Impact of renal transplantation on glucose tolerance in Japanese recipients with impaired glucose tolerance.

AIMS: To investigate changes in glucose tolerance, insulin secretion and insulin sensitivity in Japanese recipients before and 1 year after renal transplantation. METHODS: We conducted a study of Japanese recipients without diabetes who underwent renal transplantation at Hokkaido University Hospital. A 75-g oral glucose tolerance test was performed before and 1 year after renal transplantation in these recipients. Insulin sensitivity was estimated using the Matsuda index and homeostasis model assessment of insulin resistance (HOMA-IR). Insulin secretion was evaluated based on the insulin secretion sensitivity index-2 (ISSI-2). RESULTS: Of the 62 renal transplant recipients, 31 were diagnosed as having impaired glucose tolerance before transplantation. Among these 31 recipients, after 1 year, four had developed new-onset diabetes after transplantation, and nine had impaired glucose tolerance. Unexpectedly, 18 changed from impaired to normal glucose tolerance. When these recipients with impaired glucose tolerance were classified into a non-amelioration group and an amelioration group, the ISSI-2 was significantly reduced, with no significant changes in the Matsuda index or HOMA-IR, in the non-amelioration group 1 year after renal transplantation. By contrast, ISSI-2 and Matsuda index values were significantly increased, with no significant changes in HOMA-IR values in the amelioration group. CONCLUSIONS: More than half of Japanese renal transplant recipients with impaired glucose tolerance had normal glucose tolerance 1 year after renal transplantation. These results suggest that an increase in insulin secretion and whole insulin sensitivity was associated with improvement in glucose tolerance in these recipients.

Purified eicosapentaenoic acid induces prolonged survival of cardiac allografts and generates regulatory T cells.

Fish oil, which is rich in eicosapentaenoic acid (EPA), has been found to have immunomodulatory effects. We examined whether administration of purified EPA affected survival of fully mismatched murine cardiac allografts. Hearts from C57BL/10 (H-2(b)) mice were transplanted into CBA (H-2(k)) recipients treated with one intraperitoneal dose of purified EPA the day of transplantation. Untreated CBA recipients and recipients given 0.1 g/kg of EPA rejected C57BL/10 hearts (median survival time [MST], 8 and 13 days, respectively). With a 1.0 g/kg dose of EPA, graft survival was markedly prolonged (MST >100 days). To determine whether regulatory cells were generated, naïve mice (secondary recipients) underwent adoptive transfer of splenocytes from EPA-treated primary recipients and cardiac allograft transplantation. Adoptive transfer of whole, CD4(+) and CD4(+)CD25(+) splenocytes from EPA-treated recipients induced indefinite survival in secondary recipients. Flow cytometry showed that the CD4(+)CD25(+) cells were Foxp3(+). In reverse transcriptase-polymerase chain reaction (RT-PCR) studies, the expression of peroxisome proliferator-activated receptor gamma (PPARgamma) mRNA was upregulated by EPA treatment. A PPARgamma antagonist abrogated the prolongation of graft survival induced by EPA treatment (MST, 13 days). Thus, in our model, purified EPA induced prolonged survival of fully mismatched cardiac allografts and generated regulatory T cells dependent on PPARgamma activation.

Percentage of CD19+ Cells in Peripheral Blood Lymphocytes After Rituximab-Based Desensitization as a Predictor of Acute Antibody-Mediated Rejection in ABO-Incompatible Kidney Transplantation.

