Complete response and long‑term survival after stereotactic body radiotherapy in a patient with liver metastasis from α‑fetoprotein‑producing gastric cancer: A case report

α-Fetoprotein (AFP)-producing gastric carcinoma (GC) (AFPGC) is a special subtype of GC that is clinically characterized by a high incidence of liver metastasis and poor prognosis. The present study reported the case of a patient with AFPGC who showed complete response (CR) after stereotactic body radiotherapy (SBRT) for liver metastasis. A 76-year-old male patient underwent total gastrectomy with D2 lymph node dissection for GC. The excised tumor was diagnosed as AFPGC due to the patient's high serum AFP level (3,763 ng/ml) and AFP expression on immunohistochemistry. The patient was diagnosed with liver metastasis two months after the surgery. 18F-fluorodeoxyglucose positron emission tomography indicated that the metastasis was a single recurrent focus. Although the patient underwent seven cycles of chemotherapy with S-1-based regimens, the metastatic tumor showed only a minor response despite the decrease in serum AFP levels. To realize high-quality disease control, SBRT was performed on the liver tumor (total dose of 48 Gy in four fractions). The metastasis showed a significant response two weeks after the completion of SBRT and CR two years later. CR was sustained and the patient survived with no evidence of recurrence 62 months after the diagnosis of liver metastasis. Literature data on the efficacy of radiotherapy for liver metastasis from AFPGC remain scarce. The present case report suggests that SBRT has high efficacy for oligometastatic diseases and may be included as an indication for the treatment of liver metastasis from AFPGC.

31 PRODUCTION EFFICIENCY OF GENE KNOCKOUT PIGS USING GENOME EDITING AND SOMATIC CELL CLONING

Genome editing technologies have been used as a powerful strategy for the generation of genetically modified pigs. We previously developed genetically modified clone pigs with organogenesis-disabled phenotypes, as well as pigs exhibiting diseases with similar features to those of humans. Here, we report the production efficiency of various gene knockout cloned pigs from somatic cells that were genetically modified using zinc finger nucleases (ZFN) or transcription activator-like effector nucleases (TALEN). The ZFN- or TALEN-encoding mRNAs, which targeted 7 autosomal or X-linked genes, were introduced into porcine fetal fibroblast cells using electroporation. Clonal cell populations carrying induced mutations were selected after limiting dilution. The targeted portion of the genes was amplified using PCR, followed by sequencing and mutation analysis. Among the collected knockout cell colonies, cells showing good proliferation and morphology were selected and used for somatic cell nuclear transfer (SCNT). In vitro-matured oocytes were obtained from porcine cumulus-oocyte complexes cultured in NCSU23-based medium and were used to obtain recipient oocytes for SCNT after enucleation. SCNT was performed as reported previously (Matsunari et al. 2008). The cloned embryos were cultured for 7 days in porcine zygote medium (PZM)-5 to assess their developmental ability. Cloned embryos were transplanted into the oviduct or uterus of oestrus-synchronized recipient gilts to evaluate their competence to develop to fetuses or piglets. Cloned embryos reconstructed with 7 types of knockout cells showed equal development to blastocysts compared with those derived from the wild-type cells (54.5–83.3% v. 60.7%). Our data (Table 1) demonstrated that the reconstructed embryos derived from knockout cells could efficiently give rise to cloned offspring regardless of the type of genome editing methodology (i.e. ZFN or TALEN). Table 1.Production efficiency of gene knockout cloned pigs using genome editing This study was supported by JST, ERATO, the Nakauchi Stem Cell and Organ Regeneration Project, JST, CREST, Meiji University International Institute for Bio-Resource Research (MUIIBR), and JSPS KAKENHI Grant Number 26870630.

