Immediate and Long-Term Effects of Hyperbaric Oxygenation in Patients with Long COVID-19 Syndrome Using SF-36 Survey and VAS Score: A Clinical Pilot Study.

(1) Background: Long COVID syndrome (LCS) is a heterogeneous long-standing condition following COVID-19 infection. Treatment options are limited to symptomatic measures, and no specific medication has been established. Hyperbaric oxygenation (HBO) has been found to have a positive impact on the treatment of COVID-19 infection. This study evaluates both the feasibility and outcome of supportive HBO in patients with LCS. (2) Methods: Within 17 months, 70 patients with proven LCS were prospectively included. Each patient underwent a cycle of 10 subsequent HBO treatment sessions administered for 75 min at 2.2 atmospheres. Evaluation of the patients was performed before the first and after the last HBO session and 3 months afterwards. Statistical evaluation was based on an intention-to-treat analysis using Fisher's exact test and Student's t-test for paired samples. (3) Results: In total, 59 patients (33 females, 26 males; mean age: 43.9 years; range: 23-74 years; median: 45.0) were evaluable. After HBO, a statistically significant improvement of physical functioning (p < 0.001), physical role (p = 0.01), energy (p < 0.001), emotional well-being (p < 0.001), social functioning (p < 0.001), pain (p = 0.01) and reduced limitation of activities (p < 0.001) was confirmed. (4) Conclusions: Physical functioning and both the physical and emotional role improved significantly and sustainably, suggesting HBO as a promising supportive therapeutic tool for the treatment of LCS.

Immunohistochemical and radiological characterization of wound healing in porcine liver after radiofrequency ablation.

BACKGROUND: Radiofrequency ablation (RFA) is a minimal invasive therapeutic option for patients with hepatocellular carcinoma or liver metastases. We investigated RFA-induced cellular changes in the liver of pigs. MATERIAL AND METHODS: Healthy pigs (n=18) were sacrificed between day 0 and 3 months after RFA. The wound healing process was evaluated by computed tomography (CT), chromotrope anilinblue (CAB) staining of large-scale and standard tissue sections. Immunohistochemistry (IHC) for heat shock protein 70, Caspase-3, Ki67, Reelin, Vinculin, Vimentin and α-SMA was perfomed. RESULTS: One day after RFA, CAB staining showed cell damage and massive hyperaemia. All IHC markers were predominantly expressed at the outer borders of the lesion, except Reelin, which was mainly detected in untreated liver regions. By staining for Hsp70, the heat stress during RFA was monitored, which was most distinct 1-2 days after RFA. CT revealed decreased lesion size after one week. Development of a Vimentin and α-SMA positive fibrotic capsule was observed. CONCLUSION: In the early phase signs of cell damage, apoptosis and proliferation are dominant. Reduced expression of Reelin suggests a minor role of hepatic stellate cells in the RFA zone. After one week myofibroblasts become prominent and contribute to the development of the fibrotic capsule. This elucidates the pathophysiology of RFA and could contribute to the future optimization of RFA procedures.

Effectiveness of porcine dermal collagen in giant hernia closure in patients with deleterious fascia constitution after orthotopic liver transplantation.

Incisional hernias (IHs) occur universally after orthotopic liver transplantation (OLT). This study aimed to investigate the effectiveness of porcine dermal collagen (PDC) as a closing aid in giant hernias after OLT in a prospective trial. If direct closure (DC) was not feasible due to the hernia size and abdominal wall constitution, a PDC mesh was implanted. All patients from the PDC and DC groups were followed prospectively for 24 months. IH recurrence rates served as the primary endpoint, and the development of infections and wound healing disorders served as the secondary endpoints. Recurrence rate was 21% (4/19) in DC patients and 12% (2/16) in PDC patients (P = 0.045). Implant site infections occurred in five of PDC and one of DC patients (P < 0.05). All of them were managed with antibiotics; two of the PDC patients required surgical drainage. Histological analysis of PDC mesh biopsies indicated good angiogenesis and integration of the PDC into the abdominal wall. PDC was effective in our study for incisional hernia repair, and our results compared favourably with those of patients in whom direct hernia closure was feasible.

