Major Histocompatibilty Complex-Restricted Adaptive Immune Responses to CT26 Colon Cancer Cell Line in Mixed Allogeneic Chimera.

BACKGROUND: Although the induction of mixed allogeneic chimera shows promising clinical tolerance results in organ transplantation, its clinical relevance as an anti-cancer therapy is yet unknown. We introduced a mixed allogenic chimera setting with the use of a murine colon cancer cell line, CT26, by performing double bone marrow transplantation. METHODS: We analyzed donor- and recipient-restricted anti-cancer T-cell responses, and phenotypes of subpopulations of T cells. The protocol involves challenging 1 × 105 cells of CT26 cells intra-hepatically on day 50 after bone marrow transplantation, and, by use of CT26 lysates and an H-2Ld-restricted AH1 pentamer, flow cytometric analysis was performed to detect the generation of cancer-specific CD4+ and CD8+ T cells at various time points. RESULTS: We found that immunocompetence against tumors depends heavily on cancer-specific CD8+ T-cell responses in a major histocompatibility complex-restricted manner; the evidence was further supported by the increase of interferon-γ-secreting CD4+ T cells. Moreover, we demonstrated that during the effector immune response to CT26 cancer challenge, there was a presence of central memory cells (CD62LhiCCR7+) as well as effector memory cells (CD62LloCCR7-). Moreover, mixed allogeneic chimeras (BALB/c to C56BL/6 or vice versa) showed similar or heightened immune responses to CT26 cells compared with that of wild-type mice. CONCLUSIONS: Our results suggest that the responses of primary immunocompetency and of pre-existing memory T cells against allogeneic cancer are sustained and preserved long-term in a mixed allogeneic chimeric environment.

Acoustic analysis of snoring sounds recorded with a smartphone according to obstruction site in OSAS patients.

Snoring is a sign of increased upper airway resistance and is the most common symptom suggestive of obstructive sleep apnea. Acoustic analysis of snoring sounds is a non-invasive diagnostic technique and may provide a screening test that can determine the location of obstruction sites. We recorded snoring sounds according to obstruction level, measured by DISE, using a smartphone and focused on the analysis of formant frequencies. The study group comprised 32 male patients (mean age 42.9 years). The spectrogram pattern, intensity (dB), fundamental frequencies (F 0), and formant frequencies (F 1, F 2, and F 3) of the snoring sounds were analyzed for each subject. On spectrographic analysis, retropalatal level obstruction tended to produce sharp and regular peaks, while retrolingual level obstruction tended to show peaks with a gradual onset and decay. On formant frequency analysis, F 1 (retropalatal level vs. retrolingual level: 488.1 ± 125.8 vs. 634.7 ± 196.6 Hz) and F 2 (retropalatal level vs. retrolingual level: 1267.3 ± 306.6 vs. 1723.7 ± 550.0 Hz) of retrolingual level obstructions showed significantly higher values than retropalatal level obstruction (p < 0.05). This suggests that the upper airway is more severely obstructed with retrolingual level obstruction and that there is a greater change in tongue position. Acoustic analysis of snoring is a non-invasive diagnostic technique that can be easily applied at a relatively low cost. The analysis of formant frequencies will be a useful screening test for the prediction of occlusion sites. Moreover, smartphone can be effective for recording snoring sounds.

Primary versus salvage living donor liver transplantation for patients with hepatocellular carcinoma: impact of microvascular invasion on survival.

