS has not been reported after living donor liver transplantation (LDLT). Among 580 adult LDLT recipients in our institution between 1997 and 2003, 3 (0.5%) showed clinical sequences typical of 7DS. All three recipients showed similar but unique clinical sequences, consisting of initial uneventful recovery, dramatic rise of serum liver enzyme levels about 1 week later despite potent antirejection therapy, and subsequent graft loss. Liver biopsy findings were compatible with massive hemorrhagic necrosis. Sustained fever lasting for 2 days preceded deterioration of liver function. All three patients died prior to the opportunity for retransplantation. Our findings suggest that, as in cadaveric donor liver transplantation, 7DS can also occur following LDLT and that a preceding episode of sustained fever may be a prodrome of 7DS although its pathogenesis is yet poorly understood.

Pulmonary complications following adult liver transplantation

PURPOSE

Pulmonary complications frequently occur after liver transplantation, but the risk factors associated with them have not been fully determined. We therefore sought to identify risk factors for pulmonary complications among adult liver transplant recipients.

METHODS

We retrospectively reviewed the medical records of 128 consecutive adult patients who underwent 131 liver transplantations during 2001. We evaluated the incidence, time of onset, and outcome of radiographically determined pulmonary complications, as well as the factors predictive of infectious complications.

RESULTS

Postoperative chest roentgenograms detected 68 cases of pulmonary complications, including pleural effusion (n = 50), atelectasis (n = 6), pneumonia (n = 6), pulmonary edema (n = 5), and acute respiratory distress syndrome associated with pneumonia (n = 1). Of the seven patients with pneumonia, five died. On univariate analysis the risk factors predictive for pneumonia were high serum creatinine and total bilirubin, hemodialysis at the time of occurrence, and history of acute rejection and on multivariate analysis increased total bilirubin and history of acute rejection. Pulmonary complications were dependent on the medical condition at the time of occurrence rather than on the preoperative condition.

CONCLUSIONS

Although the incidence of pneumonia in liver recipients was relatively low, the mortality rate in patients who developed this complication was high. High-risk patients undergoing liver transplantation thus require early diagnosis and intensive treatment to diminish the morbidity and mortality associated with pulmonary complications.

Efficacy of 6-Month Pretransplant Abstinence for Patients With Alcoholic Liver Disease Undergoing Living Donor Liver Transplantation

PURPOSE

Questions have been raised regarding the ethics of liver transplantation in patients with alcoholic liver disease (ALD), including the fairness of cadaveric organ allocation to individuals who abuse alcohol and the efficacy of transplantation in these patients, many of whom may relapse. Living donor liver transplantation (LDLT) for ALD patients raises the similar ethical issues. ALD candidates for cadaveric liver transplants are required to abstain from alcohol for 6 months before being listed, but the efficacy of 6 months of abstinence in ALD patients receiving LDLT is not known.

METHODS

We therefore determined the efficacy of 6 months of pretransplant abstinence in 15 ALD patients who underwent LDLT from February 1997 to December 2003.

RESULTS

The Model for End-stage Liver Disease score was 24 +/- 10, and mean pretransplant abstinence period was 15 +/- 13 months, with 11 (73.3%) patients being abstinent for at least 6 months. Four patients received dual grafts, making the number of living donors 19: 12 children, two wives, one brother, three nephews, and one aunt. There were no unrelated donors. Three patients showed a relapse to alcohol drinking. The overall 1-, 3-, and 5-year survival rates were 100%, 100%, and 87.5%, respectively, and the cumulative 1-, 3-, and 5-year relapse rates were 6.7%, 20%, and 20%, respectively. The relapse rates in patients who did and did not maintain 6 months of abstinence were 9.1% and 50%, respectively; this difference was not significant (P = .154), likely due to the small sample size. Younger recipient age was a significant risk factor for alcohol relapse (40 +/- 8 years versus 53 +/- 6 years; P = .004).