73 APPLICATION OF THE HOLLOW FIBER VITRIFICATION METHOD TO THE CRYOPRESERVATION OF HIGHLY CRYOSENSITIVE EMBRYOS

We recently demonstrated that the hollow fibre vitrification (HFV) method (Matsunari et al. 2012) could effectively be applied to the cryopreservation of embryos from diverse species. In this study, we applied the HFV method to the cryopreservation of highly cryosensitive specimens, such as in vitro matured (IVM)/IVF-derived porcine zona-free morulae and blastomeres isolated from those morulae, as well as IVM/IVF-derived cattle embryos at early cleavage stages. Porcine parthenogenetic morulae (d-4) derived from IVM oocytes were treated with 0.25% pronase to remove zona pellucidae. The resulting blastomeres were isolated from the zona-free morulae by a decompaction treatment followed by gentle pipetting. Bovine IVM-IVF embryos at the 2 to 4 cell (d-1), 8 to 16 cell (d-3), and morula stages (d-5) were then subjected to vitrification. The HFV procedure was performed as described previously using 15% dimethyl sulfoxide, 15% ethylene glycol, and 0.5 M trehalose as cryoprotectants. Four to twenty embryos, or all of the blastomeres isolated from a single morula, were individually loaded into a cellulose acetate hollow fibre (25 mm long, 185 μm φ, 15 μm membrane thickness) and vitrified. Survival of the vitrified embryos was assessed by in vitro development to blastocysts. Blastomeres recovered after vitrification were aggregated in micro-wells to examine their ability to form blastocysts. The HFV method was demonstrated to be effective for cryopreserving zona-free in vitro-produced porcine morulae and the blastomeres isolated from them (Table 1), as well as bovine IVM-IVF embryos at early cleavage stages. These data demonstrate that the HFV method is effective for highly cryosensitive specimens, such as IVM/IVF-derived porcine zona-free morulae and blastomeres isolated from those morulae, and IVM/IVF-derived cattle embryos at early cleavage stages. These achievements may expand the technological options in the production of cloned and genetically modified pigs that are useful for biomedical research. Table 1.Survival of zona-free porcine morulae and isolated blastomeres after vitrification (top) and blastocyst formation rates in bovine early-stage in vitro matured-IVF embryos after vitrification (bottom) This study was supported by JST, ERATO, the Nakauchi Stem Cell and Organ Regeneration Project, and MUIIBR.

Temporary cardiac pacing for fatal arrhythmia in living-donor liver transplantation: three case reports

Cardiac pacing often turns out to be the only effective treatment of severe, life-threatening arrhythmias. We performed 77 living-donor liver transplantations (LDLT) from 1999 to 2007. In these cases, three recipients experienced fatal arrhythmia and required temporary cardiac pacing during the perioperative period. The first case was a 68-year-old woman diagnosed with liver cirrhosis and hepatocellular carcinoma (HCC). Her Model for End-Stage Liver Disease (MELD) score was 34. We performed LDLT using a right lobe graft. She showed complete atrioventricular block with cardiac arrest at postoperative day (POD) 42 after a bacterial infection. We performed a resuscitation and instituted temporary cardiac pacing. However, she was dead at POD 43. Pathologic findings at autopsy showed a diffuse myocardial abscess, which caused the fatal arrhythmia. The second case was a 58-year-old man diagnosed with HCC and liver cirrhosis; his MELD score was 9. We performed LDLT using a right lobe graft. He showed atrial fibrillation after septic shock. He also showed sinus bradycardia with a cardiac arrest at POD 10. We performed resuscitation and emergent temporary pacing. He recovered and was alive without recurrence of arrhythmia or infection. The third case was a 58-year-old woman diagnosed with multiple HCC. During preoperative regular check-up, she was diagnosed to have cardiac hypertrophy and was started on beta-blockers as treatment for cardiac hypertrophy. However, severe bradycardia necessitated temporary cardiac pacing. LDLT was performed safely after implantation of a pacemaker. Early use of temporary cardiac pacing for severe arrhythmias may be effective to maintain the hemodynamic state in LDLT.

Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation

BACKGROUND/PURPOSE

Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living-donor liver transplantation. The aim of this study was to analyze the clinical implications of three different methods of biliary reconstruction in left-lobe adult living-donor liver transplantation.

METHODS

We retrospectively compared three groups of patients: those who had Roux-en-Y hepaticojejunostomy (HJ; n = 11) biliary reconstruction, those who had duct-to-duct hepaticohepaticostomy (HH) with external stent (n = 11), and those who had HH with a T-tube (n = 6). Median follow-up for each group was 31, 30, and 10 months, respectively.

RESULTS

Bile leaks were observed in 45.5% of the patients in both the HJ group and the HH with external stent group. Biliary anastomotic strictures occurred in 9% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with external stent. No biliary complications were observed in the HH with a T-tube group (P = 0.049).

CONCLUSIONS

Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up period, these encouraging preliminary results may warrant further studies of this biliary reconstruction technique in left-lobe adult living-donor liver transplantation.

Management of Major Portosystemic Shunting in Small-for-Size Adult Living-Related Donor Liver Transplantation with a Left-Sided Graft Liver

PURPOSE

We investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver.

METHODS

Five patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 +/- 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated.

RESULTS

The portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH(2)O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH(2)O to 258 mmH(2)O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl.

CONCLUSIONS

We recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.

Preoperative human-telomerase reverse transcriptase mRNA in peripheral blood and tumor recurrence in living-related liver transplantation for hepatocellular carcinoma

BACKGROUND/AIMS

In this study we evaluated the potential role of preoperative h-TERT mRNA expression in peripheral blood as a tool for predicting prognosis and tumor recurrence after living-related liver donor transplantation (LRLDT).

METHODOLOGY

The study included patients with unresectable HCC who underwent LRLDT from July 1999 to May 2003.

RESULTS

There was no significant difference between the survival curves of those patients who met the Milan criteria and those who did not. However, there was a statistically significant difference (p=0.032) between the survival curves of those patients with positive preoperative h-TERT mRNA expression, and those who either had an initially negative preoperative h-TERT mRNA or who converted from positive to negative after neoadjuvant immunochemotherapy.

