Characteristics associated with liver graft failure: the concept of a donor risk index

Transplant physicians and candidates have become increasingly aware that donor characteristics significantly impact liver transplantation outcomes. Although the qualitative effect of individual donor variables are understood, the quantitative risk associated with combinations of characteristics are unclear. Using national data from 1998 to 2002, we developed a quantitative donor risk index. Cox regression models identified seven donor characteristics that independently predicted significantly increased risk of graft failure. Donor age over 40 years (and particularly over 60 years), donation after cardiac death (DCD), and split/partial grafts were strongly associated with graft failure, while African-American race, less height, cerebrovascular accident and 'other' causes of brain death were more modestly but still significantly associated with graft failure. Grafts with an increased donor risk index have been preferentially transplanted into older candidates (>50 years of age) with moderate disease severity (nonstatus 1 with lower model for end-stage liver disease (MELD) scores) and without hepatitis C. Quantitative assessment of the risk of donor liver graft failure using a donor risk index is useful to inform the process of organ acceptance.

"Coulomb Staircase" at Room Temperature in a Self-Assembled Molecular Nanostructure

Double-ended aryl dithiols [alpha,alpha'-xylyldithiol (XYL) and 4,4'-biphenyldithiol] formed self-assembled monolayers (SAMs) on gold(111) substrates and were used to tether nanometer-sized gold clusters deposited from a cluster beam. An ultrahigh-vacuum scanning tunneling microscope was used to image these nanostructures and to measure their current-voltage characteristics as a function of the separation between the probe tip and the metal cluster. At room temperature, when the tip was positioned over a cluster bonded to the XYL SAM, the current-voltage data showed "Coulomb staircase" behavior. These data are in good agreement with semiclassical predictions for correlated single-electron tunneling and permit estimation of the electrical resistance of a single XYL molecule (approximately18 ± 12 megohms).

Structural basis for the binding of proline-rich peptides to SH3 domains

A common RXL motif was found in proline-rich ligands that were selected from a biased combinatorial peptide library on the basis of their ability to bind specifically to the SH3 domains from phosphatidylinositol 3-kinase (PI3K) or c-Src. The solution structure of the PI3K SH3 domain complexed to one of these ligands, RKLPPRPSK (RLP1), was determined. Structure-based mutations were introduced into the PI3K SH3 domain and the RLP1 ligand, and the influence of these mutations on binding was evaluated. We conclude that SH3 domains recognize proline-rich motifs possessing the left-handed type II polyproline (PPII) helix conformation. Two proline residues directly contact the receptor. Other prolines in the ligands appear to function as a molecular scaffold, promoting the formation of the PPII helix. Three nonproline residues consisting of combinations of arginine and leucine interact extensively with the SH3 domain and appear to confer ligand specificity.

Direct activation of inward rectifier potassium channels by PIP2 and its stabilization by Gbetagamma

Inward rectifier K+ channels, which modulate electrical activity in many cell types, are regulated by protein kinases, guanine-nucleotide-binding proteins (G proteins) and probably actin cytoskeleton. Generation of phosphatidylinositol 4,5-bisphosphate (PIP2) by ATP-dependent lipid kinases is known to activate inward rectifier K+ channels in cardiac membrane patches. Here we report that several cloned inward rectifier K+ channels directly bind PIP2, and that this binding correlates with channel activity. Application of ATP or PIP2 liposomes activates the cloned channels. Stabilized by lipid phosphatase inhibitors, PIP2 antibodies potently inhibit each channel with a unique rate (GIRK1/4 approximately GIRK2 >> IRK1 approximately ROMK. Consistent with the faster dissociation of PIP2 from the GIRK channels, the carboxy terminus of GIRK1 binds 3H-PIP2 liposomes more weakly than does that of IRK1 or ROMK1. Mutation of a conserved arginine to glutamine at position 188 reduces the ability of ROMK1 to bind PIP2 and increases its sensitivity to inhibition by PIP2 antibodies. Interactions between GIRK channels and PIP2 are modulated by the betagamma subunits of the G protein (Gbetagamma). When GIRK1/4 channels are allowed to run down completely, they are not activated by addition of Gbetagamma alone, but application of PIP2 activates them in minutes without Gbetagamma and in just seconds with Gbetagamma. Finally, coexpression of Gbetagamma with GIRK channels slows the inhibition of K+ currents by PIP2 antibodies by more than 10-fold. Thus Gbetagamma activates GIRK channels by stabilizing interactions between PIP2 and the K+ channel.