BACKGROUND: Rituximab (RIT) is effective as a part of the desensitization therapy before ABO-incompatible kidney transplantation (ABOi-KTx), and a single dose of RIT at 375 mg/m2 or less is recommended. However, adequate RIT dose recommendations have not yet been established for individual recipients. Therefore, we evaluated the relationship between the proportion of B cells in peripheral blood and acute antibody-mediated rejection (AAMR). METHODS: Forty-four consecutive ABOi-KTx recipients were enrolled in this retrospective study. Before transplantation, subjects were treated with RIT at various doses, ranging from 65 to 400 mg/body (46-263 mg/m2), followed by plasmapheresis and intravenous immunoglobulin as a desensitization therapy. The percentage of CD19+ cells in the total peripheral blood lymphocytes population (%CD19) was determined the day before transplantation. Transplant recipients were divided into 2 groups according to pretransplant %CD19, as follows: low %CD19 group, ≤ 1.2% (n = 35) and high %CD19 group, > 1.2% (n = 9). The relationship between %CD19 and incidence of AAMR was evaluated, and the predicting factors for AAMR incidence were determined by univariate and multivariate analyses. RESULTS: The incidence of AAMR was significantly higher in the high %CD19 group than in the low %CD19 group (44.4% vs 5.7%, P = .006). Furthermore, multivariate analysis showed that %CD19 > 1.2% was the only independent factor to predict AAMR, with an odds ratio of 14.31 (P = .038). CONCLUSION: High %CD19 values after rituximab administration in ABOi-KTx recipients implies insufficient depletion of B cells, which can lead to AAMR.

Optimal Settings for Double Filtration Plasmapheresis With Targeted Removal Rate of Preexisting Antibody in Antibody-Incompatible Kidney Transplant.

BACKGROUND: Elimination of preexisting donor-reactive antibodies is essential for antibody-incompatible kidney transplantation. Double filtration plasmapheresis (DFPP) using albumin (Alb) replacement fluid (Rf) removes immunoglobulin more selectively than plasma exchange; however, fixed-dose treatment can result in insufficient removal of antibody or excess loss of osmotic pressure and subsequent hypotension. The aim of this study was to determine the optimal setting (volume and concentration of Rf) of DFPP to remove donor-reactive antibodies. MATERIALS AND METHODS: One hundred seventeen DFPPs were performed in 41 patients for kidney transplant in an ABO-incompatible or crossmatch-positive setting. A formula for Rf volume was determined based on volume-removal rate (RR) curve of IgG. Another formula for Alb concentration of Rf was also established to keep plasma volume within pre-DFPP plasma volume ± 10% calculated by post- to pre-DFPP hematocrit ratio to avoid hypotensive events. RESULTS: RR-IgG was obtained based on patient data: Rf (mL) = BW (kg) × eX, [X = (RR-IgG + 10.757)/25.603] (R2 = 0.401, P < .001). Rf Alb concentration was determined by AlbRf ≥ (2.982 - 2.36 × RR-IgG) × Albpre + (2.36 × RR-IgG - 0.236) × pre-DFPP total protein. CONCLUSIONS: Optimal volume and concentration of Alb Rf can be calculated using our formulae with targeted RR-IgG.

Highly Immunogenic DQB1 Mismatch Eplets Are Associated With Development of Chronic Active Antibody-Mediated Rejection: A First Report From Japan.

BACKGROUND: De novo donor-specific antibody (dnDSA), especially against class II HLA, correlates with chronic active antibody-mediated rejection (CAAMR), which eventually leads to graft loss. It would be helpful if we could identify the patients at high risk of dnDSA development in terms of histocompatibility. Structure-based matching strategy assessing mismatched epitopes/eplets by comparing polymorphic amino acid sequences can predict the risk of development of dnDSA and CAAMR. However, it has not been evaluated in Japanese patients whose diversity in HLA is limited. PATIENTS AND METHODS: We retrospectively studied 55 living related kidney transplant patients and ascertained donor and recipient HLA-A, -B, -DRB1, and -DQB1. The number of mismatched eplets was determined using an algorithm, HLAMatchmaker version 3. The relationship between characteristics of mismatched eplets and development of CAAMR was evaluated. RESULTS: There were 8 patients in the CAAMR group and 47 in the control group. The numbers of mismatched HLAs (3.6 ± 1.2 in CAAMR and 3.7 ± 2.0 in control groups), mismatched eplets (32.2 ± 10.4 in CAAMR and 34.4 ± 19.8 in control groups), mismatched DRB1 eplets (11.2 ± 4.3 in CAAMR and 11.5 ± 7.9 in control groups), and mismatched DQB1 eplets (9.2 ± 4.3 in CAAMR and 10.5 ± 7.3 in control groups) were not significantly different. Significantly more patients had at least one highly immunogenic mismatched eplet (62.5% in CAAMR and 25.5% in control groups; P = .024 by χ2 test). CONCLUSIONS: The presence of highly immunogenic mismatched eplets is associated with development of CAAMR.

