The internal nasal valve: a validated grading system and operative guide

Purpose

Nasal obstruction is a highly subjective and commonly reported symptom. The internal nasal valve (INV) is the rate limiting step to nasal airflow. A static INV grading score was devised with regard to visibility of the middle turbinate.

Methods

A prospective study of all patients who underwent primary external functional septorhinoplasty in 2017 for nasal obstruction. All patients’ INV score was assessed pre- and postoperatively in a blinded and independent fashion by surgeons of varying seniority.

Results

Twenty-eight patients were studied, with mean age 30.9 years and follow-up 18.8 weeks. Inter-rater and test–retest reliability of INV grading were excellent, with Cronbach’s alpha 0.936 and 0.920, respectively. There was also statistically significant improvement in both subjective and objective postoperative outcome measures including nasal inspiratory peak flows.

Conclusions

We demonstrate a novel, easy to interpret, clinically valuable grading system of the static internal nasal valve that is reliable and reproducible.

Validation of the sino-nasal outcome test-23 in septorhinoplasty surgery

BACKGROUND

There has been a great expansion in patient-based outcome measures to face the ever-increasing demand to demonstrate surgical efficacy. However, surgeons have not adopted until now any systematic outcome instrument. The 22-item Sino-Nasal Outcome Test (SNOT-22) is a validated sinonasal outcome score in sinonasal and septorhinoplasty surgery but does not measure aesthetic outcome. The aim of this paper is to validate a modification to the Sino-Nasal Outcomes Test-22 (SNOT-22) with a new question regarding the shape of the nose (SNOT-23).

METHODOLOGY

We conducted a prospective cohort study on 69 consecutive patients undergoing septorhinoplasty and a control group of healthy volunteers. Reproducibility, responsiveness to treatment, known group differences and validity of the SNOT-23 were analysed. Scores were compared to visual analogue scales, nasal obstruction symptoms evaluation (NOSE) score and nasal inspiratory peak flow.

RESULTS

SNOT-23 has good test-retest reliability and is a valid outcome measure for assessing response to surgery especially with regards to shape of the nose and nasal obstruction when compared to other patient reported measures.

CONCLUSION

SNOT-23 is a valid and reliable tool that can be easily used in routine clinical practice to assess the functional and aesthetic outcomes from septorhinoplasty surgery. The SNOT-23 could be adopted as a universal, easy to use tool in rhinology clinics for the assessment of response to septorhinoplasty and sinus surgery.

Peak nasal inspiratory flow correlates with quality of life in functional endoscopic sinus surgery

OBJECTIVES

Whilst nasal function and airflow improve subjectively following functional endoscopic sinus surgery (FESS), a clinically useful and objective tool for quantifying such improvement is lacking. The peak nasal inspiratory flow (PNIF) metre offers convenient and objective measures of nasal patency. However, it has not yet been established whether changes in PNIF after surgery reflect changes in subjective disease burden. In this study we aimed to determine whether changes in PNIF correlate with commonly used subjective symptom and quality of life outcome measures following FESS for chronic rhinosinusitis (CRS).

DESIGN

Prospective cohort.

SETTING

Royal National Throat Nose and Ear Hospital.

PARTICIPANTS

Thirty-seven patients undergoing FESS for CRS, with or without polyps (21 male, mean age 48.8).

MAIN OUTCOME MEASURES

PNIF, "SNOT-22", "NOSE" and "VAS" questionnaires were performed before and after surgery.

RESULTS

In all patients, there was a strong negative correlation between change in PNIF and change in "SNOT-22" score following surgery (Pearson r=-.64, P<.0001). Strong negative correlations were also seen during subgroup analysis of patients with and without polyps (r=-.57, P=.006 and r=-.67, P=.005, respectively). Change in PNIF correlated significantly with change in "NOSE" score following surgery in all patients and those without polyps (r=-.54, P=.0005 and r=-.68, P=.003). There were no significant correlations between PNIF and VAS (nasal obstruction).

CONCLUSIONS

Changes in PNIF after FESS appear to best reflect improvements in quality of life in CRS as measured using the "SNOT-22" questionnaire.

The outcome of septorhinoplasty surgery on olfactory function

OBJECTIVES

To assess olfactory outcomes in patients undergoing septorhinoplasty surgery in our unit.

DESIGN

Prospective cohort study.

SETTING

The Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

Forty-three patients undergoing functional septorhinoplasty (Males = 26; mean age = 34.1 ± 12.2) were recruited into the study.

MAIN OUTCOME MEASURES

The primary outcome of olfactory function was assessed using 'Sniffin sticks'. Our secondary outcomes were assessment of patient quality of life using the disease specific Sino-nasal Outcome Test-23 questionnaire (SNOT-23) and a visual analogue scale for sense of smell. These measures were repeated at 12 weeks post operatively.

RESULTS

There was a significant change in the Sniffin' sticks score post-operatively (8.3 versus 9.6; P < 0.001). The SNOT-23 score also showed a significant improvement post-operatively (53.5 versus 40.4; P < 0.001). A significant improvement was not found in the smell/taste question (question 21) of the SNOT-23 questionnaire as well as the visual analogue scale for sense of smell. A difference in olfactory outcome was not found between open versus closed approaches, primary versus revision surgery and traumatic versus non traumatic cases.

CONCLUSIONS

The results show a measured significant improvement in olfaction following functional Septorhinoplasty but not a subjective improvement in the patients perception of their sense of smell and hence not a clinically significant difference. The reasons for the measured improvement are not clear and are likely to be multifactorial.

The need for an objective measure in septorhinoplasty surgery: are we any closer to finding an answer?

OBJECTIVES

To assess the reliability of nasal inspiratory peak flow (NIPF) in providing a clinically accurate objective measure following functional septorhinoplasty by comparing it to the validated disease-specific quality-of-life questionnaire, SNOT-22. Studies so far have demonstrated poor correlation between bilateral NIPF and symptom-specific nasal questionnaires following septorhinoplasty.

DESIGN

To perform a prospective comparative analysis between NIPF and the validated disease-specific quality-of-life questionnaire SNOT-22 and to determine whether a correlation exists following septorhinoplasty surgery.

SETTING

The Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

A total of 122 patients (78 males, 44 females; mean age 33.5 ± 12.2 years) were recruited from the senior authors rhinology clinic and underwent functional septorhinoplasty surgery.

MAIN OUTCOME MEASURES

Preoperative and postoperative nasal inspiratory peak flow (NIPF) measurements were performed in addition to the completion of three subjective quality-of-life and symptom assessment tool questionnaires; Sinonasal Outcome Test 22 (SNOT-22), Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS: 0-10).