Two binding orientations for peptides to the Src SH3 domain: development of a general model for SH3-ligand interactions

Solution structures of two Src homology 3 (SH3) domain-ligand complexes have been determined by nuclear magnetic resonance. Each complex consists of the SH3 domain and a nine-residue proline-rich peptide selected from a large library of ligands prepared by combinatorial synthesis. The bound ligands adopt a left-handed polyproline type II (PPII) helix, although the amino to carboxyl directionalities of their helices are opposite. The peptide orientation is determined by a salt bridge formed by the terminal arginine residues of the ligands and the conserved aspartate-99 of the SH3 domain. Residues at positions 3, 4, 6, and 7 of both peptides also intercalate into the ligand-binding site; however, the respective proline and nonproline residues show exchanged binding positions in the two complexes. These structural results led to a model for the interactions of SH3 domains with proline-rich peptides that can be used to predict critical residues in complexes of unknown structure. The model was used to identify correctly both the binding orientation and the contact and noncontact residues of a peptide derived from the nucleotide exchange factor Sos in association with the amino-terminal SH3 domain of the adaptor protein Grb2.

HIV-1 tat trans-activation requires the loop sequence within tar

Human immunodeficiency virus (HIV-1) is the primary retroviral agent responsible for AIDS and related disorders worldwide. One of its identified gene products, tat protein, stimulates in trans the expression of all HIV-1 genes by several orders of magnitude. Cells infected with HIV-1 require tat protein to produce virus, suggesting that trans-activation is crucial for viral replication. The essential cis-acting site for trans-activation, termed tar, resides within the R region of the HIV-1 long terminal repeat (LTR), between -17 and +54 with respect to the initiation site of viral transcription. It is striking that the RNA encoded between +1 and +59 has the potential to form an extensive stem-loop secondary structure which, as a portion of the untranslated leader RNA, would be common to all HIV-1 mRNAs. We now present the results of nucleotide substitution experiments which suggest that tat trans-activation requires presentation of the sequence +30CUGGG+34 in tar within the loop of a RNA hairpin structure.

New materials in hydrothermal synthesis

In this Account we describe the hydrothermal synthesis of some new materials including microporous crystals, ionic conductors, complex oxides and fluorides, low-dimensional aluminophosphates, inorganic-organic hybrid materials, and particularly condensed materials such as diamond and inorganic helical chains. Hydrothermal synthesis in biology and environment sciences is also introduced. The increasing interest in hydrothemal synthesis derives from its advantages in terms of high reactivity of reactants, easy control of solution or interface reactions, formation of metastable and unique condensed phases, less air pollution, and low energy consumption.

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.

The complex and intriguing lives of PIP2 with ion channels and transporters

Phosphatidylinositol-4,5-bisphosphate (PIP(2)), the precursor of several signaling molecules in eukayotic cells, is itself also used by cells to signal to membrane-associated proteins. PIP(2) anchors numerous signaling molecules and cytoskeleton at the cell membrane, and the metabolism of PIP(2) is closely connected to membrane trafficking. Recently, ion transporters and channels have been discovered to be regulated by PIP(2). Systems reported to be activated by PIP(2) include (i) plasmalemmal calcium pumps (PMCA), (ii) cardiac sodium-calcium exchangers (NCX1), (iii) sodium-proton exchangers (NHE1-4), (iv) a sodium-magnesium exchanger of unknown identity, (v) all inward rectifier potassium channels (KATP, IRK, GIRK, and ROMK channels), (vi) epithelial sodium channels (ENaC), and (vii) ryanodine-sensitive calcium release channels (RyR). Systems reported to be inhibited by PIP(2) include (i) cyclic nucleotide-gated channels of the rod (CNG), (ii) transient receptor potential-like (TRPL) Drosophila phototransduction channels, (iii) capsaicin-activated transient receptor potential (TRP) channels (VR1), and (iv) IP(3)-gated calcium release channels (IP3R). Systems that appear to be completely insensitive to PIP(2) include (i) voltage-gated sodium channels, (ii) most voltage-gated potassium channels, (iii) sodium-potassium pumps, (iv) several neurotransmitter transporters, and (v) cystic fibrosis transmembrane receptor (CFTR)-type chloride channels. Presumably, local changes of the concentration of PIP(2) in the plasma membrane represent cell signals to those mechanisms sensitive to PIP(2) changes. Unfortunately, our understanding of how local PIP(2) concentrations are regulated remains very limited. One important complexity is the probable existence of phospholipid microdomains, or lipid rafts. Such domains may serve to localize PIP(2) and thereby PIP(2) signaling, as well as to organize PIP(2) binding partners into signaling complexes. A related biological role of PIP(2) may be to control the activity of ion transporters and channels during biosynthesis or vesicle trafficking. Low PIP(2) concentrations in the secretory pathway would inactivate all of the systems that are stimulated by PIP(2). How, in detail, is PIP(2) used by cells to control ion channel and transporter activities? Further progress requires an improved understanding of lipid kinases and phosphatases, how they are regulated, where they are localized in cells, and with which ion channels and transporters they might localize.

