Incidence and clinical significance of bacterial and fungal contamination of the preservation solution in liver transplantation.

A perfusion fluid used in the preservation of the grafted liver represents a medium suitable for microorganism growth. In this observational study, a sample of 232 transplanted livers was collected. Perfusion fluid samples were stored for microbiological analysis from harvested donors. Bacteria were isolated in 91 out of 232 samples, post-operative infections related to contaminated perfusion solution occurred in 13 cases. The contamination rate of the preservation medium appears to be high, but postoperative infections occurs rarely. We suggest periodic detection and a protocol in place designed for antibiotic use for transplanted patients exposed to contaminated perfusion solution.

Comparative study of target antigens for primate xenoreactive natural antibodies in pig and rat endothelial cells.

BACKGROUND: A rat-to-primate cardiac xenograft model has been proposed as an alternative to the clinically relevant but more cumbersome pig-to-primate model for assessing the efficacy of strategies aimed at preventing xenograft hyperacute rejection. As in pig xenografts, the rejection of rat hearts was mediated by the binding of xenoreactive natural antibodies (XNA) and complement activation. The present study was conducted to identify target antigens recognized by cynomolgus and rhesus monkey IgM XNA on rat tissues and cells in comparison with pig cells. METHODS: The reactivity of rhesus or cynomolgus serum on pig and rat endothelial cells (ECs) was studied by flow cytometry, ELISA, and complement-dependent cytotoxicity, after removal of primate XNA by perfusion of pig livers, immunoadsorption on a Gal alpha(1,3)Gal affinity column, and enzymatic removal of alpha-galactosyl epitopes from the cell surface. Rat and pig EC extracts were also immunoprecipitated with primate serum and resolved in sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The expression of the Gal alpha(1,3)Gal epitope was analyzed on rat tissues and ECs by immunohistochemistry, flow cytometry, and Western blot, using the isolectin B4 from Griffonia simplicifolia. RESULTS: Removal of primate XNA or of alphaGal epitopes resulted in a decrease in XNA binding to pig and rat cells, leaving a similar degree of residual reactivity in the two species. At least five proteins of 260, 210, 110, 56, and 50 kDa were immunoprecipitated on rat ECs, with molecular weight similar to several proteins identified on pig ECs. These results suggest that primate XNA recognize similar antigens on rat and pig ECs. Rat cells expressed lower levels of the Gal alpha(1,3)Gal epitope than pig cells. A large proportion, but not all, of primate XNA react with this epitope on pig and rat ECs. CONCLUSION: This study suggests that the rat is a valuable species for the evaluation of genetic engineering strategies on the vascular endothelium aimed at preventing hyperacute xenograft rejection.

Effects of platelet-activating factor antagonist on preservation/reperfusion injury of the graft in porcine orthotopic liver transplantation.

To investigate the role of platelet-activating factor (PAF) in the preservation/reperfusion injury of the liver graft, the effect of treatment with a potent PAF antagonist (E5880) was evaluated in a pig orthotopic liver transplantation model. The graft liver was flushed out and preserved for 8 hr at 4 degrees C using a simplified University of Wisconsin solution. The PAF antagonist was administered into the University of Wisconsin solution (1 mg/L), into the rinsing solution (1 mg/L), and to a recipient pig (0.3 mg/kg d.i.v.) in group 1. The PAF antagonist was not given in the control group (group 2). Postoperative survival of more than 12 hr was 100% (9/9) in group 1 and 56% (5/9) in group 2 (P < 0.05). At 12 hr after reperfusion of the graft (RPF), the arterial ketone body ratio (acetoacetate to 3-hydroxybutyrate) increased to 1.54 +/- 0.15 (mean +/- SEM) in group 1, compared with 0.95 +/- 0.09 (P < 0.05) in group 2. In group 2, blood leukocyte count decreased to 8.3 +/- 0.9 (x 10(3)/microliters) at 2 hr after RPF, in contrast to a slight increase in group 1 (14.3 +/- 1.8 x 10(3)/microliter, P < 0.01). At 4 hr after RPF, glutamic oxaloacetic transaminase (461 +/- 59 vs. 712 +/- 97 U/L, P < 0.05), glutamic pyruvic transaminase (65 +/- 4 vs. 82 +/- 5 U/L, P < 0.05), and the lactate level (6.2 +/- 1.1 vs. 9.4 +/- 1.0 mmol/L, P < 0.05) in arterial blood were significantly lower in group 1 than in group 2. Light and electron microscopic study at 1 hr after RPF showed neutrophil sludging in the sinusoids and sinusoidal endothelial cell damage in group 2, while these findings were attenuated in group 1. It is suggested that PAF plays a key role in microcirculatory disturbance of the liver graft manifested on reperfusion, and that the treatment with E5880 has a protective effect against preservation/reperfusion injury of the graft in liver transplantation.