RESULTS

The mean preoperative NIPF was 88.2 L/min, and the postoperative value was 101.6 L/min and showed a significant improvement following surgery (P = 0.0064). The mean total SNOT-22 score improved significantly from 48.6 to 26.6 (P < 0.0001); the NOSE score from 14.1 to 6.6 (P < 0.0001); and the Visual Analogue Scale (VAS) blockage score from 6.9 to 3.2 (P < 0.0001). All individual domains assessed showed improvements postoperatively, but no correlation was found between the NIPF and SNOT-22 score. Equally, we did not find a correlation between NIPF and the symptom-specific NOSE questionnaire and the nasal blockage domain on the Visual Analogue Scale (VAS) scale.

CONCLUSION

We have demonstrated that NIPF does not correlate with the SNOT-22 disease-specific questionnaire, although both outcomes significantly improve postoperatively. At present, we are still lacking a clinically accurate objective measure of nasal function for the evaluation of patients undergoing septorhinoplasty surgery.

2016 Comprehensive Update of the Banff Working Group on Liver Allograft Pathology: Introduction of Antibody-Mediated Rejection

The Banff Working Group on Liver Allograft Pathology reviewed and discussed literature evidence regarding antibody-mediated liver allograft rejection at the 11th (Paris, France, June 5-10, 2011), 12th (Comandatuba, Brazil, August 19-23, 2013), and 13th (Vancouver, British Columbia, Canada, October 5-10, 2015) meetings of the Banff Conference on Allograft Pathology. Discussion continued online. The primary goal was to introduce guidelines and consensus criteria for the diagnosis of liver allograft antibody-mediated rejection and provide a comprehensive update of all Banff Schema recommendations. Included are new recommendations for complement component 4d tissue staining and interpretation, staging liver allograft fibrosis, and findings related to immunosuppression minimization. In an effort to create a single reference document, previous unchanged criteria are also included.

Pharmacokinetics of low-dose cidofovir in kidney transplant recipients with BK virus infection

BACKGROUND

BK virus (BKV) infection in kidney transplant recipients is associated with progressive graft dysfunction and graft loss. Cidofovir, an antiviral agent with known nephrotoxicity, has been used in low doses to treat BKV infections. However, the systemic exposure and disposition of the low-dose cidofovir regimen are not known in kidney transplant recipients.

METHODS

We investigated the pharmacokinetics (PK) of low-dose cidofovir (0.24 - 0.62 mg/kg) both without and with oral probenecid in 9 transplant patients with persistent BK viremia without nephropathy in a crossover design.

RESULTS

The mean estimated glomerular filtration rate (eGFR) of the study participants was 46.2 mL/min/1.73 m(2) (range: 17-75 mL/min/1.73 m(2) ). The contribution of active renal secretion to cidofovir total body clearance was assessed by evaluating the effect of probenecid on cidofovir PK. Maximum cidofovir plasma concentrations, which averaged approximately 1 μg/mL, were significantly below the 36 μg/mL 50% effective concentration in vitro for cidofovir against BKV. The plasma concentration of cidofovir declined with an overall disposition half-life of 5.1 ± 3.5 and 5.3 ± 2.9 h in the absence and in the presence of probenecid, respectively (P > 0.05).

CONCLUSIONS

Cidofovir clearance and eGFR were linearly related irrespective of probenecid administration (r(2) = 0.8 without probenecid; r(2) = 0.7 with probenecid). This relationship allows for the prediction of systemic cidofovir exposure in individual patients and may be utilized to evaluate exposure-response relationships to optimize the cidofovir dosing regimen for BKV infection.

Evaluation of human polyomavirus BK as a potential cause of villitis of unknown etiology and spontaneous abortion

Polyomavirus BK (BKV) is a widely latent pathogen in man. Although viral reactivation during pregnancy has been demonstrated, and polyomaviruses have been linked to chromosomal abnormalities, a pathogenic role for BKV in fetoplacental disease has not been explored. We performed in situ hybridization studies with BKV probes on cases of villitis of unknown etiology (102), diffuse villitis (25), and spontaneous abortion (22). We found no evidence that BKV plays a role in the pathogenesis of these common fetoplacental disorders.

Validation of the Clinical COPD Questionnaire as a psychophysical outcome measure in adult laryngotracheal stenosis

OBJECTIVES

To validate the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ), a patient-administered instrument developed for bronchopulmonary disease as a disease-specific psychophysical outcome measure for adult laryngotracheal stenosis.

DESIGN

Prospective observational study.

SETTINGS

Tertiary/National referral airway reconstruction centre.

PARTICIPANTS

Thirty-three tracheostomy-free patients undergoing endoscopic laryngotracheoplasty.

MAIN OUTCOME MEASURES

CCQ and the Medical Research Council (MRC) Dyspnoea scale, a previously validated but more limited scale, were administered to patients 2 weeks before surgery, preoperatively, and 2 weeks after endoscopic laryngotracheoplasty. Pulmonary function was assessed preoperatively. Internal consistency was assessed with Cronbach alpha statistics and test-retest reliability was determined using intraclass correlation. Correlations between CCQ and MRC scale, and pulmonary function were used to assess convergent and divergent validity respectively. Instrument responsiveness was assessed by correlating total and domain-specific CCQ scores with anatomical disease severity and post-treatment effect size.

RESULTS

There were 12 males and 21 females. Mean age was 44 +/- 15 years. Cronbach alpha coefficient and intraclass correlation coefficient were 0.88 and 0.95 respectively. Total and domain-specific CCQ scores significantly correlated with the MRC scores (P < 0.001) and significant correlations between CCQ and peak expiratory flow rate and FEV(1) were identified (P < 0.03). There were statistically significant changes in total and domain-specific CCQ scores when different stenosis severities were compared. Clinical COPD Questionnaire scores also changed significantly and congruently following surgery (P < 0.05 in both cases).

DISCUSSION

Clinical COPD Questionnaire is a valid and sensitive instrument for assessing symptom severity and levels of function and well-being in adult patients with laryngotracheal stenosis and can be used as a patient-centred disease-specific outcome measure for this condition.

Primary hyperparathyroidism: do perioperative biochemical variables correlate with parathyroid adenoma weight or volume?

OBJECTIVES

To investigate the relationship between clinical variables and biochemical markers of calcium homeostasis and parathyroid adenoma size, in patients undergoing surgery for primary hyperparathyroidism. To determine the potential clinical utility of the findings in preoperative planning and prediction of postoperative hypocalcaemia.

DESIGN

Retrospective data analysis.

PARTICIPANTS

Ninety-two patients treated surgically for primary hyperparathyroidism caused by a solitary parathyroid adenoma between 1996 and 2006.

MAIN OUTCOME MEASURES

Complete data was obtained for 77 participants including patient demographics, perioperative calcium, parathyroid hormone and phosphate levels, adenoma weight and histological dimensions. Multiple and binary logistic regression analyses were used to investigate the relationship between clinical and biochemical variables and adenoma weight and volume. Similar analysis was used to identify predictors of postoperative hypocalcaemia.