CONCLUSIONS

In conclusion, the presence or absence of h-TERT mRNA in the peripheral blood may be a useful criterion in evaluating HCC patients for transplantation, as well as a valuable method of assessing anti-tumor therapy and tumor relapse.

Successful surgical treatment for hepatocellular carcinoma and concomitant risky esophageal varices

BACKGROUND/AIMS

In our frequent encounters with liver cirrhotic patients with hepatocellular carcinoma (HCC) and concomitant risky esophageal varices, we have found that some of them required endoscopic injection sclerotherapy (EIS) and/or surgical treatment for esophageal variceal bleeding due to increased portal venous pressure after aggressive hepatectomy. In this study, we investigated the short-term effect of aggressive hepatectomy accompanied with left gastric venous caval shunt (Inokuchi's shunt) for esophageal varices and postoperative liver function.

METHODOLOGY

Four cirrhotic patients with HCC and concomitant risky esophageal varices underwent hepatectomy with Inokuchi's shunt from 1999 to 2001. The mean age was 58.0 +/- 15.3 years old and all patients were classified in Child grade A or B. We investigated hematochemical data and endoscopic findings before and after surgery.

RESULTS

One of the patients experienced disappearance of esophageal varices at discharge. In the others, postoperative endoscopy showed disappearance of CRS and reduced sizes of varices. In one patient, hepatic encephalopathy appeared transiently with bleeding from a duodenal ulcer at one month after surgery. However, the patient improved by conservative treatment. Three of the patients have survived well without recurrence of HCC and esophageal variceal bleeding; the remaining patient died from a recurrence of HCC.

CONCLUSIONS

Inokuchi's shunt may be sufficiently effective to treat risky esophageal varices associated with resectable HCC and may be safe even if it is undertaken along with a major hepatectomy.

Augmentation of heme oxygenase-1 expression in the graft immediately after implantation in adult living-donor liver transplantation

Heme oxygenase (HO)-1 is a cytoprotective protein and has recently been identified as a graft survival gene. However, there are little data currently available regarding the expression of HO-1 in human living-related liver transplantation. This is the first report that HO-1 expression is increased in small-for-size liver allografts. We performed biopsies of the graft liver and donor liver left in six patients at four time points during the procedure and studied HO-1 expression by reverse-transcriptase polymerase chain reaction and immunohistochemistry. HO-1 mRNA was expressed at a low level in steady-state liver tissue but was strongly expressed after perfusion of the graft liver. HO-1 expression increased in nonparenchymal cells in the human graft liver. The number of HO-1 positive cells increased threefold by the end of liver transplantation. This study suggests that ischemia-reperfusion injury and excessive shear stress secondary to portal hypertension might augment HO-1 expression in the graft liver.

Serum LECT2 level as a prognostic indicator in acute liver failure

In the present study, we investigated the relationship between serum leukocyte cell-derived chemotaxin2 (LECT2) levels and liver function in patients with acute liver failure, and its use as a prognostic indicator. We studied six acute liver failure patients (two women, four men; 49.8 +/- 20.7 years old) admitted to our hospital in 2002. These patients had diagnoses of fulminant hepatitis due to acute liver failure (1) from congestive heart failure; (2) from portal venous gas, and (3) from postoperative disseminated intravascular coagulation (DIC). We measured serum LECT2, GOT, and GPT levels, the last two being inversely proportionate to the serum LECT2 levels. When the serum GPT levels peaked, the serum LECT2 levels were the lowest. When the liver function recovered, serum LECT2 levels increased. Three of four patients died due to liver failure, one to congestive heart failure. Maximum serum LECT2 levels among the expired group were significantly lower than those among the alive group (0.96 +/- 0.8 ng/mL vs 12.9 +/- 4.3 ng/mL). Serum LECT2 levels may be a prognostic indicator of recovery from liver failure. The present study suggests that in clinical medicine LECT2 participates in regeneration after injury of hepatocytes.

Changes in serum LECT 2 levels during the early period of liver regeneration after adult living related donor liver transplantation

We investigated changes in serum leukocyte cell-derived chemotaxin2 (LECT2) levels between donors and recipients in the early period during liver regeneration following adult living related donor liver transplantation (LRDLT). Five recipients (three women, two men; 37.0 +/- 15.8 years old), all of whom had end-stage liver failure, underwent LRDLT from healthy five donors (two women, three men; 41.6 +/- 14.3 years old) between June 2000 and February 2001. FK506 and methylprednisolone were used as immunosuppressants for recipients. Serum LECT2 levels decreased immediately after both the hepatectomy in all donors and the implantation of liver graft in all recipients. Donors showed a nadir at 3 to 12 hours, increasing at 24 to 48 hours. The nadir in recipients occurred several hours after the donors. The serum LECT2 levels of donors were significantly higher than those of recipients on day 5 (9.5 +/- 5.9 ng/mL vs 3.1 +/- 2.2 ng/mL, P = .04) and on day 7 (9.3 +/- 3.8 ng/mL vs 3.5 +/- 1.1 ng/mL, P = .04). Serum GPT and GOT levels were inversely proportionate to the serum LECT2 levels. The present studies suggest that LECT2 participates in liver regeneration and injury following hepatectomy.