CONCLUSIONS

Pretransplant abstinence of 6 months seemed to be beneficial. For ethical reasons, a 6-month abstinence rule should be strictly observed in LDLT.

Supplementation of whole persimmon leaf improves lipid profiles and suppresses body weight gain in rats fed high-fat diet

The objective of this study was to investigate the hypolipidemic effects of powdered whole persimmon leaf supplement in rats fed high-fat diet. Three groups of male Sprague-Dawley rats during 6 weeks were fed different diet: normal control (NC), high-fat (HF), and high-fat supplemented with powdered whole persimmon leaf (PL; 5%, wt/wt) groups. Body weight and relative weight of interscapular brown adipose tissue were significantly lower in the PL group than in the HF group, while plasma leptin concentration was higher. The supplementation of persimmon leaf significantly lowered the plasma total cholesterol and triglyceride concentrations, whereas elevated the ratio of HDL-C/total-C and improved the atherogenic index. Persimmon leaf supplementation led the hepatic cholesterol and triglyceride values to similar levels to the NC group. Accumulation of hepatic lipid droplets and the epididymal white adipocyte size of PL group were diminished comparing to the HF group. Hepatic HMG-CoA and ACAT activities were significantly higher in the PL group than in other groups. Contents of fecal triglyceride, cholesterol and acidic sterol were significantly higher in the PL group than in the HF group. Accordingly, we suggest that supplementation of the powdered whole persimmon leaf improves plasma and hepatic lipid levels profile partly via the increased fecal lipids in high-fat fed rats. These beneficial effects may be due to the properties of its phenolic compounds (1.15 g/100g) and high fiber (63.48 g/100g) content in the powdered persimmon leaf.

Refined Suture Techniques to Prevent Bleeding From Accidental Slippage of Vascular Clamps During Living Donor Hepatectomy

Accidental slippage of vascular clamps during living donor hepatectomy can induce brisk bleeding and even imperil the donor. After practicing more than 1000 cases of living donor hepatectomy, the investigators realized that specialized suture techniques were important to secure the vascular closure to prevent unnecessary bleeding. For secure division of intrahepatic vein branches, we devised a continuous penetration suture method in which the orders of procedures were changed to clamping-closure-cut sequence. For secure division of the main and accessory hepatic vein branches from the inferior vena cava, we applied stay sutures at each corner and midpoint of the hepatic vein stump so as not to permit its slippage. After application of these methods, we did not experience any episode of accidental clamp slippage. We are sure that these suture techniques are beneficial to prevent unnecessary bleeding during living donor hepatectomy and to make surgeons feel at ease during the living donor operation.

A case report of split liver transplantation for two adult recipients in Korea

We report a case of split liver transplantation (SLT) for two adult recipients, which was the first successful case in Korea. The brain-dead donor was a 22-year-old man weighing 65 kg, but his liver volume was estimated as 2120 mL on computed tomographic volumetry. As it seemed to be too large for a 60-kg recipient candidate, SLT was planned after assessment of lobar liver volume and middle hepatic vein anatomy. The right lobe was mobilized first and the liver parenchyma transected along the right border of the middle hepatic vein. The 1240-g right lobe (segments 5 to 8) graft was implanted into a 57-year-old male patient with acute-on-chronic liver failure in the same manner as a living-donor graft. After that, routine procedures of cadaveric multiorgan procurement were performed. The 670-g left lobe (segments 1 to 4) with a retrohepatic vena cava, common bile duct, and aortic patch was implanted into another 37-year-old male recipient. These two recipients recovered uneventfully surviving 12 months to date. We integrated the surgical techniques learned from hundreds of adult-to-adult living donor liver transplants into this first trial of two adult SLT.