Oxidative stress and apoptosis in a pig model of brain death (BD) and living donation (LD).

BACKGROUND: As organ shortage is increasing, the acceptance of marginal donors increases, which might result in poor organ function and patient survival. Mostly, organ damage is caused during brain death (BD), cold ischemic time (CIT) or after reperfusion due to oxidative stress or the induction of apoptosis. The aim of this study was to study a panel of genes involved in oxidative stress and apoptosis and compare these findings with immunohistochemistry from a BD and living donation (LD) pig model and after cold ischemia time (CIT). METHODS: BD was induced in pigs; after 12 h organ retrieval was performed; heart, liver and kidney tissue specimens were collected in the BD (n = 6) and in a LD model (n = 6). PCR analysis for NFKB1, GSS, SOD2, PPAR-alpha, OXSR1, BAX, BCL2L1, and HSP 70.2 was performed and immunohistochemistry used to show apoptosis and nitrosative stress induced cell damage. RESULTS: In heart tissue of BD BAX, BCL2L1 and HSP 70.2 increased significantly after CIT. Only SOD2 was over-expressed after CIT in BD liver tissue. In kidney tissue, BCL2L1, NFKB, OXSR1, SOD2 and HSP 70.2 expression was significantly elevated in LD. Immunohistochemistry showed a significant increase in activated Caspase 3 and nitrotyrosine positive cells after CIT in BD in liver and in kidney tissue but not in heart tissue. CONCLUSION: The up-regulation of protective and apoptotic genes seems to be divergent in the different organs in the BD and LD setting; however, immunohistochemistry revealed more apoptotic and nitrotyrosine positive cells in the BD setting in liver and kidney tissue whereas in heart tissue both BD and LD showed an increase.

Long-term outcome of en bloc pediatric kidney transplantation in adult recipients - up to 22 years of center experience.

BACKGROUND: Renal transplantation has been shown to be the best therapeutic option in end-stage renal disease patients. En bloc transplantation of pediatric kidneys into adult recipients (EBKT) is one strategy to increase the donor pool. We here report on 10 to 22 years of follow-up (median of 12.8 years) of patients receiving EBKT in a single-center, retrospective cohort study. MATERIAL AND METHODS: The mean donor age was 14 ± 12 months and mean donor body weight was 8 ± 3 kilograms. Thirteen recipients (6 females, 7 males) were followed for 10 to 22 years. The mean recipient age was 44 ± 13 years at the time of transplantation. RESULTS: Two of 13 patients lost their grafts in the first week because of hemorrhagic infarction of the kidney transplants or sepsis (septic shock). Only 1 patient had an acute cellular rejection, which was successfully treated with steroids and anti-CD3 antibody. Eleven out of 13 patients after EBKT survived and had a functioning graft 10 to 22 years after successful EBKT. The serum creatinine was 1.34 ± 0.6 mg/dl at 5 years (n=11), 1.37 ± 0.7 mg/dl at 10 years (n=11), 1.40 ± 0.6 mg/dl at 15 years (n=4), and 1.08 mg/dl at 20 years after EBKT (n=2). The eGFR, evaluated by using MDRD-2, was 66.5 ± 22 ml/min/m2 at 5 years (n=11), 62 ± 28 ml/min/m2 at 10 years (n=11), 56 ± 23 ml/min/m2 at 15 years (n=4), and 61 ml/min/m2 at 20 years after EBKT (n=2). Proteinuria did not increase significantly within the observation period. CONCLUSIONS: In our experience, if the acute post-operative phase is uncomplicated, EBKT has excellent long-term graft and patient survival.

The assessment of GFR after orthotopic liver transplantation using cystatin C and creatinine-based equations.