Living related donor liver transplantation for primary sclerosing cholangitis with hepatocellular carcinoma and Crohn's disease: a case report

INTRODUCTION

Primary sclerosing cholangitis (PSC) is a premalignant condition associated with a risk of developing cholangiocarcinoma in 10% to 20% of patients. However, the prevalence of hepatocellular carcinoma (HCC) in patients with PSC is estimated to be only 2%. In addition, PSC often occurs in association with inflammatory bowel disease. Ulcerative colitis occurs in 60% of PSC patients and Crohn's disease occurs in about 10%. We diagnosed a patient as having PSC with HCC and concomitant Crohn's disease prior to living related donor liver transplantation (LRDLT).

PATIENTS AND METHODS

A 63-year-old woman was diagnosed as having PSC with solitary HCC. Preoperative liver condition was Child-Pugh grade C. Colonoscopic findings showed an active longitudinal ulcer in the terminal ileum and clinically diagnosed Crohn's disease. The medical treatment was 5'-aminosalicylates. She received a left lobe graft from her daughter. The immunosuppressants were tacrolimus and azathioprine, which was changed to predonisolone because of leukopenia and moderate acute cellular rejection, after which the postoperative course was uneventful. Colonoscopic findings revealed disappearance of the longitudinal ulcer in the terminal ileum at 15 months after LRDLT. There was no evidence of PSC or HCC recurrence.

CONCLUSIONS

Generally, PSC with HCC is rare with a poor prognosis; however, LRDLT may be a treatments option although the patient with PSC had a combined HCC. Moreover, aminosalicylates together with the immunosuppressants may be effective for the clinical management of concomitant Crohn's disease.

Biliary reconstruction and complications of left lobe living donor liver transplantation

Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living donor liver transplantation. The aim of this study was to analyze the clinical implications of three methods of biliary reconstruction in left lobe adult living donor liver transplantation. We retrospectively compared three groups of patients who underwent various biliary reconstructions: those who had Roux-en-Y hepaticojejunostomy (HJ) (n = 11); duct to duct hepaticohepaticostomy (HH) with an external stent (n = 11); or HH with T-tube (n = 6). The median follow-up for each group was 29, 28, and 8 months, respectively. Bile leaks were observed in 45.5% of both the HJ and the HH with external stent groups. Biliary anastomotic strictures occurred in 9.1% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with an external stent. No biliary complications were observed in the HH over a T-tube group (P = .049). Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up, these encouraging preliminary results warrant further studies of this biliary reconstruction technique for left lobe adult living donor liver transplantations.

Surgical Procedures for Decompression of Excessive Shear Stress in Small-For-Size Living Donor Liver Transplantation—New Hepatic Vein Reconstruction

We have reported that acute elevation of portal pressure, reflecting wall shear stress of sinusoidal endothelial cells, triggers liver regeneration after partial hepatectomy and that excessive portal hypertension induces liver failure. For prevention of excessive shear stress in small-for-size living donor liver transplantation (LDLT), we developed a new hepatic vein reconstruction to expand the anastomotic site. Fourteen adult patients, who underwent LDLT, were divided into two groups: previous end-to-end hepatic vein reconstruction in nine patients (group P) and the new method in five patients (group N). The outside middle and left hepatic veins of the graft were incised and enlarged to 40 mm. The vena cava was cut 40 mm longitudinally. The graft was positioned a quarter turn counterclockwise with the hepatic vein of the graft anastomosed end-to-side to the vena cava longitudinally. Postoperative portal pressures and serum total bilirubin levels of these two groups showed portal pressure in group N to rapidly decrease below 25 cm H2O following LDLT. No cases showed posttransplanted hyperbilirubinemia above 10 mg/dL in group N; however, all cases were small-for-size grafts. Moreover, serum total bilirubin levels in group N were significantly lower than those in group P. This procedure is simple despite not using a venous patch. If the hepatic vein is narrow or obstructed, such as in Budd-Chiari syndrome, the procedure is applicable. Even in small-for-size grafts, excessive tension did not occurred at the portal vein or hepatic artery anastomoses. Moreover, it is possible to avoid outflow block and posttransplanted hyperbilirubinemia.