SETTING

University Teaching Hospital Otolaryngology Department.

RESULTS

The mean age at presentation was 59 years. The mean preoperative calcium and PTH levels were 2.86 +/- 0.2 mmol/L and 17.2 +/- 12.3 ng/L, respectively, falling to 2.3 +/- 0.01 and 4.1 +/- 2.7 postoperatively. The mean adenoma weight was 1.71 +/- 1.41 g. No correlation existed between clinical variables and preoperative biochemical markers of calcium homeostasis and adenoma weight or volume. There was a weak correlation between the preoperative to postoperative change in calcium and PTH levels {[deltaCa(2)+] vs. [deltaPTH]} (r = 0.24; P < 0.05) but no predictors of postoperative hypocalcaemia could be identified.

CONCLUSIONS

Biochemical parameters will not accurately predict the size of a parathyroid adenoma. The size of a parathyroid adenoma does not correlate with postoperative calcium levels and is therefore not useful as a predictor of postoperative hypocalcaemia.

Outcomes after transplantation of deceased-donor kidneys with rising serum creatinine

The increasing number of candidates for kidney transplantation and relatively unchanged deceased-donor pool has led to expansion in the criteria for donor acceptability. Outcomes of kidneys from donors with progressively rising creatinine values have not been reported. Patients transplanted between September 2003 and August 2006 with kidneys from donors with peak creatinine levels >2.0 mg/dL were stratified into two groups based on the terminal creatinine and evaluated for outcome: (1) falling creatinine (FC)(n= 27), terminal creatinine at least 0.2mg/dL less than peak, and (2) rising creatinine (RC)(n=24), terminal creatinine = peak. The mean terminal creatinine was significantly higher in the RC group (3.2 +/- 1.3 mg/dL) compared to the FC group (1.9 +/- 0.9 mg/dL)(p<0.0001). Peak creatinine values were similar (RC, 3.2 +/- 1.3; FC, 3.1 +/- 1.3; p=0.6521) between the two groups. Rates of delayed graft function (RC, 24%; FC 32%; p=0.7881) and mean creatinine at follow-up (RC, 1.6 +/- 0.6, FC 1.6 +/- 0.4; p=0.3533) were not significantly different. With a mean follow-up of 287 +/- 274 days, allograft survival was 92% in the RC recipients and 89% in the FC recipients. Under certain conditions, kidneys from donors with rising serum creatinine can be used safely with reasonable early outcomes.

Chronic allograft nephropathy score before sirolimus rescue predicts allograft function in renal transplant patients

Chronic allograft nephropathy (CAN) is a major indication for initiation of sirolimus (SRL) in renal transplantation (TX) to prevent deterioration of renal function. We evaluated whether the CAN score at time of sirolimus rescue (SRL-R) predicts renal allograft function. CAN score is the sum of the following 4 categories: glomerulopathy (cg, 0-3), interstitial fibrosis (ci, 0-3), tubular atrophy (ct, 0-3), and vasculopathy (cv, 0-3). This is a retrospective cohort study of renal transplant recipients from July 2001 to March 2004. Immunosuppression consisted of preconditioning with rabbit anti-thymocyte globulin or alemtuzumab and maintenance with tacrolimus (TAC) monotherapy with spaced weaning, if applicable, SRL-R was achieved by conversion from TAC, or by addition to reduced doses of TAC. Ninety patients received SRL. Thirty-three of these patients met the inclusion criteria of the following: (1) receipt of SRL for >6 months, and (2) follow-up of > or =6 months. There were 16 patients in the low-CAN (0-4) group and 17 patients in the high-CAN (>4) group. Cockcroft-Gault (C-G) glomerular filtration rate (GFR) was calculated at SRL-R and at 1, 3, 6, and 12 months. The DeltaGFR was significantly better in the low-CAN group at 1, 3, and 6 months. A trend toward an improved DeltaGFR was present at 12 months in the low-CAN group (P = .16). CAN scoring at the time of SRL-R predicts recovery of renal allograft function (as measured using DeltaGFR), and should be used in preference to biochemical markers (Cr and C-G GFR), which may not be reliable predictors.

Acute cellular rejection with CD20-positive lymphoid clusters in kidney transplant patients following lymphocyte depletion

Lymphoid clusters (LC) containing CD20-positive B cells in kidney allografts undergoing acute cellular rejection (ACR) have been identified in small studies as a prognostic factor for glucocorticoid resistance and graft loss. Allograft biopsies obtained during the first episode of ACR in 120 recipients were evaluated for LC, immunostained with CD20 antibody, and correlated with conventional histopathologic criteria, response to treatment and outcome. LC were found in 71 (59%) of the 120 biopsies. All contained CD20 positive B cells that accounted for 5-90% of the LC leukocyte content. The incidence of LC was highest in the patients who had no lymphoid depletion or had been treated with Thymoglobulin preconditioning (79% vs. 75%, respectively) compared to 37% in patients pretreated with Campath (p = 0.0001). Banff 1a/1b ACR were more frequent in the LC-positive than the LC-negative group (96% vs. 80%, respectively; p = 0.0051). With a posttransplant follow-up of 953 +/- 430 days, no significant differences were detected between LC-postitive and LC-negative groups in time to ACR, steroid resistance, serum creatinine and graft loss. CD20+LC did not portend glucocorticoid resistance or worse short to medium term outcomes. CD20+LC may represent a heterogenous collection in which there may be a small still to be fully defined unfavorable subgroup.

Polyomavirus-associated nephropathy: update on antiviral strategies

Polyomavirus-associated nephropathy (PVAN) is a major complication of kidney transplantation. Many centers respond to PVAN by reducing immunosuppression. Concern over precipitating rejection, as well as situations in which some PVAN-afflicted individuals have multi-organ transplants, can make reduction of immunosuppression undesirable. In these cases, effective antiviral strategies would be useful. This article describes clinical observations and experiences with 3 different antiviral protocols. Two protocols address antiviral treatment of nephropathy (cidofovir in one, and leflunomide in the other). The third protocol examines fluoroquinolone control of polyoma urinary excretion. Patients responded to all 3 strategies. These promising approaches deserve further evaluation with prospective controlled studies.

Arteriolitis in renal transplant biopsies is associated with poor graft outcome

AIMS

The Banff 1997 classification of renal allograft pathology identifies arteriolitis as a finding of uncertain significance. We sought to improve our understanding of arteriolitis by correlating its occurrence with histopathological and clinical parameters.