OBJECTIVE: Salvage liver transplantation (LT) has been proposed for patients with a small hepatocellular carcinoma (HCC) and preserved liver function. Few reports have been issued on salvage LT in a living-donor (LD) LT setting. Therefore, we performed this study to evaluate differences in tumor invasiveness and other risk factors on survival after salvage versus primary LDLT. METHODS: Between September 1996 and December 2008, 324 patients with HCC underwent LT. We excluded 138 patient from the analysis, leaving 186 HCC patients for analysis, including 17 (9.1%) who had undergone earlier resection, the salvage LDLT cohort. The other 169 patients underwent primary LDLT. RESULTS: Intrahepatic metastasis, Edmonson-Steiner histologic grade, microscopic vascular invasion, and preoperative serum alpha-fetoprotein levels significantly influenced tumor recurrence. Microscopic vascular invasion, intrahepatic metastasis, Edmonson-Steiner histologic grade, and treatment by salvage LDLT were significantly associated with poor patient survival univariate analysis. However, only microscopic vascular invasion was significant on multivariate analysis. The treatment modality (primary or salvage LDLT) was not observed to affect overall or disease-free survival significantly on multivariate analysis. Disease-free survival was significantly better in the primary than in the salvage LDLT group. Furthermore, patients in the primary LDLT group tended to show better survival. However, when stratified by the presence or absence of microscopic vascular invasion, no significant group difference was found for overall or disease-free survival among those without versus with microscopic vascular invasion. CONCLUSIONS: Five-year overall survival after primary versus salvage LDLT were similar when differences in tumor pathologic features, such as microscopic vascular invasion, were taken into account. Multivariate analysis showed that the treatment itself was not a significant prognostic factor for survival.

Patients with unresectable hepatocellular carcinoma beyond Milan criteria: should we perform transarterial chemoembolization or liver transplantation?

Patients with unresectable, beyond Milan criteria, hepatocellular carcinoma (HCC) invariably undergo palliative transarterial chemoembolization (TACE). The aim of this study was to compare the outcomes of conventional TACE versus liver transplantation (LT) in unresectable (beyond Milan criteria) HCC. Twelve patients underwent LT and 86 TACE for unresectable, beyond Milan criteria HCC. The inclusion criteria were a single tumor60 years, vascular invasion, or extrahepatic spread. Survival rates were calculated using the Kaplan-Meier method. Multivariate analysis showed that TACE was a prognostic factor for survival (hazard ratio, 16.66, P=.000). The LT group showed significantly better survival than the TACE cohort. Two cases (16.7%) in the LT group recurred at a median time of 13.5 months. Survival rates at 1, 3, and 5 years were 100%, 88.9%, and 76.2% in the LT group, and 85.6%, 45.6%, and 21.4% in the TACE group, respectively. Patients with unresectable, beyond Milan criteria HCC should be given the option to receive LDLT, because LT offers a significantly better likelihood of survival than TACE.

Living donor liver transplantation in Budd-Chiari syndrome: a single-center experience.

Budd-Chiari syndrome (BCS), which is characterized by hepatic venous outflow obstruction due to occlusion of the major hepatic vein and/or the inferior vena cava (IVC), is rare. Traditionally, a caval resection is advocated for these patients; however, such a maneuver renders living donor liver transplantation (LDLT) impossible. We encountered BCS in 4/377 LDLT patients during a 5-year period (January 2003 to December 2007). This report examine the various surgical modifications in these 4 patients, who underwent to LDLT for BCS. Resection of right hepatic vein (RHV) with an adjacent fibrotic part of the IVC with direct anastomosis of the graft RHV to the IVC was performed in 2 patients. One patient underwent retrohepatic IVC excision and reconstruction with a cryopreserved autologous IVC graft. The fourth patient, with a preexisting mesoatrial shunt for BCS, underwent conversion of this to a RHV atrial shunt. Graft and patient survivals were 100%. There were few complications in either donors or recipients. LDLT for BCS can be performed safely with adequate venous drainage techniques and with anticoagulant therapy and good follow-up for early diagnosis and treatment of recurrence leading to excellent long-term results.

Pharmacokinetics of mycophenolic acid in living donor liver transplantation.