Does the Age of Donor Kidneys Affect Nocturnal Polyuria in Patients With Successful Real Transplantation?

BACKGROUND: We investigated whether the age of donor kidneys influences the incidence of nocturnal polyuria in patients with successful renal transplantation (RTX). METHODS: Eighty-five patients (45 men and 40 women) undergoing RTX (median age, 47 years) were included in this study. Twenty-four-hour bladder diaries were kept for 3 days, and nocturnal polyuria was defined as a nocturnal polyuria index (nocturnal urine volume/24-hour urine volume) of >0.33. Risk factors for nocturnal polyuria were analyzed in patients with RTX by means of the Mann-Whitney U test, χ2 test, and a logistic regression analysis. RESULTS: End-stage renal disease (ESRD) developed from diabetes mellitus in 16 patients (19%). Sixty-five patients (76%) received pre-transplant dialysis, with a median duration of 5 years. The median serum creatinine level and body mass index at the most recent visit were 1.2 mg/dL and 21.2 kg/m2, respectively. On the basis of the 24-hour bladder diaries, nocturnal polyuria was identified in 48 patients (56%). A logistic regression analysis revealed that diabetes mellitus as the original disease for ESRD was the only risk factor for nocturnal polyuria (odds ratio, 8.95; 95% confidence interval, 2.01-65.3; P = .0028). The age of donor kidneys at examination did not affect the incidence of nocturnal polyuria (P = .9402). CONCLUSIONS: Nocturnal polyuria was not uncommon in patients with successful RTX. Diabetes mellitus as the original disease for ESRD was the only risk factor for nocturnal polyuria, whereas the age of donor kidneys at examination did not affect the incidence of nocturnal polyuria. Thus, nocturnal polyuria is caused by recipient factors but not donor factors.

Mesenteric teratoma in an 8-month-old girl.

The authors report the case of a solid, mature teratoma of the mesentery occurring in an 8-month-old girl. The tumor was enucleated from the ileocecal mesentery. Histologically the tumor included all three embryonal layers. This is the youngest patient reported to have mesenteric teratoma.

Current status of 21 patients who have survived more than 20 years since undergoing surgery for biliary atresia.

Between 1952 and 1993, 289 patients with biliary atresia underwent surgery at the authors' institution. Twenty-two of them survived more than 20 years; one has since died of hepatic failure (at age 28 years). Of the 21 current survivors (age range, 20 to 39 years), 13 underwent hepatic portoenterostomy; the others had hepaticoenterostomy. None of these patients has undergone liver transplantation. Sixteen patients have led near-normal lives. This includes three married women, one of whom has given birth to a healthy baby boy. Of the six patients who had portal hypertension, three underwent both splenectomy and proximal splenorenal shunting in or before 1985. None of these patients has required additional treatment for portal hypertension. The quality of life of one patient has been severely affected by an unrelated condition (Turner's syndrome). A 22-year-old man was diagnosed as having intrahepatic stones 3 years ago. In another 22-year-old man, hepatic dysfunction developed after frequent episodes of cholangitis. He is now being considered for liver transplantation. The majority of the long-term survivors have good quality of life. However, a few continue to suffer from complications including recurrent cholangitis. Close long-term postoperative follow-up is required for patients with biliary atresia.

[Long-term outcome of surgery for biliary atresia].