METHODS AND RESULTS

Twenty allograft kidney biopsies from 19 patients, showing arteriolitis, were identified. Arterioles were defined as small vessels with: (1) wall thickness of 1-3 myocytes; (2) diameter less than one-third of an adjacent glomerulus; and (3) discontinuous or absent elastica. Arteriolitis was defined as mural infiltration by lymphocytes. Other histological findings were categorized according to the Banff 1997 working formulation. Ten biopsies (50%) showed type IIA rejection, seven (35%) showed type I rejection, and three (15%) showed borderline change. Two patients with borderline change had acute rejection in the next biopsy. None of the seven patients with type I rejection had previous or subsequent type II rejection on biopsy. A total 11/20 biopsies (10/19 patients) showing arteriolitis had type IIA rejection in the index or next biopsy. On follow-up, graft loss due to rejection occurred in 5/19 (26%) patients (median 126 days); all had shown type IIA rejection on a previous biopsy. Chronic allograft nephropathy developed in a further 4/19 (21%) patients (median 157 days), of whom three had shown only type I rejection on biopsy.

CONCLUSION

Arteriolitis is associated with acute rejection, often type II rejection, and is associated with poor graft outcome. Other causes of arteriolitis were not encountered in this series.

Biopsy of marginal donor kidneys: correlation of histologic findings with graft dysfunction

BACKGROUND

Kidney biopsies are being used to evaluate marginal donors, but rigorous statistical validation of this practice with multivariate analysis has not been performed.

METHODS

To analyze histologic parameters in 78 donor biopsies for their ability to predict graft dysfunction, we used a proportional odds model that included both donor and recipient factors. Glomerulosclerosis was categorized into grades 0, 1, 2, and 3, corresponding to 0, 1-10%, 11-20%, and 21-30% global sclerosis, respectively. The degrees of interstitial fibrosis, tubular atrophy, arteriosclerosis, and arteriolar hyalinosis were graded from 0 to 3+, using definitions suggested by the Banff Schema of allograft pathology.

RESULTS

Increasing donor age was associated with higher glomerulosclerosis, tubular atrophy, and arteriosclerosis. Kidneys with any degree of interstitial fibrosis were 2.6 times [odds ratio (OR)] more likely to experience a worse outcome at 6 months (P = 0.02). This association held up after correction for acute rejection (OR 2.5, P = 0.03) and high panel-reactive antibody (OR 3.4, P = 0.006), However, the OR was reduced to 1.9 (P = 0.15) after controlling for recipient age. With each increment in the grade of glomerulosclerosis, the odds for a worse outcome at 12 months increased to 2.3 (P = 0.005). The value for OR became 2.0 (P = 0.03) when controlling for recipient age (P = 0.01), 2.4 (P = 0.005), when controlling for acute rejection, and 2.3 (P = 0.006) when controlling for high panel-reactive antibody.

CONCLUSIONS

Histopathological parameters present in donor biopsies can independently predict post-transplant graft function. Implications for the pool of donor organs available for transplantation are discussed.

Acute renal allograft rejection with severe tubulitis (Banff 1997 grade IB)

Recent studies have correlated renal allograft function with individual histologic lesions defined in the Banff schema of kidney transplantation pathology. The clinical significance of severe tubulitis (Banff 97 grade t3) has not been specifically examined. We compared the clinical course and response to antirejection therapy in 36 patients with t3 tubulitis, and 137 patients with milder grades of tubulitis and varying grades of intimal arteritis. Rejection associated with severe tubulitis (grade t3) was associated with graft outcome that was worse than mild to moderate tubulitis (grades t1 or t2) and approached that seen in grade v1 intimal arteritis. Rejection characterized by grade v2 or v3 intimal arteritis had worse prognosis than v1 intimal arteritis and all grades of tubulitis without coexisting intimal arteritis. These observations validate the Banff 97 recommendation that the severity of both tubulitis and intimal arteritis needs to be graded in renal allograft biopsies. In addition, grade t3 tubulitis is identified as a lesion which should be a cause for clinical concern.

Familial nephrotic syndrome: clinical spectrum and linkage to chromosome 19q13

BACKGROUND

Familial nephrotic syndrome (NS) has both autosomal dominant and recessive forms of inheritance. Recent studies in families with an autosomal dominant form of focal segmental glomerulosclerosis (FSGS) have been at odds concerning linkage to chromosome 19q13 (Mathis et al, Kidney Int 53:282-286, 1998; Winn et al, Kidney Int 55:1241-1246, 1999), suggesting genetic heterogeneity. This study examines the clinical features and confirms linkage to chromosome 19q13 in a family with autosomal dominant NS.

METHODS

DNA samples were obtained from 16 of 17 family members. Genomic DNA was isolated, and polymerase chain reaction was performed for five markers spanning the area of interest on chromosome 19q13. Data were evaluated using two- and six-point linkage analysis.

RESULTS

Clinical features included presentation of NS in childhood, steroid unresponsiveness, and slow progression to renal failure. Renal biopsy in affected family members showed lesions ranging from minimal change to mesangial proliferative glomerulonephritis to FSGS. Linkage was confirmed between the disease state and chromosome 19q13, with a maximum logarithm of odds (LOD) score of 2.41. Linkage was observed for a 7 cM region on chromosome 19q13, defined by markers D19S425 and D19S220.

CONCLUSIONS

This study confirms the Mathis et al report of linkage to chromosome 19q13 in a family with autosomal dominant NS. However, there were notable differences in the presenting clinical and histopathologic features of our affected family members compared with those of Mathis et al. This suggests that the gene on chromosome 19q13 may be responsible for considerable phenotypic heterogeneity and variable expression in both clinical presentation and renal histopathology.

"Striped" pattern of medullary ray fibrosis in allograft biopsies from kidney transplant recipients maintained on tacrolimus

BACKGROUND

A striped pattern of fibrosis has been described in the kidneys of patients undergoing long-term cyclosporine or tacrolimus therapy. This lesion is frequently misconstrued as being specific for drug toxicity.

METHODS

We performed clinicopathologic correlation on 18 patients with striped fibrosis identified by reviewing 61 biopsies from kidney transplant recipients maintained with tacrolimus.

RESULTS

Acute rejection was identified in 14 of 18 patients, chronic rejection in 9 of 18 patients, potential diabetic microvascular injury in 8 of 18, and pre-existing donor disease in 2 of 18. In only one patient could striped fibrosis be ascribed primarily to tacrolimus. Striped fibrosis could also be demonstrated in 6 of 10 late allograft biopsy specimens from patients maintained with only azathioprine, and 8 of 10 native biopsies from patients with advanced diabetes mellitus.

CONCLUSION

Multiple insults contribute to the pathogenesis of striped fibrosis in the kidney. This lesion can be attributed entirely to chronic drug toxicity in only a minority of allografts.