Important role for macrophages in induction of crescentic anti-GBM glomerulonephritis in WKY rats

BACKGROUND

A crucial role for CD8(+) cells in induction of crescentic anti-glomerular basement membrane (GBM) glomerulonephritis (GN) in WKY rats was demonstrated in studies showing that depletion of CD8(+) cells completely suppressed glomerular accumulation of monocytes/macrophages (Mo/Mphi), crescent formation and proteinuria. Because these studies did not definitively identify CD8(+) cells as the cause of tissue injury, we examined the roles of Mo/Mphi in the development of anti-GBM GN.

METHODS

We examined correlations between the amount of urinary protein and the numbers of glomerular CD8(+) cells or Mo/Mphi in rats after administrating different doses of anti-GBM antibody (5.0, 7.5, 10.0 and 25.0 microl/100 g body weight). The roles of Mo/Mphi in induction of GN were examined in animals by depleting Mo/Mphi in the glomerulus. To do this, rats were injected intravenously with liposome-encapsulated dichloromethylene diphosphonate (liposome-MDP) from day 3 to day 7 after anti-GBM antibody injection and they were then sacrificed at day 8.

RESULTS

Liposome-MDP treatment significantly reduced the number of ED-1(+) Mo/Mphi accumulated in glomeruli from 32.1 +/- 1.2 to 1.4 +/- 0.3/glomerular cross-section (mean +/- SD, P < 0.01), and the amount of urinary protein from 103.8 +/- 19.8 to 31.8 +/- 15.9 mg/day (P < 0.01), as well as the incidence of crescentic glomeruli from 91.3 +/- 2.7 to 23.3 +/- 7.6% (P < 0.01) at day 8. This treatment also reduced the number of CD8(+) cells accumulating in the glomeruli from 5.4 +/- 0.7 to 0.5 +/- 0.1/glomerular cross-section (P < 0.01). Upregulation of glomerular intercellular adhesion molecule 1 (ICAM-1) and monocyte chemoattractant protein 1 (MCP-1) mRNA expression was suppressed by Mo/Mphi depletion.

CONCLUSION

These results indicate that Mo/Mphi play an important role in the induction of crescentic anti-GBM GN and glomerular injury.

Decreased proteinuria following liver transplantation in a patient with type C liver cirrhosis complicated with nephrotic syndrome: A case report

Type C liver cirrhosis is often associated with a nephrotic syndrome secondary to membranoproliferative glomerulonephritis. Liver transplantation in such patients may sometimes worsen viremia, causing renal dysfunction upon the introduction of immunosuppressive drugs. We present a case of a patient whose proteinuria decreased after liver transplantation. The patient was a 49-year-old male who had been followed due to chronic hepatitis type C from 1984. From 1999 he was diagnosed as having nephrotic syndrome. We performed a living related liver transplant on August 21, 2001. An intraoperative renal biopsy revealed the histology to show membranoproliferative glomerulonephritis. The volume of proteinuria was 2 to 11 g/day before surgery. After surgery it varied from 6 to 10 g/day, gradually decreasing to 1 to 2 g/day. One of the causes of reduced proteinuria may be alleviation of membranoproliferative glomerulonephritis by immunosuppression. But from the view that the recovery of the renal function followed the recovery of liver function, the major effect may have been alleviated hepatorenal syndrome.

Inferior mesenteric venous left renal vein shunting for decompression of excessive portal hypertension in adult living related liver transplantation

In the present study, we investigated the effect of decompression of excessive portal hypertension by inferior mesenteric venous (IMV) left renal vein shunting in 7 cirrhotic patients with esophago-gastric varices and 2 patients who underwent adult living related donor liver transplantation (ALRDLT). The portal pressure remarkably decreased after shunting in all patients with esophago-gastric varices (388 +/- 42 mm H2O vs. 247 +/- 57 mm H2O; P < .05). It also decreased after a shunt operation in patients who had undergone liver transplantation. We report that the excessive shear stress by portal hypertension after small-for-size LRDLT induces a liver injury and the decompression of portal hypertension by splenic arterial ligation or splenectomy prevents postoperative liver injury following massive hepatectomy and small-for-size LRDLT. Our present studies suggested that IMV left renal vein shunting might prevent postoperative liver injury by partial decompression of excessive portal hypertension following small-for-size LRDLT.

Rapid progressive hepatitis C after liver transplantation: A case report

A 56-year-old man on hemodialysis for 3 years because of chronic renal failure underwent living related donor liver transplantation (LRDLT) and splenectomy using the right hepatic lobe for liver cirrhosis type C (genotype 1b) with hepatocellular carcinoma. At 69 postoperative days (POD), he displayed a high fever and his blood transaminase and total bilirubin were increased. Based on finding in his liver biopsy, we diagnosed rapid recurrence of progressive hepatitis C after LRDLT, so we administered IFNbeta. Thereafter his liver function returned to normal and his HCV-mRNA decreased to 1200 kcopy/mL. We inferred that hemodialysis and splenectomy decreased his immunity, allowing rapidly progressive hepatitis C recurrence after LRDLT.