PURPOSE: This study sought to define the pharmacokinetics of mycophenolic acid (MPA) in Korean living donor liver transplant recipients. METHODS: Thirty-two liver transplant recipients (29 males, 3 females) were administered 750 mg mycophenolate mofetil (MMF) twice daily with concomitant tacrolimus. Plasma MPA concentrations were measured by liquid chromatography with tandem mass spectrometry detection assay from samples drawn before dosing (C0) and after dosing at 0.5 hours (C1/2) and 2 hours (C2), providing a total of 114 pharmacokinetic profiles at various periods from 3 days to 6 months posttransplantation (D3, D7, D14, M1, M3, and M6). RESULTS: The mean area-under-the-curve from 0 to 2 hours (AUC0-2) was 30.0+/-11.6 microg.h/mL (range, 7.8-60.7). Of 114 pharmacokinetic profiles, 40 (35%) AUC and 7 (6.1%) trough values were within the target value (30-60 microg.h/mL and 1.7-4.0 microg/mL, respectively). The C0, C1/2, and C2 concentrations showed large interindividual variability: C0 (0.01-4.46 microg/mL), C1/2 (0.14-36.86 microg/mL), and C2 (0.79-18.19 microg/mL). A positive correlation was observed between AUC and C0 (r=.6374; P<.0001), and C2 (r=.7460; P<.0001). When analyzed according to the date posttransplant, a positive correlation between AUC and C0 was shown on day 7, day 14, and at month 1. There was no difference in any pharmacokinetic parameter relative to age, weight, or albumin level. CONCLUSION: This study demonstrated that C0 values on day 7, day 14, and at month 1 provided valuable information for MPA monitoring. C0 was shown to be the most reliable monitoring time in relation to AUC. However, results from a larger randomized trial with more time intervals are eagerly awaited.

Early and delayed onset cytomegalovirus infection of liver transplant recipients in endemic areas.

BACKGROUND: The delayed onset of cytomegalovirus (CMV) infection after liver transplantation can place patients at risk for graft failure and mortality. METHODS: We compared early versus delayed onset of CMV infection to identify risk factors for mortality among liver transplant recipients in an endemic area. RESULTS: Among 710 consecutive adult liver transplant recipients, incidence of CMV infection was 47.5% (337/710). Male gender, biliary complications, acute rejection episodes, antilymphocyte antibodies high hemoglobin, and high total bilirubin were significantly different among patients with delayed versus early onset CMV infections. The overall incidence of early versus delayed CMV infections was 43.1% (306/710) versus 4.4% (31/710). Among them, 11.1% (34/306) and 25.8% (8/31) of patients developed CMV disease. CONCLUSION: These results showed that a higher proportion of patients developed disease among delayed CMV infected patients (P=.039). The overall and graft survival curves for patients with early onset CMV infections were better than those of patients who had delayed onset CMV infections (P=.026 and P=.014). Recurrence of hepatitis B virus, hepatic dysfunction, and retransplantation were associated with increased mortality among patients who had a delayed CMV infection.

Risk factors for posttransplant lymphoproliferative disorder in pediatric liver transplant recipients with cytomegalovirus antigenemia.

Epstein-Barr virus (EBV) infections, associated with posttransplant lymphoproliferative disorder (PTLD) are known to develop in cytomegalovirus (CMV)-infected transplant recipients due to the indirect effects of CMV. This study evaluated risk factors for PTLD among pediatric liver transplant recipients with CMV infections. We reviewed the medical records of 119 patients

Intestinal transplantation with alemtuzumab (Campath-1H) induction for adult patients.

BACKGROUND: Alemtuzumab (Campath-1H [C1H]) is a humanized monoclonal antibody directed against the CD 52 antigen that is present on the surface of T cells, B cells, natural killer cells and monocytes. We studied its application in intestinal transplantation. METHODS: This is a retrospective review of adult patients who underwent intestinal transplantation between December 1994 and May 2005. Group 1: non-C1H group (n = 39); group 2: C1H group (n = 37). C1H was administered as an induction immunosuppression in four doses (0.3 mg/kg), or in two doses (30 mg/kg). Tacrolimus levels were maintained at low level (5-10 ng/dL). No maintenance steroids were given. RESULTS: One-year survival of group 1 and group 2 patients were 57% and 70%, respectively. This difference is not statistically significant. Of 37 patients in group 2, 21 are alive. The incidence of rejection was lower in group 2 (P < .005). Average current tacrolimus level is 6.97 +/- 3.98 ng/dL. Seventeen patients (81%) are steroid free, and 15 (71%) are maintained solely on tacrolimus. There was no graft versus host disease in group 2. CONCLUSIONS: Our preliminary data suggest that C1H can provide effective immunosuppression for intestinal transplantation. Incidence of rejection was less with this regimen using low maintenance tacrolimus and minimal steroids.