Cytokine mRNA profiles in Epstein-Barr virus-associated post-transplant lymphoproliferative disorders

Cytokine mRNA patterns were analyzed in 11 post-transplant lymphoproliferative disorder (PTLD) specimens using qualitative reverse-transcriptase polymerase chain reaction (RT-PCR). In each case, a pattern of IL2-, IFN gamma-, IL4+, IL10+ was seen. A similar pattern was observed in a spleen sample from 1 patient with contemporaneous PTLD elsewhere. Semiquantitative RT-PCR for cytokine message was performed using RNA from bronchoalveolar lavage (BAL) specimens obtained from 2 patients with pulmonary PTLD. In both cases, IL4 message predominated. Reduction of message coincided with resolution of the tumors. The pattern differed from that seen in 1 patient with acute pulmonary rejection, in which RT-PCR of BAL cells showed predominance of IL6 and IFN gamma. We conclude that at least some PTLDs exist within a T-helper cell type 2 (Th2)-like cytokine microenvironment. The presence of a similar mRNA pattern in an extratumoral specimen at the time of PTLD suggests that it may reflect a systemic phenomenon. Disappearance of this pattern following PTLD resolution indicates its dynamic nature and is consistent with the hypothesis that specific cytokines contribute to the development of PTLDs.

Clinical significance of renal biopsies showing concurrent acute rejection and tacrolimus-associated tubular vacuolization

BACKGROUND

The clinical significance of biopsies showing both rejection and isometric tubular vacuolization has not been well defined in the literature.

METHODS

The clinical picture, sequential histopathologic findings, and response to therapy were compared between 24 renal allograft biopsies showing both tubular vacuolization and rejection and 14 biopsies showing vacuolization alone.

RESULTS

The rejection was categorized as grade 1 in 4/24 (16.6%), grade 2A in 10/24 (41.6%), and grade 2B in 10/24 (41.6%) cases (Banff schema, 1993-1995). Treatment with additional steroids and tacrolimus led to a decrease in the interstitial inflammation score (2.6+/-0.1 to 1.3+/-0.1, P<0.001), tubulitis score (2.6+/-0.1 to 1.1+/-0.1, P<0.001), and serum creatinine (4.4+/-2.2 mg/dl to 3.3+/-2.6 mg/dl, P=0.001). Complete response, partial response and no response to antirejection therapy were observed in 16/24 (66.7%), 3/24 (12.5%), and 5/24 (20.8%) patients, respectively. Although there was a rise in the plasma (1.4+/-0.2 ng/ml to 2.8+/-0.3 ng/ml, P<0.001) and whole blood (16.5+/-2.8 ng/ml to 31.2+/-5.7 ng/ml, P<0.001) tacrolimus levels, repeat biopsy showed no change in the size or extent of tubular vacuolization (mean score 2.88+/-0.19 vs. 2.83+/-0.21). The morphologic characteristics of the tubular vacuoles in these cases did not differ from those observed in 14 cases of tacrolimus nephrotoxicity not complicated by rejection.

CONCLUSION

Patients with concurrent acute rejection and tubular vacuolization usually benefit from increased immunosuppression. The pathogenesis of the vacuolization in this clinical setting is not clear, but may reflect immune-mediated tubular injury.

The clinical significance of cytomegaloviral inclusions in the allograft kidney

BACKGROUND

Renal allografts are a frequent site of subclinical cytomegalovirus (CMV) infection diagnosed by culture, but histologic inclusions occur in less than 1% of biopsies. The natural history of this subgroup of patients has been reported only occasionally, mostly before the availability of ganciclovir therapy.

METHODS

We analyzed the clinical parameters and pathologic findings in 10 patients with CMV inclusions at allograft biopsy.

RESULTS

The patients were 29-72 years old, and 9 of 10 (90%) had previous episodes of acute rejection, 3 of whom needed OKT3 administration. Histopathologic examination of the allografts showed interstitial inflammation with tubulitis in 7 of 10 (70%) patients; in 3 of 10 (30%) patients, viral inclusions were present in the glomerular capillary endothelia without any associated inflammatory response. Morphologic criteria for acute transplant glomerulopathy or proliferative glomerulonephritis were not satisfied. Extrarenal viral inclusions were documented in the gastrointestinal tracts of 2 of 10 (20%) patients. The patients were treated with reduced immunosuppression and ganciclovir. Five patients lost their grafts 56.6+/-86.6 days (range, 4-210 days; median, 21 days) after initial diagnosis. The serum creatinine in the remaining five patients was 3.3+/-2.0 mg/dl (range, 1.2-6.5 mg/dl; median, 2.5 mg/dl) 77+/-16 days (range, 56-101 days; median, 77 days) after transplantation. Histopathologic examination showed no residual viral inclusions in 5 of 7 (71.4%) follow-up specimens available for examination.

CONCLUSIONS

CMV inclusions in renal allograft biopsies typically occur after treatment for rejection. Ganciclovir eradicates replicative virus, but graft outcome is determined by coexisting acute rejection and chronic allograft nephropathy. Graft loss primarily attributable to CMV was not observed.

Human polyoma virus-associated interstitial nephritis in the allograft kidney

BACKGROUND

Asymptomatic polyoma virus infection documented by urine cytology or serology is well known, but the clinical course of biopsy-proven interstitial nephritis is not well defined.

METHODS

Twenty-two cases were identified by histology, immunostaining, in situ hybridization, electron microscopy, or polymerase chain reaction.

RESULTS

The clinical features mimicked acute rejection (n=19), chronic rejection with incidental diagnosis at nephrectomy (n=2), or drug toxicity (n=1). Histology showed homogenous intranuclear inclusions. In situ hybridization showed BK virus (BKV) to be the predominant species, but polymerase chain reaction documented JC virus co-infection in one of five cases so tested. Electron microscopy in seven cases showed 20-51-nm virions. The two cases diagnosed at nephrectomy received no therapy. Initial antirejection therapy in 12 cases led to clearance of the virus in 1/12 (8%), partial therapeutic response in 3/12 (25%), and graft loss in 8/12 (67%) cases. The last recorded creatinine in patients with functional grafts ranged from 1.9 to 7.0 (median: 4.5) mg/dl, 0.4-45 (median: 4.0) months after initial diagnosis. The remaining eight cases treated by reduction of immunosuppression at the outset have been free of graft loss for 0.2-10.0 (median: 4.8) months since diagnosis, and clearance of virus has been documented in three of six (50%) cases. The serum creatinine in these patients is 1.7-6.0 (median: 2.4) mg/dl, 0.2-10 (median: 4.8) months after diagnosis. Follow-up biopsies performed 1-23.5 months after diagnosis show chronic allograft nephropathy.

CONCLUSIONS

Polyoma virus tubulo-interstitial nephritis-associated graft dysfunction usually calls for judicious decrease in immunosuppression and monitoring for acute rejection. Development of methods to serially quantify the viral load in individual patients could potentially improve clinical outcome.