Intraoperative assessment of hepatic venous congestion with direct clamping of the hepatic vein trunk for living donor liver transplantation

We devised a hepatic vein clamping method to assess the amount of hepatic venous congestion (HVC) before liver transection. From February 2003 to May 2003, this method was applied to 5 of 58 living donor livers especially to assess donor safety. The left portal vein and proper hepatic artery as well as the middle hepatic vein (MHV)-left hepatic vein (LHV) trunk were clamped simultaneously to assess the HVC in the remnant right lobe before performing extended left lobectomy. As three donors demonstrated the extent of the HVC equivalent to about 40% of the right lobe volume (RLV), their operations proceeded according to the preoperative plan. The territory of HVC after liver transection was the same as that observed with direct clamping of the hepatic vein. However, one donor showed massive HVC more than 50% of RLV and the operative plan was adjusted to harvest only the left lobe without the MHV trunk for donor safety. To assess the HVC in the remnant left lobe, the isolated LHV trunk was occluded after clamping the donor's proper hepatic artery. The whole left lobe except for a small area at the anterior portion of the medial segment became discolored on LHV clamping: the opposite demarcation appeared on MHV clamping. The amount of HVC was so small that we harvested the right lobe with the MHV trunk. All donors and recipients recovered uneventfully. We believe that this direct clamping method makes the assessment of HVC feasible before parenchymal transection of a donor liver.

Contribution of a high dose of L-ascorbic acid to carnitine synthesis in guinea pigs fed high-fat diets

Ascorbate is a cofactor of two-enzyme hydroxylation in the pathway of carnitine biosynthesis. The purpose of this study was to investigate the contribution of ascorbate to endogenous carnitine in guinea pigs fed high-fat diets. The contents of carnitine in plasma, urine and tissues of guinea pigs supplemented with L-ascorbic acid were determined and compared with those supplemented with carnitine. Albino-Hartley guinea pigs were fed vitamin C-deficient diets containing lard throughout the experiment. They were administered orally with 5 mg L-ascorbic acid/d/animal for 14 d, and then divided into three groups and administered orally with the following supplements (/d/animal) for 14 d; L (5 mg L-ascorbic acid), LASA (100 mg L-ascorbic acid), and LCAR (10 mg carnitine plus 5 mg L-ascorbic acid). As a control, a normal group was fed vitamin C-deficient diets and administered orally with 5 mg L-ascorbic acid/d/animal for 28 d. The animals fed high-fat diets (L group) had higher free-carnitine contents in the muscle and urine than the normal group. The groups of LCAR and LASA had significantly higher contents of acid-soluble carnitine (p < 0.05) in plasma than the L group. Urinary excretion of carnitine in the LASA group was decreased to the same level as that in the normal group, although no significant difference between the groups of L and LCAR was observed. Moreover, the supplement of ascorbic acid, but not of carnitine, induced a significantly lower content of triacylglycerol in the plasma of the LASA group as compared to the L group (p < 0.05). These data suggest that high doses of ascorbic acid in guinea pigs fed high-fat diets contribute to the enhancement of carnitine synthesis and improvement of the triacylglycerol content in the plasma.

Immunoglobulin E-dependent active fatal anaphylaxis in mast cell-deficient mice

Mast cells have long been believed to be the central effector cells in the development of immunoglobulin (Ig)E-dependent anaphylaxis. In this study, we investigated the role of mast cells in IgE-dependent hapten-induced active fatal anaphylaxis using mast cell-deficient WBB6F1- W/Wv (W/Wv) and congenic normal (+/+) mice. Although a 5-min delay in shock signs and death were observed in W/Wv mice, 100% fatal reactions to penicillin V (Pen V) occurred in both +/+ and W/Wv mice. Administration of monoclonal anti-IL-4 antibody completely prevented the fatal reactions, and the effect of anti-IL-4 was associated with its suppressive activity on Pen V-specific serum levels of IgE, but not IgG. The platelet-activating factor (PAF) antagonist, BN 50739, completely prevented the fatal reactions in both strains of mice. Our kinetic study revealed, in contrast to no elevation of plasma histamine level in W/Wv mice, high levels of PAF in the circulation after challenge in both +/+ and W/Wv mice, albeit to a lesser degree in the latter case. These data indicate that cells other than mast cells are sufficient to induce an IgE-dependent active fatal anaphylaxis by elaborating PAF, which is the critical mediator for fatal murine anaphylaxis.