Assessment of hyperacute rejection in a rat-to-primate cardiac xenograft model.

We studied a rat-to-cynomolgous monkey model for xenotransplantation of vascularized organs and found that a rat heart was rejected in 5.5 +/- 1.4 min (n = 10). This hyperacute rejection (HAR) was consistent with kinetic experiments in vitro that showed damage to rat endothelial cells (ECs) after 3 min of incubation with primate serum. Histopathology and ultrastructural analysis of rejected hearts showed marked EC damage and early adherence of platelets and polymorphonuclear leukocytes to the endothelium. Immunohistochemical analysis revealed deposition along endothelial surfaces of IgG, IgM, and complement (C) components of the classical but not the alternative pathway, suggesting that, as in the pig-to-primate model, HAR is mediated by the binding of recipient xenogeneic natural antibodies and C activation. The effect of C depletion on xenograft survival was evaluated in two recipients that were treated with cobra venom factor (CVF). CVF caused complete C inactivation, demonstrated by lack of serum hemolytic activity and C-dependent EC cytotoxicity at engraftment and until the animals died. The rat cardiac transplants survived for at least 9 hr and 77 hr. Histology showed massive interstitial hemorrhage, edema, and cellular infiltration with scanty fibrin deposits. These results in CVF-treated recipient monkeys indicate that C activation mediates the development of HAR in this rat-to-primate model. We suggest that the model may be of interest as an alternative to the more expensive and time-consuming pig-to-primate model for testing the efficacy of transgenic modification of donor organs to prolong xenograft survival and for studying mechanisms of discordant xenograft rejection.

Comparative evaluation of Celsior solution versus Viaspan in a pig liver transplantation model.

BACKGROUND: In a pig liver transplantation model, we compared the effects of Celsior solution (CS), an extracellular preservation solution, with Viaspan (University of Wisconsin solution, UW) on graft function and animal survival. METHODS: Pig livers were flushed with either CS or UW solution and cold-stored for 12 hr (group 1) or for 8 to 10 hr (group 2). Grafts were transplanted orthotopically. Intrahepatic reduced and oxidized glutathione and adenine nucleotides were evaluated 1 hr after reperfusion. Liver function of transplanted animals was monitored for up to 6 days by serum transaminases, total bilirubin, purine nucleoside phosphorylase, and prothrombin levels. RESULTS: In group 1, all animals died within 24 hr after reperfusion regardless of the preservation solution used. In group 2, no significant difference was seen in survival between the CS (72%) and the UW (67%) groups 6 days after transplantation, and there were no statistically significant differences in the biochemical data. There were no differences in histological evaluation of the livers at the time of death or killing of the animals between the CS and UW groups. CONCLUSION: Within the limits of this pilot study, CS is equivalent to UW in terms of graft function and animal survival.

Removal of primate xenoreactive natural antibodies by extracorporeal perfusion of pig kidneys and livers.