Effects of immunotherapy on experimental immunodeficiency-related lymphoproliferative disease

BACKGROUND

Human lymphokine-activated cells (LAK cells) and interferon alpha (IFN-alpha) have been used clinically in the therapy of posttransplant lymphoproliferative disease (PTLD). However, the efficacy of such therapy has not been extensively tested under controlled experimental conditions.

METHODS

A B-cell line, derived from PTLD tissue and clonally related to the parent lesion, was tested for its response to IFN-alpha in vitro. The effects of LAK cells and IFN-alpha therapy were examined in a severe combined immunodeficiency disease (SCID) mouse model in vivo.

RESULTS

The PTLD cell line studied showed a 30% decrease in the rate of growth upon incubation with 500 U/ml of IFN-alpha. This in vitro response was also reproduced in vivo, in tumor therapy studies conducted in SCID mice. The magnitude of this inhibitory effect in vivo was a function of tumor burden and dose of IFN-alpha. In parallel experiments, LAK cells reduced the tumorigenicity of a lymphoblastoid cell line derived from the peripheral blood of a patient with PTLD, and prolonged the survival of SCID-beige mice with established lymphoproliferative disease. In contrast with two prior studies, in which the use of autologous cytotoxic T cells was found to be necessary, we found the administration of third-party non-HLA-matched LAK cells also to be effective in reducing tumor burden.

CONCLUSIONS

These observations demonstrate the efficacy of immunotherapy for lymphoproliferative disease under controlled experimental conditions, and validate currently ongoing efforts exploring the utility of such therapy in the clinical setting.

Acute renal allograft rejection in patients with Epstein-Barr virus associated post-transplant lymphoproliferative disorder

BACKGROUND

There is a reciprocal relationship between post-transplant lymphoproliferative disorder (PTLD) and rejection: aggressive treatment of rejection can result in PTLD, while treatment of PTLD by reducing immunosuppression can result in recrudescence of rejection. The literature on the relationship between PTLD and rejection episodes is limited.

METHODS

The clinical course and outcome of rejection episodes occurring prior to and following a diagnosis of PTLD were studied in 20 renal transplant recipients.

RESULTS

The diagnosis of PTLD was preceded by rejection in 12/20 (60%) patients. OKT3 treatment was associated with early onset PTLD, which involved the allograft in 6/7 patients (86%). The risk of rejection following reduced immunosuppression was 7/14 (50%). Post-PTLD rejection left untreated led to graft loss in 3 patients. The remaining 4 patients responded satisfactorily to anti-rejection therapy.

CONCLUSIONS

Reduction of immunosuppression for PTLD is frequently, but not invariably, complicated by rejection. The clinical outcome of PTLD does not correlate with the occurrence or reversibility of rejection episodes.

Adenovirus hepatitis in the adult allograft liver

BACKGROUND

Adenovirus hepatitis in the allograft liver is an uncommon condition hitherto recognized only in pediatric patients. We describe two adult cases.

METHODS

Clinical information was obtained by reviewing the medical records. The diagnosis of adenoviral infection was made by immunohistochemistry or culture.

RESULTS

Both patients had received recent antirejection treatment and presented with fever, hepatic dysfunction, and progressive leukopenia. One patient had some viral inclusions resembling those described in herpes simplex infections. Adenovirus was cultured from the liver in both cases and from the lung in one case. Both patients were treated by decreasing the immunosuppression and intravenous acyclovir, but died.

CONCLUSIONS

Adenovirus infection should be considered when evaluating adult liver transplant patients with necrotizing lesions or microabscess formation at allograft biopsy. A review of the literature shows that most previously reported infections have led to graft loss or death, but occasional remissions of disease are also on record.

Clinical significance of renal allograft biopsies with "borderline changes," as defined in the Banff Schema

BACKGROUND

The Banff Schema suggests the term "borderline changes" for biopsies showing changes insufficient for a diagnosis of mild acute rejection. The appropriate clinical management for patients showing such changes on biopsy is controversial.

METHODS

We reviewed the clinical course and response to antirejection therapy of 24 patients with borderline changes, and compared our findings with those obtained from 14 patients with mild acute rejection. Patients were classified as showing complete response, partial response, or no response to antirejection treatment, depending on whether the posttreatment fall in serum creatinine was >70%, 30-70%, or <30% of the pretreatment rise, respectively. Renal allograft biopsies were systematically evaluated in accordance with the Banff schema.

RESULTS

Complete response to antirejection therapy was seen in 15/24 (63%), partial response in 3/24 (13%), and nonresponse in 6/24 (25%) patients with borderline change. Compared with patients showing complete response, nonresponse was associated with higher scores of acute tubular necrosis and chronic allograft nephropathy (P<0.05). By comparison, 12/14 (86%) cases of mild acute rejection showed complete response to antirejection therapy (P=0.25 vs. patients with borderline change), and lack of response was associated with a higher score for chronic allograft nephropathy.

CONCLUSION

When biopsies are done in the context of renal allograft dysfunction, borderline changes frequently require increased immunosuppression. These findings should not be extrapolated to protocol biopsies performed in the setting of stable graft function.

Herpesvirus 6 variant A infection after heart transplantation with giant cell transformation in bile ductular and gastroduodenal epithelium

Herpesvirus 6 (HHV-6) is a ubiquitous virus known to cause febrile syndromes and exanthema subitum in children. Less commonly, and particularly in organ transplant recipients, it may result in hepatitis, bone marrow suppression, interstitial pneunonitis, and meningoencephalitis. This report expands the spectrum of clinical disease associated with HHV-6 by documenting viral infection in a 44-year-old heart transplant recipient presenting with gastroduodenitis, pancreatitis, and hepatitis. On histopathologic examination, the gastric, duodenal, and bile ductular epithelium showed a multinucleate giant cell transformation similar to the cytopathic effect caused by the virus in human T-lymphocytes infected in vitro. Electron microscopy showed herpes particles with a thick tegument layer in the duodenum. Polymerase chain reaction amplified HHV-6 variant A sequences from multiple sites. Serology confirmed the presence of an acute HHV-6 infection. Thus, HHV-6 variant A can cause gastroduodenitis and pancreatitis in immunosuppressed individuals. Multinucleate giant cells and enveloped virions with a prominent tegument can be used as morphologic criteria to raise the possibility of HHV-6 infection in human biopsy tissue.