Between 1953 and 1995, 300 patients with biliary atresia underwent surgery at Tohoku University Hospital. Among them, 31 patients survived more than 20 years, while one of these patients died of hepatic failure at the age of 28 years. Of the 30 surviving patients (10 males and 20 females, age range; 20 to 41 years), 20 underwent hepatic portoenterostomy, 8 underwent hepaticoenterostomy and the remaining 2 underwent hepatic portocholecystostomy. None of these patients has undergone liver transplantation. Twenty-two patients have led near normal lives. This includes three married women, one of whom gave birth to 2 healthy babies. The remaining 8 patients have had experienced some troubles due to cholangitis, portal hypertension and intrahepatic gallstones. Two of them who have progressive liver dysfunction are being considered as candidates for liver transplantation. The quality of life of one patient has been severely affected by an unrelated (Turner's syndrome). While the majority of long-term survivors of biliary atresia have good quality of life, close long-term postoperative follow-up is required.

Long-term outcome of single institutional experience with conservative and surgical management for renal artery aneurysm.

BACKGROUND: Spontaneous rupture risk of a renal artery aneurysm (RAA) is extremely low. Indications for surgical repair of RAA remain uncertain. OBJECTIVE: Long-term outcomes of conservative therapy and surgical repair were evaluated. PATIENTS: The study included 58 patients (17 males, 41 females) who were diagnosed with RAA during the last 21 years. Median age at the time of diagnosis was 62 (19-85) years, and the median follow-up 69 months (range 3-216). METHODS: The patients were divided into two groups, conservative group (n = 30) who had been followed with blood pressure control, and treatment group (n = 29), who underwent an intervention. RESULTS: Multiple efferent aneurysmal branches were observed in seven conservative and 16 treatment cases (P = .002). The median maximum diameter of the aneurysm was lower in the conservative than the treatment group (15 versus 25 mm, P = .005). Two conservative group cases showed increases in aneurysm size during follow-up. The hypertensive state showed essentially no change in either group during the follow-up. Renal function decreased with age similarly both in conservative and treatment groups. CONCLUSIONS: Our conservative management criteria for RAA are justifiable and even too strict.

Percentages of water, muscle, and bone decrease and lipid increases in early period after successful kidney transplantation: a body composition analysis.

BACKGROUND: Successful kidney transplantation (KT) can theoretically reconstitute body composition of a patient with chronic kidney disease (CKD). However, the practical changes have not been well documented. We evaluated changes in body composition among candidates before and 1 year after KT. METHODS: We enrolled 37 male and 18 female kidney recipients eligible for comparison of their body mass index (BMI), body composition, and lipid metabolism before and 1 year after KT. Twenty-one patients had been induced with a calcineurin inhibitor, mycophenolate mofetil, steroid, and basiliximab, and 34 others underwent steroid withdrawal on postoperative day 3. The body composition was analyzed using bioelectrical impedance. We also analyzed changes in BMI and lipid profiles. RESULTS: There was no significant change in BMI (21.4 ± 3.1 vs 21.7 ± 3.5 kg/m(2)). Regarding body composition, the water level decreased significantly (61.2 ± 4.9% vs 58.3 ± 5.3%; P < .05). In contrast, fat significantly increased (16.4 ± 6.7% vs 20.3 ± 7.1%; P < .05). More interestingly, successful KT significantly decreased the muscle and bone mass at 1 year after KT (37.3 ± 5.1% vs 34.8 ± 4.7%; 16.3 ± 2.1% vs 15.2 ± 2.1%; respectively; P < .05). Serum lipid profiles of total cholesterol, low-density lipoprotein cholesterol, and triglyceride worsened after KT. Comparing the 2 protocols, there was no difference in any item. CONCLUSIONS: Care must be taken even after successful KT to avoid dyslipidemia, which is a risk factor for cardiovascular disease. Well programmed dietary and/or exercise protocols to prevent muscle atrophy and fat gain should be considered even after successful KT.

Successful kidney transplantation ameliorates arterial stiffness in end-stage renal disease patients.