Involvement of nuclear factor-kappa B in platelet-activating factor-mediated tumor necrosis factor-alpha expression

Tumor necrosis factor (TNF)-alpha and platelet-activating factor (PAF) are important mediators of inflammatory reactions, and their release is controlled by a positive feedback network. However, the regulatory mechanisms underlying the interaction of these two molecules are unknown. Within 10 min of the injection of lipopolysaccharide (LPS) into C57BL/6 mice, effects inducible by PAF such as anaphylactic shock-like symptoms, disseminated intravascular coagulation, and hemorrhage in renal medullae were observed, and all these pathological changes were prevented by the PAF antagonist, BN 50739. The plasma level of PAF after LPS injection reached a peak at 5 min. TNF-alpha gene expression was evident 20 min after LPS injection and was maximal at 40 min, and the level of serum TNF-alpha reached a peak at 1 h. Pretreatment with BN 50739 inhibited LPS-induced TNF-alpha gene expression and protein synthesis in a dose-dependent manner. Injection of PAF or treatment of the macrophage cell line, J774A.1, with PAF activated the transcription factor, nuclear factor (NF)-kappa B, which is essential for inducible TNF-alpha transcription. The activation of NF-kappa B by PAF preceded the LPS-mediated TNF-alpha gene expression. Pretreatment with BN 50739 inhibited LPS-induced mobilization of NF-kappa B in a dose-dependent manner in vivo as well as in vitro. These data suggest that PAF, which is released immediately or shortly after LPS injection, induces the expression of TNF-alpha through the activation of NF-kappa B.

Anti-IL-4 monoclonal antibody prevents antibiotics-induced active fatal anaphylaxis

We previously reported that anti-IL-4 mAb (11B11) failed to prevent protein-induced fatal murine anaphylaxis. To investigate the effect of anti-IL-4 on hapten-induced anaphylaxis, a model of murine anaphylaxis induced by antibiotics, penicillin V (Pen V) and cephalothin (CET), was developed, and the effect of anti-IL-4 on the anaphylaxis was observed. Pen V and CET induced 100 and 70 to 90% fatal reactions, respectively, when C57BL/6 mice were sensitized i.p. with 500 microg of antibiotic-OVA conjugate with 2 x 10(9) Bordetella pertussis and 1.0 mg of alum and challenged i.v. with 100 microg of antibiotic-BSA conjugate 14 days later. Serum taken from mice sensitized to Pen V passively sensitized normal mice to develop systemic anaphylaxis, and this ability of the serum was abrogated by heating at 56 degrees C for 2 h or depletion of IgE, but not IgG, Abs. Thus, the antibiotic-induced fatal reaction was an IgE-dependent anaphylactic reaction. Administration of anti-IL-4 at the beginning of sensitization completely prevented the fatal anaphylactic reactions to both Pen V and CET. This effect of anti-IL-4 was associated with its suppressive activity on antibiotic-specific serum IgE, but not IgG, levels. More importantly, anti-IL-4 therapy in previously sensitized mice was also effective in preventing the fatal reactions and rapidly reduced the established IgE levels. This study provides a new animal model of hapten-induced anaphylaxis and indicates that blocking of IL-4 activity may be beneficial in allergic diseases caused by a variety of haptens in which IgE Abs play a major role.

Anti-IL-4 monoclonal antibody prevents antibiotics-induced active fatal anaphylaxis