Clinical features of acute reversible tacrolimus (FK 506) nephrotoxicity in kidney transplant recipients

This study was designed to (a) estimate the contribution of tacrolimus nephrotoxicity to episodes of renal allograft dysfunction investigated by needle biopsy, (b) describe the temporal evolution of nephrotoxicity and its response to therapy, and (c) ascertain how often renal dysfunction is associated with concurrent extra-renal toxicity. Patients were selected based on a rising serum creatinine, normal ultrasound, and biopsy findings leading to a reduction in the dose of tacrolimus and a fall in serum creatinine. Twenty two (17%) cases of nephrotoxicity were identified amongst 128 consecutive kidney transplant biopsies with sufficient clinical data for analysis. There were 13 males and 9 females, 17-75 yr in age. Tacrolimus was administered initially as a 0.075-0.1 mg/kg/d IV continuous infusion followed by an oral dose of 0.15 mg/kg twice daily. The onset of nephrotoxicity in this study occurred 1-156 wk post-operatively. The mean baseline creatinine was 212.2 +/- 168.0 mumol/l (range 88.4-875.2) and rose 40.6% +/- 14.2% (range 11-66) during episodes of nephrotoxicity (p < 0.001). The highest recorded plasma and whole-blood tacrolimus levels during the toxic episodes were respectively 2.7 +/- 0.8 ng/ml (range 1.1-3.5) and 31.6 +/- 10.6 ng/ml (range 14.5-50.5). The drug levels were considered to be beyond the therapeutic range in 18/22 (82%) patients. The highest tacrolimus level preceeded the rise in serum creatinine in 20 cases by an interval of 1.6 +/- 1.8 d. A mean reduction in tacrolimus dosage of 41% +/- 21% (range 11-89) led to a 86% +/- 18% (range 45-100) fall in the serum creatinine within 1-14 d (p < 0.001). Interactions between tacrolimus and clarithromycin, diltiazem, or itraconazole modified the pharmakokinetic parameters in three cases. Serum potassium > 5.0 mequiv/l was recorded in 9/22 (41%) cases. Three or more elevations in blood glucose > 7.7 mmol/l (140 mg/dl) were recorded in 4/11 (36%) non-diabetic patients. Hand tremors were seen in two (9%) cases and elevated diastolic blood pressure > 90 mmHg in seven (32%) patients. In conclusion, tacrolimus nephrotoxicity accounted for 17% of graft dysfunction episodes investigated by biopsy. Concurrent hyperglycemia, hyperkalemia, or tremors were noted in several patients. Nephrotoxicity responded well to reduction in the drug dosage.

Significance of tubulitis in chronic allograft nephropathy: a clinicopathologic study

Tubulitis is the principal lesion used for the diagnosis of acute rejection (AR) in the Banff schema for renal allograft pathology. It is considered to be reliable for assessing AR early after transplantation. However, its significance in biopsies with concurrent changes of chronic allograft nephropathy (CAN) is less well understood. To address this issue we studied seventeen allograft biopsies taken 9-108 (median 39) months post-transplant from 17 patients. All specimens were scored for AR and CAN using Banff criteria. Medical records were reviewed to determine the clinical course of the patients. Five biopsies showed t1 changes, whereas nine biopsies graded as t2, and three biopsies as t3. The CAN scores varied from cg0, ci1, ct1, cv1, to cg1, ci3, ct3, cv3. A response to increased immunosuppression, defined as a fall in the serum creatinine of at least 20% compared to the peak value, was observed in 7/17 (41%) cases. The responsive cases included 2/5, 4/9, and 1/3 cases respectively with t1, t2, and t3 tubulitis. The mean +/- SD CAN scores in these three groups were 8.4 +/- 1.8, 6.5 +/- 1.4, and 7.0 +/- 1.4, respectively. We conclude that the presence of coexisting tubulitis and CAN in renal allograft biopsies may indicate reversible acute rejection. In this study, clinical response was observed in 7/17 (41%) patients. Patients with therapeutically responsive rejection could not be differentiated from refractory cases by serum creatinine, tubulitis grade, per cent glomerulosclerosis and sum scores for AR or CAN. Hence a trial of anti-rejection therapy may be warranted pre-emptively in all such cases.

Spontaneous arterioenteric fistula after pancreas transplantation

Chronic pancreas transplant rejection with enteric exocrine drainage can lead to significant long-term complications. We report a case of a 47-year-old male insulin-dependent diabetic who survived the complications of peripancreatic abscess, enterocutaneous fistula, and arterioenteric fistula related to pancreas transplantation. To avoid these long-term complications, we now recommend elective removal of nonfunctioning, enterically drained pancreas allografts.

Subcutaneous implantation of human post-transplant lymphoproliferative disease lesions in SCID mice

The tumorigenic potential of six post-transplant B-cell lymphoproliferative disease (PTLD) lesions was evaluated in SCID mice. Three animals developed local subcutaneous B cell tumours, two of which contained Epstein-Barr virus (EBV) DNA. Two animals developed CD3 positive thymic neoplasms, and one mouse developed an uncharacterized spontaneously regressing subcutaneous tumour. Immunoglobulin gene rearrangements studies with a JH probe, and EBV clonality studies with a Bam NJ fused terminal probe, showed only one mouse tumour to be genealogically related to the corresponding clinical lesion. It is concluded that lymphoid clones which constitute human PTLD are not autonomous, but sustained by host-derived growth stimuli distinct from those operating in the SCID mouse mileu.

Effect of pulsatility and hemodynamic power on recovery of renal function

Circulatory assist devices are used to treat patients awaiting cardiac transplantation to preserve life as well as to permit recovery of end-organ function. The efficacy of pulseless perfusion versus pulsatile perfusion in the recovery of end-organ function has not been fully determined. In this study, the efficacy of pulseless perfusion compared to pulsatile perfusion on the recovery of renal function after a 30 min period of normothermic ischemia was examined. Pigs were randomly assigned to four groups. In all groups, acute renal ischemia was induced by clamping both renal arteries for 30 min. Reperfusion for 120 min was performed using either pulsatile perfusion or pulseless perfusion at 65 +/- 1.6 mm Hg (Groups I [pulsatile] and II [pulseless]) and at 40 +/- 1.1 mm Hg (Groups III [pulsatile] and IV [pulseless]). After reperfusion, renal blood flow, hemodynamic power (pressure * flow: hemodynamic power), oxygen consumption (VO2), tissue ATP, and urine output (UO) in Groups I, II, and III were significantly higher than in Group IV (p < .01 by ANOVA). Histopathologic examinations were not significantly different between groups. Under hypotensive conditions, pulsatile perfusion improves hemodynamic power delivery to the organ compared to pulseless perfusion. These results suggest that a pulseless pump is acceptable as an assist device when normal flow or perfusion pressure is maintained.