Sclerosing encapsulating peritonitis in two patients with liver cirrhosis

Sclerosing encapsulating peritonitis (SEP) has been reported in a wide variety of patients, including those who have undergone peritoneal dialysis (PD), young adolescent girls, cirrhotic patients after peritoneal-venous shunting (PVS), and patients treated with Beta-blockers. Nevertheless, the etiology of SEP remains obscure. In this article, we report on two patients with severe liver cirrhosis who were diagnosed as having SEP. The association of SEP with liver cirrhosis in patients who have not undergone PVS has previously been reported only rarely. Neither of our two patients had received PD or PVS, and neither had been treated with Beta-blockers, but both had suffered persistent intraabdominal infection. In one patient, we performed therapy combining total enterolysis with the oral administration of prednisolone, at 5 mg/day. The patient recovered and is currently free of symptoms at approximately 15 months after surgery. We believe that SEP may produce complications in cirrhotic patients with persistent intraabdominal infection, and that a combination therapy of surgical and immunosuppressive treatment may be effective for alleviating the small-intestinal obstruction due to SEP.

Living related heterotopic auxiliary partial liver transplantation for extremely small-for-size graft in fulminant liver failure

Adult living related liver transplantation seeks a balance between donor safety and the need to save the recipient's life. A small-for-size graft is a major obstacle for high-risk patients. We experienced a case of heterotopic auxiliary partial liver transplantation with extremely small-for-size graft for fulminant liver failure. The other reasons why we chose to perform heterotopic auxiliary partial liver transplantation were acute renal failure, subshock state, and a left lobe volume of 24% in the standard liver volume of the donor. Hepatic vein reconstruction was made using an inferior meserteric vein patch graft. Portal vein reconstruction was made using end-to-side anastomosis employing an interposed left external iliac vein. The left hepatic artery of the graft was connected to the distal gastroduodenal artery. The patient was discharged 3 months after transplantation. We would recommend heterotopic auxiliary partial liver transplantation as an optional procedure for patients with severe preoperative conditions or extremely small-for-size graft donors.

Impaired splenic erythropoiesis in phlebotomized mice injected with CL2MDP-liposome: an experimental model for studying the role of stromal macrophages in erythropoiesis

Erythropoiesis occurs in the presence of erythropoietin (EPO) without macrophages in vitro. In hematopoietic tissues, however, erythroid cells associate closely with stromal macrophages, forming erythroblastic islands via interactions with adhesion molecules. To elucidate the role of macrophages in erythropoiesis, we selectively abrogated stromal macrophages of splenic red pulp of phlebotomized mice by injection with dichloromethylene diphosphonate encapsulated in multilamellar liposomes (CL2MDP-liposome). In the spleen, no erythropoietic activity occurred until 5 days after the treatment. Colony assay revealed that the erythropoiesis was suppressed at the level of CFU-E. The splenic erythropoietic activity gradually developed from day 6 after the treatment, when F4/80+ macrophages began to appear in the red pulp. EPO mRNA was expressed in kidney but not in liver or spleen of phlebotomized mice injected with CL2MDP-liposome, and the serum EPO concentration in these mice was higher than that in phlebotomized mice. These findings suggest that abrogation of stromal macrophages by injection with CL2MDP-liposome impairs the splenic microenvironment for erythropoiesis induced by hypoxic stress, and this may be an excellent experimental model for further characterization of the in vivo role of splenic macrophages in erythropoiesis.

The role of Kupffer cells in liver regeneration

The liver has a remarkable proliferative capacity after a partial hepatectomy. Previous studies have indicated that Kupffer cells have the potential to exert both stimulatory and inhibitory influences on hepatocyte proliferation. To elucidate the role of Kupffer cells in liver regeneration, mice were selectively depleted of Kupffer cells by injection of liposome-encapsulated dichloromethylene diphosphonate (lipo-MDP) at day 3 after a two-thirds hepatectomy. Results showed that liver regeneration was delayed after Kupffer cell-depletion. In control mice, hepatocyte growth factor (HGF) mRNA expressions were enhanced during liver regeneration and expressions of HGF were localized in fat-storing cells (Ito cells). In Kupffer cell-depleted mice, the number of HGF-expressing cells decreased in the regenerating liver, and expressions of HGF and its receptor (c-met) as well as other growth factors/cytokines were less prominent than in control mice. In contrast, expressions of TNF-alpha, another potent cytokine involved in liver regeneration, did not differ between Kupffer cell-depleted and control mice during the regeneration. Administration of TNF-alpha antibody did not reduce the expression of HGF or liver regeneration. These findings imply that Kupffer cells play a stimulatory role in liver regeneration by enhancing HGF expression via TNF-alpha-non-mediated mechanisms.