We previously reported that anti-IL-4 mAb (11B11) failed to prevent protein-induced fatal murine anaphylaxis. To investigate the effect of anti-IL-4 on hapten-induced anaphylaxis, a model of murine anaphylaxis induced by antibiotics, penicillin V (Pen V) and cephalothin (CET), was developed, and the effect of anti-IL-4 on the anaphylaxis was observed. Pen V and CET induced 100 and 70 to 90% fatal reactions, respectively, when C57BL/6 mice were sensitized i.p. with 500 microg of antibiotic-OVA conjugate with 2 x 10(9) Bordetella pertussis and 1.0 mg of alum and challenged i.v. with 100 microg of antibiotic-BSA conjugate 14 days later. Serum taken from mice sensitized to Pen V passively sensitized normal mice to develop systemic anaphylaxis, and this ability of the serum was abrogated by heating at 56 degrees C for 2 h or depletion of IgE, but not IgG, Abs. Thus, the antibiotic-induced fatal reaction was an IgE-dependent anaphylactic reaction. Administration of anti-IL-4 at the beginning of sensitization completely prevented the fatal anaphylactic reactions to both Pen V and CET. This effect of anti-IL-4 was associated with its suppressive activity on antibiotic-specific serum IgE, but not IgG, levels. More importantly, anti-IL-4 therapy in previously sensitized mice was also effective in preventing the fatal reactions and rapidly reduced the established IgE levels. This study provides a new animal model of hapten-induced anaphylaxis and indicates that blocking of IL-4 activity may be beneficial in allergic diseases caused by a variety of haptens in which IgE Abs play a major role.

A protective role of platelet-activating factor in murine candidiasis

Platelet-activating factor (PAF) is a potent phospholipid-derived modulator of immunological and inflammatory processes. In this study, the role of exogenous and endogenous PAF in resistance to infection with Candida albicans was investigated. Administration of PAF following a lethal challenge of C. albicans significantly protected mice from death and reduced the number of organisms in the kidneys. Neutralization of endogenous PAF with the PAF antagonist BN50739 shortened the mean survival time and increased the number of C. albicans cells per kidney. Shortly after infection of mice (30 min), significant levels of PAF were detected in the serum. PAF-induced protection appears to be mediated through the actions of tumor necrosis factor alpha (TNF-alpha), since pretreatment with anti-TNF-alpha before each injection of PAF abrogated the majority of PAF-induced enhanced resistance. Administration of PAF in vivo elevated serum TNF-alpha levels and TNF-alpha mRNA expression in the kidney. Production of TNF-alpha was markedly diminished by pretreatment with the PAF antagonist BN50739 prior to infection with C. albicans. We conclude that PAF, which is produced during infection with C. albicans, plays an important role in determining the level of resistance to this infectious microorganism. This effect of PAF appears to be mediated, at least in part, through the induction of TNF-alpha.

Augmentation of tumor metastasis by platelet-activating factor

The effect of platelet-activating factor (PAF) on experimental pulmonary metastasis by the B16F10 murine melanoma and the possible involvement of PAF in the activities of tumor necrosis factor alpha (TNF-alpha) and interleukin 1alpha (IL-1alpha) in tumor metastasis were investigated. i.p. injection of PAF enhanced the lung colonization in a dose- and time-dependent manner. PAF enhanced lung colonization when it was administered after, but not before, B16F10 inoculation. Multiple injections of PAF were more effective than a single injection. Neutralization of endogenous PAF with PAF antagonist BN50739 decreased lung colonization, suggesting that endogenous PAF plays an important role in pulmonary metastases. A single i.p. injection of TNF-alpha or IL-1alpha caused a marked enhancement in lung colonization. TNF-alpha- and IL-1alpha-mediated enhancement in lung colonies was significantly inhibited by BN50739. These results demonstrate that PAF has a metastasis-enhancing effect and is a mediator of the metastatic activities of TNF-alpha and IL-1alpha.