The measurement of kidney function after orthotopic liver transplantation (OLT) is still a clinical challenge. Cystatin C (CysC) has been proposed as a more accurate marker of renal function than serum creatinine (sCr). The aim of this study was to evaluate sCr- and CysC-based equations including the Chronic kidney disease (CKD)-EPI to determine renal function in liver transplant recipients. CysC and sCr were measured in 49 patients 24 months after OLT. The glomerular filtration rate (GFR) was calculated using the MDRD 4, the Cockroft-Gault, Hoek, Larsson, and the CKD-EPI equations based on sCr and/or CysC. As reference method, inulin clearance (IC) was estimated. Bias, precision, and accuracy of each equation were assessed and compared with respect to IC. Forty-five percent had a GFR < 60 ml/min/1.73 m(2) according to the IC. The Larsson, the Hoek and the CKD-EPI-CysC formula identified the highest percentage of patients with CKD correctly (88%, 88%, and 84%, respectively). The sCr-based equations showed less bias than CysC-based formulas with a similar precision. All CysC-based equations were superior as compared with sCr-based equations in the assessment of renal function in patients with an IC < 60 ml/min/1.73 m(2).

Cell to cell interactions influence sensitivity of liver cell lines during hyperthermia.

BACKGROUND: Thermal cancer therapy is used for hepatocellular carcinoma treatment. In this study we investigated the effect of hyperthermia on liver cells and compared data of our different cell culture fibrosis models (transwell vs. co-culture model). MATERIALS AND METHODS: The cell lines HepG2 and LX-1 were seeded in different numbers in transwells to simulate different grades of fibrosis and then heated from 55°C to 85°C for different time spans. Thereafter, metabolic activity was measured. RESULTS: Heating at 65°C showed that the greater the number of LX-1 cells treated together with HepG2 cells the lower the metabolic activity of HepG2 cells was. Compared to our previous co-culture study, there were significantly different results in cell survival from 55°C to 75°C. CONCLUSION: The co-culture fibrosis model is more physiological than the transwell model because it allows a higher seeding density and a higher degree of cell to cell interactions. Therefore, it is more efficient for investigating the effect of hyperthermia on liver cells.

Management of complications after varicoportal anastomosis in liver transplantation.

The presence of portal vein thrombosis is a potential limitation for liver transplantation. An intraoperative diagnosis is linked to extensive surgical treatment and massive postoperative complications and mortality. We present a surgical less risky method for the treatment of intraoperatively diagnosed portal and mesenteric vein thrombosis that served as salvage therapy for a patient who underwent liver transplantation in our centre. Postoperative complications were ascites and renal failure. Persistent ascites required repeated paracentesis during the first month after liver transplantation but medical treatment sufficed thereafter. Moderate renal failure as defined by the K/DOQI-guidelines improved gradually and dialysis was never indicated. Six months after transplantation, the patient had normal liver function and adequate renal function.

Effect of hyperthermia on liver cell lines: important findings for thermal therapy in hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma is the fifth most common malignant tumour, with a high mortality rate. This study aimed to investigate the effect of hyperthermia on HepG2 and LX-1 cell lines to gain more information on thermal treatment of liver tumours. MATERIALS AND METHODS: The cell lines HepG2, LX-1 and their co-cultures were heated from 55°C to 85°C for different time spans. After heat exposure, metabolic activity was measured immediately, and after 24 h and 48 h using the 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium) (MTS) test to assess how many cells had survived heating. RESULTS: Our results show highly significant differences between the temperature tolerance of HepG2 and LX-1 cells. Alone, HepG2 cells are most sensitive to heat-induced cell death, their sensitivity decreased with rising percentages of LX-1 cells in the co-culture. CONCLUSION: Our results suggest that the outcome of thermal cancer therapy is dependent on the temperature and the grade of fibrosis in the treated livers.

Creation of a prevascularized site for cell transplantation in rats.