Organ perfusion is one of the possible strategies to attenuate rejection of discordant xenografts by reducing the levels of the recipient's xenoreactive natural antibodies (XNA). Its efficacy in terms of XNA removal was studied in models of primate blood or plasma perfusion through porcine kidneys or livers, with special attention to haematological consequences and potential side-effects. We first perfused the blood of rhesus monkeys through pig kidneys and livers, and demonstrated that the perfusion of a pig liver resulted in higher XNA adsorption (72 +/- 13%) than the perfusion of a pig kidney (51 +/- 25%). However, when we normalized for the weight of the perfused organs and for levels of natural antibodies in individual monkeys, livers adsorbed less antibody (1.4 +/- 0.9 U antibody/g) than kidneys (7.2 +/- 7 U antibody/g). Histological signs of rejection were observed in perfused kidneys, but not in perfused livers. A major drawback of the perfusion of blood through livers was a considerable decrease in the primates' haemoglobin and platelet levels. To avoid this, we developed a plasma liver perfusion device. This method allowed a significant improvement in the haemodynamic state of primates and was particularly effective in preventing anaemia. Moreover, plasma liver perfusion was as effective as blood liver perfusion to remove natural antibodies and, resulted in a marked decrease in their functional activity as assessed by complement-dependent cytotoxicity (CDC) and antibody-dependent cell-mediated cytotoxicity (ADCC). The level of other plasma proteins was not significantly affected, apart from a dilution effect. After xenoperfusion a strong antibody response was evidenced by ELISA, CDC and ADCC between days 7 and 14 and then decreased progressively. We conclude that the separation of blood to allow the perfusion of plasma through a pig organ is safer than the perfusion of unseparated blood and is associated with efficient natural antibody removal. However, organ perfusion is limited by a rebound in antibody levels after a few days, and thus will have to be associated with anti-B cell immunosuppressive therapy for long-term or repeated applications.

A surgical solution to extrahepatic portal thrombosis and portal cavernoma: the splanchnic-intrahepatic portal bypass.

Three cases of prehepatic portal vein thrombosis, complicated by the clinical manifestations of portal hypertension, were successfully treated by surgically created splanchnic-intrahepatic portal bypass. Two out of three patients had been previously submitted to liver transplantation. No significant morbidity was observed and long-term Doppler evaluations proved the patency of the venous grafts. Together with the technical aspects of the procedures, the possible role of this technique, primarily proposed by De Ville de Goyet in 1992, is discussed in relation to the available therapies for the extrahepatic portal vein thrombosis.

[Effect of nutritional status of the donor on the quality of hepatic graft. Value of restoration of glycogenic reserves of the donor]. / Influence du statut nutritionnel du donneur sur la qualité du greffon hépatique. Intérêt de la restauration des réserves glycogéniques du donneur.

Initial function of the graft is an essential factor for successful liver transplantation. The aim of this study was to evaluate the influence of the nutritional status of the donor on hepatic graft quality at reperfusion. Livers (n = 41) were taken from pigs normally fed or fasted for 24 h or fasted for 24 h and conditioned for 2 hours with a solution containing glucose, fructose and glutamine. The quality of liver grafts was evaluated using an original, blood-free isolated perfusion model, after 8 h cold storage, or after 15 min warm ischemia performed prior to harvesting. The hepatic concentration of glycogen and ATP, measured from in vivo biopsies, was decreased in fasted animals (P less than 0.05 vs fed) and restored by nutritional conditioning (P less than 0.05 vs fasted). At the time of reperfusion following 8 h cold ischemia, the liberation of aminotransferases and lactate dehydrogenase was elevated in livers coming from fasted animals (P less than 0.05 vs fed) and restored to fed levels after nutritional conditioning (P less than 0.01 vs fasted). After 15 min of warm ischemia, the bile secretion during the reperfusion period was decreased in the 24 h fasted livers (P less than 0.01 vs fed) and reestablished after nutritional conditioning (P less than 0.01 vs fasted). Perfusion of the donor liver, in the 2 h preceding harvest, with a solution of glucose plus neoglucogenic precursors enhances the quality of the liver graft at the time of reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of pre-, intra- and post-operative parameters of donor liver on the outcome of isolated human hepatocytes.