Anti-IL-4 antibody inhibits antigen specific IgE response but fails to prevent chicken gamma globulin-induced active systemic anaphylaxis: evidence for the involvement of IgG antibodies

It has recently been reported that interleukin-4 (IL-4) is required for the production of IgE, and anti-IL-4 monoclonal antibody (mAb) inhibits in vivo IgE responses. These suggest that blocking of IL-4 activity may be useful for the prevention or treatment of immediate hypersensitivity disorders. In this study we investigated whether anti-IL-4 has a regulatory role in chicken-gamma globulin (CGG)-induced active systemic anaphylaxis. Multiple injections of anti-IL-4 (up to 40 mg/mouse) failed to protect the mice from fatal anaphylaxis. Anti-IL-4 strongly suppressed CGG-specific IgE response (> 90%) without any suppressive effect on CGG-specific IgG (IgG1, IgG2a, IgG2b, and IgG3) responses. Because these data suggest the possibility that fatal anaphylaxis could be induced by IgG antibodies, we examined the possibility using anti-CGG polyclonal and the subclasses of IgG monoclonal antibodies. Passive sensitization of mice with polyclonal antibodies elicited severe and fatal anaphylactic shock; about 50% of the mice died. The activity of antibodies was not diminished by heat treatment (56 degrees C, 2h), suggesting that the anaphylaxis was not mediated by IgE. Shock was also elicited by each subclass of IgG mAb; of these, IgG1 was the most effective. Combination of the IgG subclasses elicited more exaggerated shock; about 30% of mice died. These data indicate that IgG antibodies are themselves sufficient to induce systemic anaphylaxis. Therefore, the failure of anti-IL-4 to prevent active anaphylaxis is probably due to the inability of anti-IL-4 to suppress the production of IgG antibodies.

Occurrence of disseminated intravascular coagulation (DIC) in active systemic anaphylaxis: role of platelet-activating factor

The possible occurrence of DIC in active systemic anaphylaxis was investigated in mice. Induction of active systemic anaphylaxis resulted in the development of DIC symptoms such as thrombocytopenia, prolongation of prothrombin time, hypofibrinogaemia, and elevated level of fibrinogen/fibrin degradation products. In addition, in histological examinations, massive congestion and cellular infiltration in pulmonary interstitia, and considerable haemorrhage in renal medullae were observed. All these changes were nearly completely prevented by pretreatment with platelet-activating factor (PAF) antagonist (BN 50739). Moreover, the same haematological and morphological changes were produced by a bolus injection of PAF. These data strongly suggest that DIC occurs in active systemic anaphylaxis and PAF plays a pivotal role in the development of DIC in anaphylaxis.

Ascorbate indirectly stimulates fatty acid utilization in primary cultured guinea pig hepatocytes by enhancing carnitine synthesis

L-Ascorbic acid is required for the synthesis of L-carnitine, which is essential for the oxidation of long-chain fatty acids. The purpose of this study was to investigate the role of ascorbate on the oxidation of long-chain fatty acids in primary cultured guinea pig hepatocytes. The hepatocytes were incubated in medium containing carnitine in the presence or absence of fatty acids. Exogenous fatty acids had no influence on the uptake of total carnitine into cells, but they lowered the free carnitine and consequently raised the concentration of short-chain acyl carnitine. Furthermore, carnitine supplementation of the medium in the presence of fatty acids led to a decrease of triglycerides in cells and an increase in the secretion of beta-hydroxybutyrate. These changes were also induced by the supplementation of the medium with both ascorbate and the precursor of carnitine (gamma-butyrobetaine) in the presence of fatty acids, although either ascorbate of gamma-butyrobetaine alone had no effect. In addition, increasing the concentration of supplemental ascorbate resulted in an enhancement of ketogenesis and a decrease of triglyceride accumulation. These results suggest that ascorbate enhances carnitine synthesis, which in turn stimulates beta-oxidation of fatty acids.

The regulatory effect of ascorbate on the carnitine synthesis in primary cultured guinea pig hepatocytes

The effect of ascorbate (AsA) on the synthesis of carnitine from gamma-butyrobetaine (BB) in primary cultured guinea pig hepatocytes was investigated. The hepatocyte monolayers preloaded with AsA were incubated for 4 h in medium with various concentrations of BB as the precursor of carnitine. The accumulation of carnitine reached a maximum when the cells were incubated with 0.05-1.0 mM BB and significantly decreased with excess BB (5 mM). In contrast, increasing concentrations of AsA supplemented to medium led to an increase in carnitine content, but AsA and total AsA contents in cells decreased by BB supplementation. Regarding the enhancement of hydroxylation of BB in the hepatocytes, AsA was the most effective among such other reducing agents as glutathione and dithiothreitol. Although erythorbate (ErA) also stimulated the hydroxylation of BB, carnitine content in cells preloaded with ErA was only 60% of that with AsA. These results suggest that AsA is specifically required for the hydroxylation of BB. Furthermore, AsA can regulate carnitine synthesis in the primary cultured guinea pig hepatocytes.