A risk prediction model for delayed graft function in the current era of deceased donor renal transplantation

Delayed graft function (DGF) impacts short- and long-term outcomes. We present a model for predicting DGF after renal transplantation. A multivariable logistic regression analysis of 24,337 deceased donor renal transplant recipients (2003-2006) was performed. We developed a nomogram, depicting relative contribution of risk factors, and a novel web-based calculator (http://www.transplantcalculator.com/DGF) as an easily accessible tool for predicting DGF. Risk factors in the modern era were compared with their relative impact in an earlier era (1995-1998). Although the impact of many risk factors remained similar over time, weight of immunological factors attenuated, while impact of donor renal function increased by 2-fold. This may reflect advances in immunosuppression and increased utilization of kidneys from expanded criteria donors (ECDs) in the modern era. The most significant factors associated with DGF were cold ischemia time, donor creatinine, body mass index, donation after cardiac death and donor age. In addition to predicting DGF, the model predicted graft failure. A 25-50% probability of DGF was associated with a 50% increased risk of graft failure relative to a DGF risk < 25%, whereas a > 50% DGF risk was associated with a 2-fold increased risk of graft failure. This tool is useful for predicting DGF and long-term outcomes at the time of transplant.

Effects of emulsifiers on the controlled release of paclitaxel (Taxol) from nanospheres of biodegradable polymers

Paclitaxel (Taxol) is an antineoplastic drug effective for various cancers especially ovarian and breast cancer. Due to its high hydrophobicity, however, an adjuvant such as Cremophor EL has to be used in its clinical administration, which causes serious side-effects. Nanospheres of biodegradable polymers could be an ideal solution. This study investigates the effects of various emulsifiers on the physical/chemical properties and release kinetics of paclitaxel loaded nanospheres fabricated by the solvent extraction/evaporation technique. It is shown that phospholipids could be a novel type of emulsifiers. The nanospheres manufactured with various emulsifiers were characterized by laser light scattering for their size and size distribution; scanning electron microscopy (SEM) and atomic force microscopy (AFM) for their surface morphology; zeta potential analyser for their surface charge; and, most importantly, X-ray photoelectron spectroscopy (XPS) for their surface chemistry. The encapsulation efficiency and in vitro release profile were measured by high performance liquid chromatography (HPLC). It is found that dipalmitoyl-phosphatidylcholine (DPPC) can provide more complete coating on the surface of the products which thus results in a higher emulsifying efficiency compared with polyvinyl alcohol (PVA). Our result shows that the chain length and unsaturation of the lipids have a significant influence on the emulsifying efficiency. Phospholipids with short and saturated chains have excellent emulsifying effects.

Relationship of necrosis to organ failure in severe acute pancreatitis

BACKGROUND & AIMS

Pancreatic necrosis and organ failure are principal determinants of severity in acute pancreatitis. The purpose of this study was to determine the relationship of necrosis to organ failure in severe acute pancreatitis.

METHODS

Patients with necrotizing pancreatitis from May 1992 to January 1996 were retrospectively studied. Pancreatic necrosis was identified by characteristic findings on dynamic contrast-enhanced computerized tomography scan and infected necrosis by computerized tomography-guided percutaneous aspiration. Organ dysfunction was defined in accordance with the Atlanta symposium.

RESULTS

Organ failure was present in only 26 of 51 patients (51%). There was no difference in the prevalence of organ failure in infected necrosis compared with sterile necrosis (approximately 50% in both groups). Patients with increased amounts of necrosis did not have an increased prevalence of organ failure or infected necrosis compared with those with lesser amounts of necrosis. Patients with organ failure had an increased morbidity and mortality compared with those without organ failure.

CONCLUSIONS

Organ failure occurred in only one half of patients with necrotizing pancreatitis. Because organ failure increases the severity of illness, studies of patients with necrotizing pancreatitis must stratify for organ failure to facilitate interpretation of results.