INTRODUCTION: Transplanted cells, especially islet cells, are likely to become apoptotic due to local hypoxia leading to graft dysfunction. Isolated pancreatic islet cells depend on the diffusion of oxygen from the surrounding tissue; therefore, access to sufficient oxygen supply is beneficial, particularly when microcapsules are used for immunoisolation in xenotransplantation. The aim of this study was to create a prevascularized site for cell transplantation in rats and test its effectiveness with microencapsulated HEK293 cells. METHODS: The combination of implantation of a foam dressing, vacuum-assisted wound closure (foam+VAC) and hyperbaric oxygenation (HBO) was used in 40 Sprague-Dawley rats. Blood flow and vascular endothelial growth factor (VEGF) levels were determined. Sodium cellulose sulphate (SCS)-microencapsulated HEK293 cells were xenotransplanted into the foam dressing in rats pre-treated with HBO, and angiogenesis and apoptosis were assessed. RESULTS: Vessel ingrowth and VEGF levels increased depending on the duration of HBO treatment. The area containing the foam was perfused significantly better in the experimental groups when compared to controls. Only a small amount of apoptosis occurs in SCS-microencapsulated HEK293 cells after xenotransplantation. CONCLUSION: As ischemia-damaged cells are likely to undergo cell death or loose functionality due to hypoxia, therefore leading to graft dysfunction, the combination foam+VAC and HBO might be a promising method to create a prevascularized site to achieve better results in xenogeneic cell transplantation.

Sirolimus has a potential to influent viral recurrence in HCV positive liver transplant candidates.

There is in vitro proof that mTOR proteins play a role in protecting HCV infected cells from apoptosis. The aim of this cohort study was to evaluate the effect of sirolimus as an mTOR inhibitor on hepatitis C recurrence in liver transplant recipients. Hepatitis C virus positive patients were followed prospectively regarding transaminases, immunosuppressive target levels, HCV RNA and influence of donor and recipient factors on viral recurrence and survival. Viral recurrence was defined as elevated liver enzymes combined with active hepatitis diagnosed on the basis of increasing viral load and/or biopsy-proven HCV relapse in the transplanted organ. Sixty-seven HCV positive patients were included: 39 received a regimen including sirolimus; 28 patients received calcineurin inhibitors. Sirolimus patients showed a significant decrease in the HCV PCR levels (p<0.05). Survival of the sirolimus patients was significantly higher (p<0.03) than in the other patient cohort. Sirolimus has been shown to be a potent immunosuppressive agent after liver transplantation, though nothing is known about its effect on HCV. This analysis suggests that sirolimus has potential to suppress viral recurrence in HCV positive liver transplant candidates.

Serum cystatin C is an easy to obtain biomarker for the onset of renal impairment in heart transplant recipients.

OBJECTIVE: With the increasing longevity of heart transplant recipients, the long-term effects of cyclosporine on renal function have become more evident. Highly sensitive, early, and effective monitoring of posttransplant renal function is still being researched. This study aimed to evaluate the prognostic value of cystatin C for patients after heart transplantation. METHODS: Seventy-three long-term recipients of a heart transplant more than 5 years before the study start were included in the analysis with a follow-up of 4 years. Serum creatinine, renal glomerular filtration rate calculated by the Modification of Diet in Renal Disease formula, and serum cystatin C levels were collected, and risk factors for renal dysfunction were assessed. Statistical analysis was performed for all patients. RESULTS: Univariate analysis showed a prognostic impact of antihypertensive medication and onset of diabetes (P < .001) on renal failure after transplantation. Multivariate analysis yielded cystatin C measured at the study start as a superior prognostic parameter for all time points (area under the receiver operating characteristic 12 months: 0.963; 24 months: 0.910; 48 months: 0.949) compared with the conventionally used creatinine levels. CONCLUSIONS: Our results showed an enormous potential of serum cystatin C as an early prognostic and easy to obtain biomarker for renal dysfunction after heart transplantation.

Prevention of oxidative stress in porcine islet isolation.