Mast cells contribute to the changes in heart rate, but not hypotension or death, associated with active anaphylaxis in mice

The mast cell is widely thought to contribute importantly to the cardiopulmonary changes associated with anaphylaxis, but much of the evidence for this is indirect. We, therefore, performed a detailed assessment of heart rate and pulmonary function during active anaphylaxis in genetically mast cell-deficient W/Wv or S1/S1d mice, the congenic normal (+/+) mice, and W/Wv mice repaired of their mast cell deficiency by transplantation of bone marrow from the congenic +/+ mice (+/+ BM-->W/Wv mice). For all five groups of mice, Ag challenge resulted in the death of more than two-thirds of the sensitized animals, whereas none of the nonsensitized control mice died as a result of Ag infusion. Sensitized normal (WBB6F1(-)+/+ or WCB6F1(-)+/+) mice and +/+BM-->W/Wv mice developed increases in heart rate that were significantly greater than those of nonsensitized +/+ mice or those of sensitized mast cell-deficient mice, indicating that mast cells contribute to the tachycardia observed in this form of active anaphylaxis. By contrast, even though some of the pulmonary changes associated with active anaphylaxis were more severe in +/+ than in mast cell-deficient mice, it was not clear to what extent this difference was mast cell dependent. W/Wv mice undergoing active anaphylaxis developed decreases in systemic arterial blood pressure that occurred more rapidly and were more severe than those observed in the congenic +/+ mice, indicating that the hypotension associated with this model of anaphylaxis also can occur by mast cell-independent mechanisms. We conclude that in this model of anaphylaxis mast cells: 1) are required for the development of the tachycardia response; 2) may contribute to, but are not essential for, production of decreases in lung function; and 3) are not necessary for the development of hypotension or death.

Mast cells contribute to the changes in heart rate, but not hypotension or death, associated with active anaphylaxis in mice

The mast cell is widely thought to contribute importantly to the cardiopulmonary changes associated with anaphylaxis, but much of the evidence for this is indirect. We, therefore, performed a detailed assessment of heart rate and pulmonary function during active anaphylaxis in genetically mast cell-deficient W/Wv or S1/S1d mice, the congenic normal (+/+) mice, and W/Wv mice repaired of their mast cell deficiency by transplantation of bone marrow from the congenic +/+ mice (+/+ BM--&gt;W/Wv mice). For all five groups of mice, Ag challenge resulted in the death of more than two-thirds of the sensitized animals, whereas none of the nonsensitized control mice died as a result of Ag infusion. Sensitized normal (WBB6F1(-)+/+ or WCB6F1(-)+/+) mice and +/+BM--&gt;W/Wv mice developed increases in heart rate that were significantly greater than those of nonsensitized +/+ mice or those of sensitized mast cell-deficient mice, indicating that mast cells contribute to the tachycardia observed in this form of active anaphylaxis. By contrast, even though some of the pulmonary changes associated with active anaphylaxis were more severe in +/+ than in mast cell-deficient mice, it was not clear to what extent this difference was mast cell dependent. W/Wv mice undergoing active anaphylaxis developed decreases in systemic arterial blood pressure that occurred more rapidly and were more severe than those observed in the congenic +/+ mice, indicating that the hypotension associated with this model of anaphylaxis also can occur by mast cell-independent mechanisms. We conclude that in this model of anaphylaxis mast cells: 1) are required for the development of the tachycardia response; 2) may contribute to, but are not essential for, production of decreases in lung function; and 3) are not necessary for the development of hypotension or death.

Mast cell activation enhances airway responsiveness to methacholine in the mouse

Mast cell-deficient mutant mice and their normal littermates were used to determine whether activation of mast cells by anti-IgE enhances airway responsiveness to bronchoactive agonists in vivo. Pulmonary conductance was used as an index of airway response as the mice were challenged with increasing intravenous doses of methacholine (Mch) or 5-hydroxytryptamine (5-HT). Mast cell activation with anti-IgE enhanced pulmonary responsiveness to Mch in both types of normal mice (P < 0.0001 by analysis of variance) but not in either genotype of mast cell-deficient mouse. Additionally, anti-IgE pretreatment of genetically mast cell-deficient W/Wv mice whose mast cell deficiency had been repaired by infusion of freshly obtained bone marrow cells or bone marrow-derived cultured mast cells from congenic normal mice led to significant (P < 0.0001) enhancement of Mch responsiveness. 5-HT responsiveness was not significantly influenced by anti-IgE pretreatment in any of the mice studied. The data support the hypothesis that IgE-mediated activation of mast cells enhances pulmonary responsiveness to cholinergic stimulation.