Granzyme B and TIA-1 expression in chronic and acute on chronic renal allograft rejection.

Although active inflammation may be deleterious and indicate immunologic activation in chronically rejected grafts, the underlying mechanism of tissue destruction has been little studied. Twenty-four cases of chronic rejection (CR) with or without acute rejection (AR) were stained with antibodies against CD3, CD8, CD68, granzyme B and TIA-1, and the number of positive cells were counted. Eleven cases of AR served as controls. The number of CD3 and CD8 positive cells increased in the acute on CR group compared to the CR group. About a half of CD3 positive T cells were CD8 positive in both groups, however, the proportion of TIA-1 or granzyme B positive cells was higher in the acute on CR group. The numbers of CD3, CD68, granzyme B and TIA-1 positive cells were higher in the AR group than the acute on CR group, however, no significant difference was found between the two groups. Serum creatinine level and proteinuria at the time of biopsy and the percentages of late onset AR and graft failure rate were higher in the acute on CR group than the CR group. Summarizing, these results suggest that infiltration of activated T cells containing cytotoxic granules plays a role in graft destruction in acute on CR.

Long-term results of kidney transplantation between HLA-identical siblings.

Long-term data on HLA-identical renal transplants are scarce, and the advantages of using cyclosporine (CsA) over azathioprine (AZA) have yet to be elucidated. In 68 recipients from HLA-identical donors (37 under AZA-steroids and 31 under CsA-steroids), we estimated the graft and patient survival to posttransplant 120 months, and compared the results between patients on different protocols. Episodes of rejection, causes of graft loss or patient death, and longterm complications were also compared retrospectively. The 10-year patient/graft survivals were comparable: 82.7/67.6% for the AZA and 78.4/63.5% for the CsA patients. The incidence of acute rejection during the first year after transplant was also comparable. We lost 25 grafts. The major causes of graft loss were patient death (7/13 in AZA and 5/12 in CsA patients) and chronic rejection (3/13 in AZA and 3/12 in CsA patients). Four grafts were lost due to poor compliance. We lost 12 patients due mostly to cerebrovascular disease and infections. There was no difference in the prevalence of complications between patients. In conclusion, the long-term outcome was excellent in this subgroup of transplant patients. We could not find any advantages of using CsA over AZA in these patients after a long-term follow-up. To achieve better results, continued attention should be paid to the prevention of poor compliance and complications.

Live donor renal allograft in end-stage renal failure patients from immunoglobulin A nephropathy.

BACKGROUND: The purpose of this study was to attempt to resolve two important issues, i.e. to determine (1) whether the course of recurrent immunoglobulin A nephropathy (IgAN) is benign, and (2) whether it is advisable to use a related donor. METHODS: We evaluated the long-term outcome, in terms of recurrence and graft survival, after live related or unrelated donor renal transplantation, and assessed the validity of the use of related donors in 90 grafts in 89 IgAN patients. RESULTS: Ten-year graft survival for IgAN patients was 66%, compared with 84% for 107 reference recipients who had other kinds of glomerulonephritis (GN), and with 69% in 90 other recipients who had non-GN renal failure (P=0.27). In 43 grafts, 54 event graft biopsies were performed, documenting the presence of mesangial IgA deposits in 19 of those grafts. In eight grafts, lesions were accompanied by chronic rejection (CR). Ten-year cumulative recurrence was 44%. Ten grafts were lost: by CR (n=3) or acute rejection (n=1) in 24 recurrence-free recipients, by CR (n=2) or recurrence (n=2) in 19 recurrent patients, and by patient death (n=2) in 46 patients devoid of graft biopsy. We found no difference in 10-year graft survival between the recurrent and recurrence-free patients (63% vs. 74%, P=0.98), or the proportion of related donors (68% vs. 83%, P=0.25). The presence or matching of HLA B12, B35, or DR4 did not affect the recurrence. CONCLUSIONS: Recurrence increased to 44% with longer follow-up, but this did not limit the graft outcome. Recurrence was not affected by the kind of live donor. We conclude that live related or unrelated kidneys should be offered to IgAN patients.