The survival benefit of deceased donor liver transplantation as a function of candidate disease severity and donor quality

The survival benefit of liver transplantation depends on candidate disease severity, as measured by MELD score. However, donor liver quality may also affect survival benefit. Using US data from the SRTR on 28 165 adult liver transplant candidates wait-listed between 2001 and 2005, we estimated survival benefit according to cross-classifications of candidate MELD score and deceased donor risk index (DRI) using sequential stratification. Covariate-adjusted hazard ratios (HR) were calculated for each liver transplant recipient at a given MELD with an organ of a given DRI, comparing posttransplant mortality to continued wait-listing with possible later transplantation using a lower-DRI organ. High-DRI organs were more often transplanted into lower-MELD recipients and vice versa. Compared to waiting for a lower-DRI organ, the lowest-MELD category recipients (MELD 6-8) who received high-DRI organs experienced significantly higher mortality (HR = 3.70; p < 0.0005). All recipients with MELD > or =20 had a significant survival benefit from transplantation, regardless of DRI. Transplantation of high-DRI organs is effective for high but not low-MELD candidates. Pairing of high-DRI livers with lower-MELD candidates fails to maximize survival benefit and may deny lifesaving organs to high-MELD candidates who are at high risk of death without transplantation.

Five unique compounds: xyloketals from mangrove fungus Xylaria sp. from the South China Sea coast

Five unique metabolites, xyloketals A (1), B (2), C (3), D (4), and E (5), and the known 6 were isolated from mangrove fungus Xylaria sp. (no. 2508), obtained from the South China Sea. The structures of these compounds were elucidated by spectroscopic and X-ray diffraction experiments. Xyloketal A is a ketal compound with a C(3) symmetry and xyloketals B-E are its analogues. It was found that xytoketal C slowly rearranged to xytoketal B in DMSO-d(6)() solution at room temperature. Xyloketal A exhibited the activity of inhibiting acetylcholine esterase.

Regulatory intramolecular association in a tyrosine kinase of the Tec family

The T-cell-specific tyrosine kinase Itk is a member of the Tec family of non-receptor tyrosine kinases, and is required for signalling through the T-cell antigen receptor (TCR). The role of Itk in TCR signalling and the manner in which Itk activity is regulated are not well understood. Substrate binding and enzymatic activity of the structurally related Src kinases are regulated by an intramolecular interaction between the Src-homology-2 (SH2) domain and a phosphotyrosine. Although Itk also contains SH3, SH2 and tyrosine kinase domains, it lacks the corresponding regulatory phosphorylation site, and therefore must be regulated by an alternative mechanism. The proline-rich sequence adjacent to the SH3 domain of Tec family kinases contains an SH3 ligand, potentially allowing a different intramolecular interaction. By using multidimensional nuclear magnetic resonance we have determined the structure of a fragment of Itk, confirming that these domains interact intramolecularly. Formation of this intramolecular SH3-ligand complex prevents the Itk SH3 domain and proline-rich region from interacting with their respective protein ligands, Sam68 and Grb-2. We believe that this structure represents the first example of an intramolecular interaction between an SH3 domain and a proline-rich ligand, and has implications for the regulation of Tec family kinases.

Posttransplant diabetes mellitus in liver transplant recipients: risk factors, temporal relationship with hepatitis C virus allograft hepatitis, and impact on mortality

BACKGROUND

Recent studies suggest an association between diabetes mellitus and hepatitis C virus (HCV) infection. Our aim was to determine (1) the prevalence and determinants of new onset posttransplant diabetes mellitus (PTDM) in HCV (+) liver transplant (OLT) recipients, (2) the temporal relationship between recurrent allograft hepatitis and the onset of PTDM, and (3) the effects of antiviral therapy on glycemic control.

METHODS

Between January of 1991 and December of 1998, of 185 OLTs performed in 176 adult patients, 47 HCV (+) cases and 111 HCV (-) controls were analyzed. We reviewed and analyzed the demographics, etiology of liver failure, pretransplant alcohol abuse, prevalence of diabetes mellitus, and clinical characteristics of both groups. In HCV (+) patients, the development of recurrent allograft hepatitis and its therapy were also studied in detail.