The aim of the present study was to analyse, retrospectively on a large panel of patients (149), the influence of the donor liver characteristics on the outcome of human hepatocyte isolation obtained from resected liver biopsies from surgical waste after hepatectomy. Among the pre-operative parameters, the type of disease, age and sex of the patient, previous chemotherapy, alcohol or tobacco consumption did not affect the yield, viability, attachment rate and function of the isolated human hepatocytes. Pre-operative biological and anatomopathological data indicated that, while mild steatosis (10% steatotic hepatocytes) tended to decrease hepatocyte yield. Cholestasis, as assessed by gamma-glutamyl transferase serum values, significantly negatively correlated with the percentage of digested liver and the yield of viable cells. Intra-operative clamping time, that is, warm ischaemia, longer than 30 min was found to decrease both the percentage of digested liver and cell yield. Among the post-operative parameters, the percentage of digested liver decreased when biopsy weights were higher than 100 g, the use of glue tended to increase both the percentage of digested tissue and the yield of viable cells.In conclusion, human diseased livers appear to be a valuable source of isolated functional human hepatocytes. We recommend, for an optimal isolation, to use liver biopsies weighing less than 100 g, to glue the section surfaces of the biopsies and to avoid the use of moderate steatotic livers (>10% steatotic hepatocytes) and cholestatic livers, as well as livers undergoing warm ischaemia or clamping during resection due to the decrease in cell yield.

[Pancreatic metastases of nephro-epitheliomas. Apropos of 2 cases]. / Les métastases pancréatiques des néphro-épithéliomes. A propos de deux observations.

Pancreatic metastasis from clear cell carcinoma of the kidney are exceptional (1 to 3 per cent). Twelve cases have been found in the literature, to which our two observations must be add. Intestinal haemorrhage rule the clinical signs. The complementary arteriography is a very good investigation. Surgery with excision may be effect when a solitary metastasis to the pancreas exist. We can argue about chemotherapy when there is a metastatic dissemination.

[Surgery of gastrointestinal vessels, selective indications for revascularization in a syndrome suggestive of chronic small intestinal ischemia]. / Chirurgie des vaisseaux digestifs, indications électives de revascularisation face à un syndrome évoquant une ischémie chronique de l'intestin grêle.

The authors present a critical review of the indications for revascularization of intestinal arteries in the presence of chronic ischaemia of the small intestine. They stress the extreme lability of the "chronic" clinical stage and emphasize the fundamental importance of establishing the diagnosis before the development of acute complications. Based on a personal experience of 92 intestinal revascularizations with a follow-up of one to 26 years, they stress the good quality of the results obtained after isolated revascularization of the superior mesenteric artery by direct or indirect reimplantation into the infrarenal aorta. However, they do not challenge the current tendency towards multiple revascularizations, but consider that the essential prerequisite for a correct result is the early surgical treatment of a disease which is still poorly understood and frequently disappointing.

[Control of massive hematuria after nephropyelotomy by selective intra-arterial injections of noradrenaline (author's transl)]. / Contrôle d'une hématurie massive aprés néphropyélotomie par injection intra-artérielle sélective de noradrénaline.

Severe hematuria after pyelonephrotomy was controlled by the selective injection of noradrenaline into the renal artery. The indications for this conservative therapeutic technique are defined as well as its place in relation to hemostatic surgical procedures.

[The influence of childbearing on the urinary tract (author's transl)]. / Influence de la gravidité sur les voies excrétrices urinaires.

The study of intravenous pyelograms taken immediately after delivery shows how the ureter has its dynamics modified during pregnancy. The role of parity and of urinary tract infection which sometimes is evidence of a pre-existing urological malformation is demonstrated.

[Renal transplantation in thrombosis of the inferior vena cava. Implantation of the graft vein in the portal vein]. / Transplantation rénale en cas de thrombose de la veine cave inférieure. Implantation de la veine du greffon dans la veine porte.

An 8-year old girl with chronic renal failure underwent allogeneic renal transplantation with implantation of the renal vein of the graft on the portal vein, as the inferior vena cava was obstructed by thrombosis. The possible technical obstacles to renal transplantation are reviewed on that occasion, and solutions are suggested. In the presence of thrombosis of the inferior vena cava it seems necessary to determine its level and to look for a patent venous segment all the way up to the diaphragm. If no such segment is found, then the renal vein can be implanted on the portal vein.

[Enhancement of the quality of hepatic graft by restoration of hepatic glycogen reserves in the donor]. / Amélioration de la qualité du greffon hépatique par la restauration des réserves hépatiques en glycogène chez le donneur.