Regulation of human B cell proliferation and differentiation by seminal plasma

To investigate the role of seminal plasma in human B cell functions, its effect on the proliferation and antibody secretion of tonsillar B cells and an Epstein-Barr virus (EBV) transformed human B cell line, A4, was examined. Seminal plasma inhibited both the proliferation and differentiation of normal B cells only when added to the cultures at the early period of culture. If addition of seminal plasma was delayed beyond 5 to 6 days, it failed to inhibit IgG secretion. Seminal plasma did not show any inhibitory effect on A4 cells, but rather enhanced both the proliferation and IgG secretion of this B cell line. When the low and high mol. wt fractions of seminal plasma were tested for their biological effects on normal and transformed B cells, the low mol. wt fraction (less than 1 kD) was associated with the inhibitory effect of seminal plasma on normal B cells, whereas high mol. wt fractions (both dialysed and 1500-kD fraction) was involved in the enhancing effect on A4 cells. We conclude that (i) seminal plasma inhibits the early proliferation of normal human B cells, but does not inhibit the antibody-secreting capacity of mature B cells; and (ii) different molecules of seminal plasma act on the different stages of B cell maturation.

The effect of graded doses of ascorbic acid on the tissue carnitine and plasma lipid concentrations

Ascorbic acid (AsA) is known to be required for the synthesis of carnitine. The present study was designed to clarify the effect of AsA on the carnitine synthesis and lipid metabolism in guinea pigs. The animals were divided into four groups, and fed AsA-free diets for three weeks. Each group was supplemented with AsA in the following doses; high-AsA group, 100 mg AsA/day/animal; control group, 5 mg AsA/day/animal; AsA-deficient group, 0.1 mg AsA/day/animal; pair-fed group, 5 mg AsA/day/animal. The pair-fed group was restricted to the amount of diet consumed by the AsA-deficient group. Tissue carnitine levels of the AsA-deficient group were significantly lower than not only the control group but the pair-fed group. Total cholesterol and phospholipid levels in plasma of the AsA-deficient group were found to be similar to those of the pair-fed group; however, plasma triglyceride levels were significantly higher than that of the pair-fed group. Furthermore, there was an inverse relationship between tissue AsA and plasma triglyceride levels. We concluded that carnitine synthesis and triglyceride metabolism in guinea pigs may be impaired by the decrease of tissue AsA level rather than by the insufficient food intake. It is suggested that tissue carnitine level altered by tissue AsA content affects plasma triglyceride level.

An improved high-performance liquid chromatographic assay for the determination of free and esterified carnitine in animal tissues

A high-performance liquid chromatographic procedure for the determination of carnitine that is converted to coenzyme A(CoA) stoichiometrically by carnitine acetyltransferase is described. The chromatographic separation was accomplished by using Unisil QC8 column and a mixture of 190 mM KH2PO4 and methanol (87:13, v/v) as eluent. The present method is rapid, sensitive, and can be used for the routine analysis of animal tissues and plasma.