PURPOSE: Successful kidney transplantation (KTx) can ameliorate bodily damage caused by end-stage renal disease (ESRD). Arterial stiffness (AS) is one of the critical factors that shorten the survival of patients due to cardiovascular events. KTx may reduce AS as well; however, this has not been investigated well. We therefore conducted a retrospective study using noninvasive pulse wave velocity (PWV), which is a useful index of aortic damage. PATIENTS AND METHODS: Fifty-eight consecutive kidney recipients (34 men, 24 women) were enrolled in this study. Mean age at transplantation was 40.5 ± 12.3 years and the dialysis period was 73.1 ± 95.8 months. The brachial-ankle PWV was measured preoperatively and 6 months postoperatively. First, we investigated the relationship between the PWV and the other parameters related to AS. Second, we studied the pre- to posttransplant change in PWV to evaluate the amelioration of AS after successful KTx. RESULTS: PWV showed significant positive correlations with age, systolic blood pressure (BP), diastolic BP, and abdominal aortic calcification index. After successful KTx, PWV significantly decreased (P < .01). In addition, systolic and diastolic BP significantly decreased (P < .01 and P < .05, respectively). CONCLUSION: Successful KTx ameliorates AS in ESRD patients. This might explain the improved cardiovascular prognosis of ESRD patients who undergo KTx.

Successfully rescued renal graft artery thrombosis by ex vivo thrombectomy: a case report.

A 40-year-old woman who had been suffering from type II diabetes mellitus and consequent end-stage renal disease underwent living related kidney transplantation. The graft renal artery was anastomosed to the right internal iliac artery (end-to-end). Postoperative renoscintigraphy demonstrated normal graft perfusion. The serum lactate dehydrogenase level increased abruptly at postoperative day 15 and digital subtraction angiography disclosed graft artery thrombosis. Despite an intervention using a metallic coil stent, the rapid formation of thrombus occluded the graft artery completely. In an emergent surgical operation, the graft was nephrectomized carefully and irrigated after extensive thrombectomy. The graft was reimplanted by using an internal iliac artery graft. After three consecutive hemodialysis treatments, the patient's kidney graft functioned well. She has been in good health with stable graft function for 3 years after the operation.

An autopsy case of malignant mesothelioma associated with asbestosis.

An autopsy case of malignant mesothelioma with asbestosis caused by asbestos exposure for 17 years is reported. Autopsy revealed that mesothelioma spread extensively in all serosal tissues including pleura, pericardium, diaphragm, peritoneum and tunica vaginalis testis. Histopathologically, most of the tumor showed an epithelial form, but sarcomatous and microcystic patterns were also observed. The tumor cells had abundant glycogen and hyaluronic acid and, immunohistochemically, they were positive for cytokeratin, vimentin and epithelial membrane antigen (EMA). Long, slender microvilli were characteristically observed in these tumor cells. All of these data were compatible with malignant mesothelioma. Procollagen type I (procol.l) immunostaining was performed to reveal the mesenchymal character of mesothelioma. Both epithelial-type cells and sarcomatous-type cells showed positive staining for procol.l, although the latter showed stronger immunoreactivity. Immunostaining for procol.l was found to be one of the useful tools for distinguishing mesothelioma from adenocarcinoma. Using an extraction method for asbestos fibers, asbestos bodies were found in many tissues including lymph nodes, liver, small intestine, spleen, kidney, testis and pleura, in addition to lung parenchyma. Although multiple tumor metastases from an undetermined primary site is not ruled out, 'multifocal tumorigenesis' is suspected from the widespread deposit of asbestos fibers.

The effect of hepatic portal dissection on the portal vein structure in biliary atresia.