Differences in the expression of the cardiopulmonary alterations associated with anti-immunoglobulin E-induced or active anaphylaxis in mast cell-deficient and normal mice. Mast cells are not required for the cardiopulmonary changes associated with certain fatal anaphylactic responses

We compared the changes in heart rate (HR), pulmonary dynamic compliance (Cdyn), and pulmonary conductance (GL) associated with three different models of anaphylaxis in genetically mast cell-deficient WBB6F1-W/Wv and congenic normal (+/+) mice. Intravenous infusion of a monoclonal rat anti-mouse IgE produced a marked tachycardia, diminutions in Cdyn and GL, and death in +/+ but not W/Wv mice, and +/+ mice sensitized to develop high circulating levels of IgE exhibited HR, Cdyn, and GL responses to rat anti-IgE challenge which were significantly less intense than those in nonimmunized +/+ mice. By contrast, virtually identical cardiopulmonary responses were observed in either +/+ or W/Wv mice challenged to elicit pure active anaphylactic responses or simultaneous active and anti-IgE-dependent anaphylaxis. These findings show that anaphylactic responses associated with significant tachycardia, reductions in Cdyn and GL, and death can occur in the virtual absence of tissue mast cells. This is true even though, in normal mice, such responses are associated with extensive degranulation of tissue mast cells. By contrast, certain models of anaphylaxis, such as that induced in nonsensitized mice by anti-mouse IgE, can not be elicited in the absence of mast cells.

Induction of mast cell proliferation, maturation, and heparin synthesis by the rat c-kit ligand, stem cell factor

We investigated the effects of a newly recognized multifunctional growth factor, the c-kit ligand stem cell factor (SCF), on mouse mast cell proliferation and phenotype. Recombinant rat SCF164 (rrSCF164) induced the development of large numbers of dermal mast cells in normal mice in vivo. Many of these mast cells had features of "connective tissue-type mast cells" (CTMC), in that they were reactive both with the heparin-binding fluorescent dye berberine sulfate and with safranin. In vitro, rrSCF164 induced the proliferation of cloned interleukin 3 (IL-3)-dependent mouse mast cells and primary populations of IL-3-dependent, bone marrow-derived cultured mast cells (BMCMC), which represent immature mast cells, and purified peritoneal mast cells, which represent a type of mature CTMC. BMCMC maintained in rrSCF164 not only proliferated but also matured. Prior to exposure to rrSCF164, the BMCMC were alcian blue positive, safranin negative, and berberine sulfate negative; had a histamine content of 0.08 +/- 0.02 pg per cell; and incorporated [35S]sulfate into chondroitin sulfates. After 4 wk in rrSCF164, the BMCMC were predominantly safranin positive and berberine sulfate positive, had a histamine content of 2.23 +/- 0.39 pg per cell, and synthesized 35S-labeled proteoglycans that included substantial amounts (41-70%) of [35S]heparin. These findings identify SCF as a single cytokine that can induce immature, IL-3-dependent mast cells to mature and to acquire multiple characteristics of CTMC. These findings also directly demonstrate that SCF can regulate the development of a cellular lineage expressing c-kit through effects on both proliferation and maturation.

The rat c-kit ligand, stem cell factor, induces the development of connective tissue-type and mucosal mast cells in vivo. Analysis by anatomical distribution, histochemistry, and protease phenotype

Mast cell development is a complex process that results in the appearance of phenotypically distinct populations of mast cells in different anatomical sites. Mice homozygous for mutations at the W or S1 locus exhibit several phenotypic abnormalities, including a virtual absence of mast cells in all organs and tissues. Recent work indicates that W encodes the c-kit tyrosine kinase receptor, whereas S1 encodes a c-kit ligand that we have designated stem cell factor (SCF). Recombinant or purified natural forms of the c-kit ligand induce proliferation of certain mast cell populations in vitro, and injection of recombinant SCF permits mast cells to develop in mast cell-deficient WCB6F1-S1/S1d mice. However, the effects of SCF on mast cell proliferation, maturation, and phenotype in normal mice in vivo were not investigated. We now report that local administration of SCF in vivo promotes the development of connective tissue-type mast cells (CTMC) in the skin of mice and that systemic administration of SCF induces the development of both CTMC and mucosal mast cells (MMC) in rats. Rats treated with SCF also develop significantly increased tissue levels of specific rat mast cell proteases (RMCP) characteristic of either CTMC (RMCP I) or MMC (RMCP II). These findings demonstrate that SCF can induce the expansion of both CTMC and MMC populations in vivo and show that SCF can regulate at least one cellular lineage that expresses c-kit, the mast cell, through complex effects on proliferation and maturation.

Air leak syndrome (ALS) as complication of asthma

Twenty-eight patients suffered 32 episodes of ALS (air leak syndrome) between 1974 and 1985 at the Department of Pediatrics of the National Minami-Fukuoka Chest Hospital. The highest incidence was observed between ten and twelve years of age and in the autumn. Their chief complaints were chest pain, sore throat and some pains in other parts. Pneumomediastinum associated with subcutaneous emphysema was observed in 50%; this was the most common type of ALS. Chest X-ray findings showed free air in the left mediastinum in 20 of 22 patients with pneumomediastinum. Free air in the left mediastinum is considered to be a diagnostic finding for ALS.