Renal allograft involvement by Epstein-Barr virus associated post-transplant lymphoproliferative disease

This study describes nine cases of post-transplant lymphoproliferative disease (PTLD) presenting as renal allograft dysfunction. Onset of symptoms was 34 to 265 days post-transplant, typically (in six of nine cases) after refractory rejection treated with OKT3. Diagnosis was made by histopathologic examination of needle biopsy (three of nine cases) or allograft nephrectomy (six of nine cases) specimens. Disease was confined to the allograft in three patients. The morphology was polymorphic in eight cases and monomorphic in one case. Five cases showed monotypic kappa or lambda light chain expression. Expansile lymphoid infiltrates, serpiginous necrosis, nuclear atypia, and presence of Epstein-Barr virus RNA helped to distinguish PTLD from severe rejection. Tubular damage and venulitis was common in PTLD lesions, but arterial involvement was not prominent. Infiltration of the ureter, hilar adipose tissue, and nerve twigs was frequent in nephrectomy specimens. Reduction of immunosuppression led to resolution of PTLD in two of three cases diagnosed by needle biopsy, but severe acute rejection led to graft loss in one case; the third case progressed to fatal multisystem disease. Among cases diagnosed at nephrectomy, two of six patients died of disseminated PTLD and one of six died of sepsis. The five surviving patients are alive 41 to 99 months after initial diagnosis without evidence of recurrent PTLD.

Microvascular changes in renal allografts associated with FK506 (Tacrolimus) therapy

FK506 (Tacrolimus) recently has been shown to be an effective immunosuppressant after renal transplantation. It is associated with less hypertension, hypercholesterolemia and steroid use compared with cyclosporine. We report 10 patients on FK506 who showed fibrin thrombi within the glomerular capillaries and/or arterioles at renal allograft biopsy. These biopsies were generally performed to assess increasing serum creatinine levels; laboratory evidence of hemolytic uremic syndrome was present in one instance. Plasma or whole blood FK506 levels were elevated in eight of 10 cases. Reduction of immunosuppression led to clinical improvement or biopsy-proven resolution of thrombi in all cases. These observations suggest that FK506 may occasionally produce microvascular changes in the renal allograft. The estimated incidence of this occurrence (1%) is comparable with that reported with cyclosporine (3%).

Human polyoma virus infection of renal allografts: histopathologic diagnosis, clinical significance, and literature review

Human polyoma virus infection was diagnosed by a needle biopsy of the allograft in two kidney transplant recipients. Viral infection was initially suggested by the occurrence of markedly enlarged tubular epithelial cells with nuclear atypia and chromatin basophilia. Confirmatory evidence was obtained by immunohistochemistry in both cases, and electron microscopy in one instance. Case 1 presented as a refractory interstitial nephritis and underwent allograft nephrectomy. Case 2 showed viral infection concurrent with acute cellular rejection. The rejection initially responded to treatment, but recurred twice on subsequent followup. A review of the literature indicates that asymptomatic infection, ureteric stricture and hemorrhagic cystitis are other possible manifestations of polyoma virus in the human urogenital tract.

Extramedullary hematopoiesis in the allograft liver

The clinicopathologic correlates of extramedullary hematopoiesis were studied in 77 allograft biopsies from 27 patients who underwent liver transplantation for end-stage liver disease. The patient cohort consisted of 19 men and 8 women, ranging in age from 23 to 75 yr (median 41). The causes of end-stage liver disease included viral hepatitis (n = 20), ethanol abuse (n = 6), and congenital hepatic fibrosis (n = 1). Most patients (23 of 27) had significant septic complications in the postoperative period. The hematocrit was typically low (25 to 31%), and a history of allograft hepatectomy with retransplantation was available in 10 of 27 (37%) patients. Extramedullary hematopoiesis was first diagnosed 5 to 461 days (median 275) post-transplant and persisted 7 days to 36 mo (median 1 mo) thereafter. Pathologic findings concurrent with extramedullary hematopoiesis were acute cellular rejection/central venulitis (n = 7), ischemic preservation injury (n = 10), chronic rejection (n = 5), and chronic hepatitis/cirrhosis (n = 5). The pathogenesis of extramedullary hematopoiesis in these cases is not clear, but a low hematocrit may have been a stimulant for the observed hematopoiesis. In addition, the frequent coexistence of infectious, immunologic, or ischemic injury within the allograft suggests that reparative responses can stimulate intrahepatic stem cells to undergo hematopoietic differentiation. The cytokines likely involved in this process are discussed.

Hepatitis C virus infection in liver allografts

HCV infection occurs de novo in 10 percent of liver transplant recipients, reflecting transmission of the virus by the donor organ or blood transfusions. A much more common scenario, however, is recurrent allograft infection following liver transplantation for HCV-associated end-stage liver disease. Removal of the native liver in this clinical setting does not lead to eradication of infection. The virus persists in the blood and subsequently replicates under immunosuppression, resulting in a positive PCR test for HCV in most patients following transplantation. Clinically significant hepatitis develops in 44 percent of patients at the University of Pittsburgh, but the reported incidence worldwide varies from 32 to 100 percent. Most patients show mild to moderately active disease, but in our experience, approximately 10 percent of patients develop progressive liver damage evolving into cirrhosis. The 3-year graft survival at Pittsburgh after a mean follow up period of 20 +/- 14 months is 68 percent, which compares with 82 percent graft survival for patients transplanted for diseases other than HCV. The long-term consequences of allograft HCV infection are not yet completely defined, but HCV-associated cirrhosis remains a valid indication for liver transplantation.

The potential role of cytokines in the pathogenesis of Epstein-Barr virus associated post-transplant lymphoproliferative disease

Post-transplant lymphoproliferative disease (PTLD) is a complication of Epstein-Barr virus infection occurring in immunosuppressed transplant recipients. Non-clonal lesions with a polymorphous histology have the potential of regressing, if the degree of immunosuppression is reduced, thereby giving the immune system a chance to recuperate. In contrast, clonal tumors with a monomorphous histology portend a bad clinical outcome. This review summarizes evidence that the biological behavior of PTLD may be predicated on intercellular interactions involving multiple cytokines. With further investigations to clarify the nature of these interactions, it should be possible to design rational strategies for the cytokine therapy of human PTLD.

Circulating immediate-early mRNA in patients with cytomegalovirus infections after solid organ transplantation

Polymerase chain reaction (PCR)-based amplification of cytomegalovirus (CMV) DNA has been demonstrated to be a sensitive tool for the diagnosis of CMV infection. However, PCR can detect the presence of viral DNA in some specimens from clinically asymptomatic patients. In an attempt to obviate this shortcoming, a reverse transcriptase-PCR-based assay (RT-PCR) was developed to look for CMV immediate-early (IE) mRNA in peripheral blood leukocytes from organ transplant recipients. The results of the PCR- and RT-PCR-based assays for CMV were correlated with clinical symptoms from 21 patients. Absence of circulating IE mRNA was associated with a lack of CMV-associated clinical symptoms in all 14 cases, irrespective of the presence or absence of CMV DNA. In contrast, all 7 RNA-positive samples were associated with CMV disease. Thus, RT-PCR appears to be more predictive than PCR for detection of clinically significant CMV disease in immunosuppressed patients.