High yields of pure and viable porcine islet cells (PICs) to be used for microencapsulation are crucial for successful xenotransplantation. Mechanical disruption of the pancreas, enzymes used for digestion, digestion temperature and time are among the factors known to cause oxidative stress and to impact on the yield, purity and viability of PICs. The aim of our study was to optimize conventional procedures in order to minimize the oxidative stress that occurs during the isolation and purification of PICs. Porcine pancreatic tissue was harvested at a local slaughterhouse, and 15 consecutive isolations of PICs were performed with a modified automated Ricordi method (Graz method) using a shorter digestion time, a lower digestion temperature and minimal mechanical stress. PICs were purified with the Lymphoprep density gradient medium. Purity and viability were assessed immediately after the isolation process and after overnight culture. PIC function was tested in glucose stimulation experiments and insulin concentration was determined by ELISA. Oxidative stress was assessed by measuring isoprostanes (IP), malondialdehyde (MDA) and lipase levels using a HPLC-based, colorimetric liquid assay or ELISA, respectively. The mean yield of PICs was 3479 +/- 542 IEQs/g pancreas, with 96.4% viability and 97.7% purity. There was no significant loss in PIC viability after overnight culture. Insulin secretion in response to glucose was not impaired after isolation and purification. IP, MDA and lipase levels did not change significantly during the isolation procedure. With our new Graz method we seem to have succeeded in preventing oxidative stress and achieving high yields of pure and viable PICs.

Evaluation of indocyanine green clearance and model for end-stage liver disease for estimation of short-term prognosis in decompensated cirrhosis.

BACKGROUND: Indocyanine green (ICG) clearance has been proposed as a quantitative liver function test several decades ago. Interest in this method has been renewed following the development of finger pulse densitometry for noninvasive estimation of the ICG plasma disappearance rate (PDR). On the other hand, the model for end-stage liver disease (MELD), which is based on routine laboratory parameters, is widely used for estimation of short-term survival in cirrhosis, but its prognostic value in critically ill cirrhotic patients is unclear. AIMS: The aim of the present study was to compare the diagnostic accuracy of ICG PDR vs. MELD for estimation of short-term prognosis in cirrhotic patients. METHODS: Ninety consecutive cirrhotic patients who were admitted for decompensated disease or were being evaluated for liver transplantation were screened. Patients who underwent liver transplantation within the following 90 days and those with hepatocellular carcinoma were excluded. In the remaining 70 patients, routine laboratory parameters and ICG clearance were analysed. Following an injection of ICG 0.25 mg/kg, PDR was measured by finger pulse densitometry. The diagnostic accuracy of ICG PDR and MELD for prediction of 90-day survival was assessed by receiver-operating characteristic (ROC) curve analysis. RESULTS: ROC curve analysis revealed superior diagnostic accuracy for MELD as compared with ICG PDR in predicting 90-day survival (area under the ROC curve 0.89 vs. 0.71). A MELD cut-off of 22 provided the best discrimination for prediction of 90-day survival. CONCLUSIONS: MELD is superior to ICG PDR for estimation of short-term survival in patients with decompensated cirrhosis.

Retroperitoneal pancreas transplantation with systemic-enteric drainage--case report.

Enteric drainage and intraperitoneal graft position is the preferred technique for pancreas transplantation at most transplant centers. The technique of retroperitoneal pancreas transplantation was first described by Boggi et al. [Transplantation,79 (2005), 1137]. In this case report, a modified model of retroperitoneal pancreas transplantation with systemic-enteric drainage is presented. A 48-yr-old patient underwent combined retroperitoneal pancreas and kidney transplantation because of type-I-diabetes, and diabetic nephropathy. At the time of transplantation, the patient had a body mass index of 31 and severe atherosclerosis of the iliac vessels. After mobilization of the colon and mesocolon ascendens, the vessels of the pancreas graft were anastomosed end-to-side to the aorta and to the inferior caval vein of the recipient. For exocrinous drainage, a side-to-side duodenojejunostomy was performed after bringing a jejunal loop through a window in the right colon mesentery. The graft was in a retroperitoneal position. The patient was insulin-independent after 48 h, the lipase and amylase levels were within the normal range. The first experience with retroperitoneal pancreas transplantation with systemic-enteric drainage showed that the technique was safe and had technical advantages when compared with the classic method.