It has been suggested that depletion of donor hepatic glycogen reserves deleteriously affects the resistance of the hepatic graft to ischemic episodes. In this study, performed in the pig model, we showed that it is possible to enhance the quality of the graft at the time of reperfusion by using a method which rapidly restores the donor hepatic glycogen reserves. With the aid of an isolated liver perfusion model, we compared grafts (n = 24) harvested from pigs fed (group N), fasted for 24h (group J), or fasted with a restoration of glycogen reserves (group P). After the grafts were subjected to 8 hours of cold ischemia, the release of alanine aminotransferase, aspartate aminotransferase and lactic dehydrogenase in the perfusate increased in group J (P < 0.05 vs group N); the increase was corrected in group P (P < 0.05 vs group J). When the grafts were subjected to 15 minutes warm ischemia prior to the liver harvest, the production of bile was reduced in group J (P < 0.05 vs group N); bile production was reestablished in group P (P < 0.05 vs group J). The clinical application of such a method of donor nutritional conditioning, in the hours which precede organ harvesting, may enhance the quality of the hepatic graft at the time of transplantation.

[Diffuse urothelial tumor. Treatment by bilateral nephro-ureterectomy, cystoprostatectomy, renal autotransplantation with cutaneous trans-ileal pyelostomy. Results after 6 years]. / Tumeur urothéliale diffuse. Traitement par néphro-urétérectomie bilatérale, cystoprostatectomie, autotransplantation rénale avec pyélostomie cutanée trans-iléale. Résultat à six ans.

A diffuse urothelial tumour in a solitary kidney does not necessarily require nephroureterocystectomy in order to satisfy oncological imperatives. The authors report the case of a 69-year-old man who, in an identical situation, was treated conservatively. Ex vivo surgery of the kidney offers remarkable exposure, allowing total pyelectomy followed by intra-hilar plasty of the excretory tract suitable for intestinal loop diversion. After a current follow-up of 6 years, the patient does not present any recurrence or metastasis.

[Radiological exploration of the inferior vena cava in nephroepithelioma]. / L'exploration radiologique de la veine cave inférieure dans les néphroépithéliomes.

The development of non-invasive procedures, namely ultrasonography and computed tomography, has modified the strategy for evaluating the spread of a nephroepithelioma to the inferior vena cava. When a complete study can be performed, ultrasonography is the most informative method. Angiographic studies are only performed as the second choice.

[A rare complication of the acetabulum: incarceration of a small intestine loop in the fracture area]. / Une complication rare des fractures du cotyle: L'incarcération d'une anse grêle dans le foyer de fracture

The authors report an exceptional case of fracture of the acetabulum complicated by tear of the small intestine due to injury to the loop of intestine by a piece of the fractured acetabulum. As it is rare, such a complication is often undiagnosed. Discovered in time, an operation avoids a fatal issue due to peritonitis.

[New technic of retro-peritoneal renal transplantation in the left lumbar position in the child. Report of two cases (author's transl)]. / Technique nouvelle de transplantation rénale rétro-péritonéale en situation lombaire gauche chez l'enfant. A propos de deux cas.

In the child, renal transplantation is almost always carried out by placing the kidney within the peritoneum for a simple reason: the donors being adults, the kidneys are too large to be placed in extra-peritoneal position. However, all authors agree that placing the kidney in an extra-peritoneal position offers undoubted advantages.

[Surveillance of patients receiving transplantation]. / Surveillance des patients transplantés.

Organ transplantation is now considered as an effective method of treatment of definitive visceral failures, but it has generated new iatrogenic disorders of the immunocompromised hosts. Each transplanted patient is subjected to a life-long follow-up in order to assess the performances of the graft and to detect the complications of the immunosuppressive treatment. The rate of the outpatient consultations is decreasing, according to the development of a state of natural tolerance between the graft and its host, which limits the risks of acute rejection. The elements of the follow-up are quite similar whatever the grafted organ, which points out the identical medical problems of transplant patients. The medical staff of public hospitals is commissioned to organize the outpatient clinics of transplantation, but the crucial role of general practitioners must be emphasized.