Superior mesenteric portograms were performed on 30 patients with biliary atresia (BA) at the time of initial portoenterostomy in 20, and at the stoma closure operation in 10. A withered-branch-shaped irregularity of the intrahepatic portal vein (PV) and collateral vessels were seen in 2 of 11 patients with portal pressures (PP) of 200 to 300 mmH2O; in 1 of 2 patients with PPs of over 300 mmH2O at the initial operation; and in 3 jaundice-free patients with PPs of 285, 320, and 305 mmH2O, respectively, at the stoma closure operation. Collaterals were the only abnormalities seen in two additional jaundice-free patients with PPs of 370 and 183 mmH2O, respectively. No anatomic changes in the extrahepatic PV at the porta hepatis were found on the portograms of either group of patients. Thus, we conclude that portal dissection itself does not affect the PV structure anatomically, a finding which has important implications in determining whether or not portoenterostomy adversely affects potential liver transplantation.

Abnormal distribution of nerve fibers in the liver of biliary atresia.

We investigated changes in the pattern of hepatic innervation in liver specimens from 15 infants with biliary atresia and 4 age-matched controls by immunohistochemical methods. In the control, nerve fibers identified by immunoreactivity for neural cell adhesion molecule (NCAM) and S100 protein were present around the branches of hepatic arteries, portal veins and bile ducts in the portal areas and the hepatic lobules. In biliary atresia, NCAM and S100 positive nerve fibers were increased in the vicinity of the hepatic arteries and the portal veins in the enlarged portal areas, while no nerve fibers were observed around bile ducts and periportal ductules which became NCAM positive. No innervation in the lobules was seen in any cases regardless of the histological alteration. These findings may suggest that the abnormal innervation in the liver with biliary atresia does not occur as a result of structural changes in liver architecture caused by portal fibrosis and inflammation, but is associated with immaturity or malformation of hepatic innervation in the patients.

Clinical significance of 99mTc-DTPA galactosyl human serum albumin scintigram in follow-up after Kasai operation.

The scintigram using 99mTechnetium-DTPA galactosyl human serum albumin (99mTc-GSA) which binds to asialoglycoprotein receptors on hepatocytes is a good index of hepatocyte function in various liver diseases in adult patients. In 43 patients (4 months to 30 years old) who had undergone Kasai procedure, we performed 53 series of 99mTc-GSA scintigrams and checked the laboratory data of blood draw and the clinical status. The indices for blood clearance and liver accumulation were evaluated on the basis of the dynamic data after 99mTc-GSA injection. HH15 as an index of the blood clearance, and LHL15 as an index of the accumulation of the hepatocytes were calculated and the HH15/LHL15 ratio (H/L15) was examined. 99mTc-GSA scintigram correlated with liver function and clinical status. Our results revealed that 1) The deterioration of the liver functions and clinical status correlates proportionally with H/L15, 2) The results of 99m Technetium-GSA scintigram correlate with several liver function tests, especially direct bilirubin, albumin and choline esterase, 3) This scintigram is an useful index of clinical status and hepatic function as well as the change of the hepatic parenchymal reserve in BA patients, especially for the evaluation of liver transplantation.

The outcome of surgery for biliary atresia and the current status of long-term survivors.

Between 1953 and 1995, 300 patients with biliary atresia underwent surgery at Tohoku University Hospital. The 10-year survival of patients who were operated on in or before 1965 was 9%. But the survival rate went up to 61% in patients operated on between 1976 and 1985. Eighty-five patients including 2 who developed liver failure after Kasai operation and underwent liver transplantation have survived more than 10 years. Eleven of them (13%) have recurrent or persistent jaundice. Of the 30 patients who have survived more than 20 years (10 males and 20 females, age range; 20 to 41 years), 20 underwent hepatic portoenterostomy, 8 underwent hepaticoenterostomy and the remaining 2 underwent hepatic portocholecystostomy. None of these patients has undergone liver transplantation. Twenty-two patients have led near-normal lives. The remaining 8 patients have experienced some troubles due to cholangitis, portal hypertension, intrahepatic gallstones and so on. Two of them are considered as candidates for liver transplantation. While the majority of long-term survivors of biliary atresia have good quality of life, close long-term follow-up is essential even in patients with biliary atresia aged 20 years or more.