Human seminal plasma suppresses delayed-type hypersensitivity responses to intravaginally deposited sheep red blood cells and sperm: separation of immunosuppressive factors

Although significant progress has been made in identifying the immunosuppressive factors in seminal plasma (SP) and their possible action in vitro, the potential role of SP in naturally occurring normal immune responses in vivo is less certain. Human SP or its fractions, administered 5 or 10 times at 3-day intervals into the mouse vagina simultaneously with washed human sperm or sheep red blood cells, suppressed the delayed-type hypersensitivity reactions to footpad injection of the antigens. However, SP failed to suppress antibody formation to these antigens in the applied experimental conditions. In an in vitro study, SP suppressed the proliferation of human peripheral blood mononuclear cells to phytohemagglutinin. This suppression of in vitro proliferation by SP was mediated by materials of both low (LMW) and high molecular weight (HMW). Among the HMW materials, a factor with approximately 1,500 kilodaltons, partially purified by DEAE-cellulose chromatography and gel filtration, exhibited the most potent suppressor activity in vitro and in vivo. The suppressive activities of SP or its fractions were not abolished by treatment with both heat (95 degrees C for 10 min) and trypsin (1.0 mg/ml, 37 degrees C for 4 h). These findings indicate that SP could contribute to the development of suppressed cellular immunity to sperm; immunosuppressive actions of SP are mediated by at least two distinct factors in vivo as well as in vitro.

Systemic anaphylaxis in mast-cell-deficient mice of W/Wv and Sl/Sld genotypes

Active systemic anaphylaxis was induced in mast-cell-deficient mice of W/Wv and Sl/Sld genotypes. The mast-cell-deficient mice were successfully sensitized either by an intraperitoneal injection of chicken gamma-globulin (C gamma G) mixed with adjuvant, alum and saline extract of Bordetella pertussis, or by an intravenous injection of C gamma G alone. Sensitized mice showed signs of systemic anaphylaxis and died after one or more intravenous challenge injections of C gamma G. These studies show that active systemic anaphylaxis can occur in mast-cell-deficient mice and suggest that cells other than mast cells may release adequate mediators to support systemic anaphylaxis.

Immune response potential of mast cell-deficient W/Wv mice

Immune responses of mast cell-deficient WBB6F1-W/Wv mice and their mast cell-sufficient littermates (LM: WBB6F1-W/+, Wv/+ and +/+) were compared. After a single intravenous injection of sheep erythrocytes (SE), polyvinylpyrrolidone or bacterial lipopolysaccharide, the antigen-specific IgM plaque-forming cell (PFC) response of W/Wv mice was similar to or greater than the response of LM mice. When both primary and secondary injections of SE or chicken gamma-globulin were given to mice and antigen-specific IgG PFC responses quantified, the response of W/Wv again was similar to or greater than that of LM mice. Serum titers of antigen-specific IgE were higher in W/Wv than in LM mice after injections of ovalbumin in alum or infections of Nippostrongylus brasiliensis. Ovalbumin-sensitized W/Wv and LM mice developed active systemic anaphylaxis after ovalbumin challenge. The ability of W/Wv mice to be sensitized for and elicit contact sensitivity (CS) reactions was studied using picryl chloride or dinitrofluorobenzene as sensitizing and challenge agents and quantifying 24-hour reactions by change in ear thickness. SE or methylated bovine serum albumin was used to sensitize and challenge mice for delayed-type hypersensitivity (DTH) reactions which were quantified at 24 h by change in foot pad or ear thickness. CS and DTH reactions of W/Wv and LM mice were similar. No evidence of immune deficiency of W/Wv mice was found.

Delayed expulsion of adult Trichinella spiralis by mast cell-deficient W/Wv mice

Mast cell-deficient W/Wv mice and their mast cell-sufficient littermates were given infections of Trichinella spiralis. W/Wv mice were slower than their littermates to expel adult T. spiralis. Repair of the mast cell deficiency of W/Wv mice by bone marrow grafting was accompanied by accelerated expulsion of T. spiralis.

The thymic suppressor cell. I. Separation of subpopulations with suppressor activity

This study confirms the finding that washed thymocytes from rats given 100 mg of BGG 48 h earlier, when transferred to syngeneic recipients, exert a specific suppressor effect on immunological responses to BGG in the latter. The active cells are found in a subpopulation of low density, making up less than 10% of the total thymocytes, and are partially resistant to hydrocortisone.