RESULTS

The prevalence of pretransplant diabetes was similar in the two groups, whereas the prevalence of PTDM was significantly higher in HCV (+) than in HCV (-) patients (64% vs. 28%, P=0.0001). By multivariate analysis, HCV infection (hazard ratio 2.5, P=0.001) and methylprednisolone boluses (hazard ratio 1.09 per bolus, P=0.02) were found to be independent risk factors for the development of PTDM. Development of PTDM was found to be an independent risk factor for mortality (hazard ratio 3.67, P<0.0001). The cumulative mortality in HCV (+) PTDM (+) versus HCV (+) PTDM (-) patients was 56% vs. 14% (P=0.001). In HCV (+) patients with PTDM, we could identify two groups based on the temporal relationship between the allograft hepatitis and the onset of PTDM: 13 patients developed PTDM either before or in the absence of hepatitis (group A), and 12 concurrently with the diagnosis of hepatitis (group B). In gr. B, 11 of 12 patients received antiviral therapy. Normalization of liver function tests with improvement in viremia was achieved in 4 of 11 patients, who also demonstrated a marked improvement in their glycemic control.

CONCLUSION

We found a high prevalence of PTDM in HCV (+) recipients. PTDM after OLT was associated with significantly increased mortality. HCV infection and methylprednisolone boluses were found to be independent risk factors for the development of PTDM. In approximately half of the HCV (+) patients with PTDM, the onset of PTDM was related to the recurrence of allograft hepatitis. Improvement in glycemic control was achieved in the patients who responded to antiviral therapy.

Specific interactions outside the proline-rich core of two classes of Src homology 3 ligands

Two dodecapeptides belonging to distinct classes of Src homology 3 (SH3) ligands and selected from biased phage display libraries were used to investigate interactions between a specificity pocket in the Src SH3 domain and ligant residues flanking the proline-rich core. The solution structures of c-Src SH3 complexed with these peptides were solved by NMR. In addition to proline-rich, polyproline type II helix-forming core, the class I and II ligands each possesses a flanking sequence that occupies a large pocket between the RT and n-Src loops of the SH3 domain. Structural and mutational analyses illustrate how the two classes of SH3 ligands exploit a specificity pocket on the receptor differently to increase binding affinity and specificity.

Simultaneous liver-kidney transplantation summit: current state and future directions

Although previous consensus recommendations have helped define patients who would benefit from simultaneous liver-kidney transplantation (SLK), there is a current need to reassess published guidelines for SLK because of continuing increase in proportion of liver transplant candidates with renal dysfunction and ongoing donor organ shortage. The purpose of this consensus meeting was to critically evaluate published and registry data regarding patient and renal outcomes following liver transplantation alone or SLK in liver transplant recipients with renal dysfunction. Modifications to the current guidelines for SLK and a research agenda were proposed.

Paternal population history of East Asia: sources, patterns, and microevolutionary processes

Asia has served as a focal point for human migration during much of the Late Pleistocene and Holocene. Clarification of East Asia's role as a source and/or transit point for human dispersals requires that this region's own settlement history be understood. To this end, we examined variation at 52 polymorphic sites on the nonrecombining portion of the Y chromosome (NRY) in 1,383 unrelated males, representing 25 populations from southern East Asia (SEAS), northern East Asia (NEAS), and central Asia (CAS). The polymorphisms defined 45 global haplogroups, 28 of which were present in these three regions. Although heterozygosity levels were similar in all three regions, the average pairwise difference among haplogroups was noticeably smaller in SEAS. Multidimensional scaling analysis indicated a general separation of SEAS versus NEAS and CAS populations, and analysis of molecular variance produced very different values of Phi(ST) in NEAS and SEAS populations. In spatial autocorrelation analyses, the overall correlogram exhibited a clinal pattern; however, the NEAS populations showed evidence of both isolation by distance and ancient clines, whereas there was no evidence of structure in SEAS populations. Nested cladistic analysis demonstrated that population history events and ongoing demographic processes both contributed to the contrasting patterns of NRY variation in NEAS and SEAS. We conclude that the peopling of East Asia was more complex than earlier models had proposed-that is, a multilayered, multidirectional, and multidisciplinary framework is necessary. For instance, in addition to the previously recognized genetic and dental dispersal signals from SEAS to NEAS populations, CAS has made a significant contribution to the contemporary gene pool of NEAS, and the Sino-Tibetan expansion has left traces of a genetic trail from northern to southern China.

Simultaneous liver-kidney transplantation: evaluation to decision making

Questions about appropriate allocation of simultaneous liver and kidney transplants (SLK) are being asked because kidney dysfunction in the context of liver failure enhances access to deceased donor organs. There is specific concern that some patients who undergo combined liver and kidney transplantation may have reversible renal failure. There is also concern that liver transplants are placed prematurely in those with end-stage renal disease. Thus to assure allocation of transplants only to those truly in need, the transplant community met in March 2006 to review post-MELD (model for end-stage liver disease) data on the impact of renal function on liver waitlist and transplant outcomes and the results of SLK.