The effect of paclitaxel powder on glaucoma filtration surgery in rabbits.

OBJECTIVE: The authors determine if the intraoperative placement of paclitaxel powder in the subconjunctival space improves the outcome of glaucoma filtration surgery in rabbits. METHODS: A posterior lip sclerectomy was performed in the right eye of 24 New Zealand white rabbits. Before the conjunctiva was fully sutured, 8 mg of mannitol powder alone, or 8 mg of mannitol powder containing either 10 micrograms or 250 micrograms of paclitaxel, was placed in the subconjunctival space of six eyes each in masked fashion. An additional six animals were treated with episcleral application of a sponge soaked in a solution of 0.5 mg/ml of mitomycin C (MMC) for 5 minutes before the sclerectomy was performed. Intraocular pressure and bleb size were measured until the operation had failed or until the 7 weeks of observation had concluded. RESULTS: Both paclitaxel powder and MMC solution improved the outcome of filtration surgery in this model as measured by magnitude of intraocular pressure (IOP) lowering and duration of surgical success. No toxic effect of either drug was observed, although endophthalmitis was observed in eight animals followed for more than 3 weeks. CONCLUSION: The introduction of paclitaxel into the subconjunctival space at the conclusion of filtration surgery has an effect comparable to intraoperative MMC.

Aqueous humor uric acid and ascorbic acid concentrations and outcome of trabeculectomy.

OBJECTIVE: To determine if there is an association between the surgical outcome of trabeculectomy and uric acid and ascorbic acid concentrations in the aqueous humor at the time of the procedure. PATIENTS, MATERIALS, AND METHODS: Aqueous humor samples were collected from the eyes of 169 of 249 adult patients who underwent trabeculectomy alone for any type of glaucoma between April 1989 and July 1995. Postoperatively, all medical records were reviewed and outcomes were classified as successful, unsuccessful, or indeterminate. The ascorbic acid and uric acid concentrations were determined in masked fashion by high-pressure liquid chromatography. Factors associated with surgical outcome were determined. RESULTS: Uric acid concentration was higher in unsuccessful eyes (mean+/-SD, 0.21+/-0.08 mmol/L, n=26) than in successful eyes (0.15+/-0.09 mmol/L, n=91, 95% confidence interval for difference, 0.02-0.10 mmol/L). Ascorbic acid levels were not significantly different in the eyes with unsuccessful (1129.9+/-601.9 micromol/L) and successful (1334.3+/-511.0 micromol/L) surgery (95% confidence interval for difference, -475.2 to 66.4 micromol/L, P=.13) surgery. Other factors associated with failure were previous surgery and surgery performed at the inferior limbus. A multiple polytomous logistic regression analysis was performed, after excluding the small number of operations performed at the inferior limbus. The odds ratio for failure increased by a factor of 1.68 for every 1-mmol/L increase in uric acid (95% confidence interval, 1.16-2.43, P=.006). CONCLUSIONS: Uric acid levels were higher at the time of surgery in eyes that had unsuccessful outcomes than in those with successful outcomes. No significant difference in ascorbic acid levels was detectable. A higher uric acid level in the aqueous humor is a risk factor for trabeculectomy failure and might be tested as a prognostic indicator [corrected].

Results of kidney transplantation from 1979 to 1997 at Yonsei University.

1. Long-term graft survival markedly improved after the introduction of CsA as the main immunosuppressant in living-donor kidney transplantation at our institution. 2. HLA-identical LRD kidney transplantation provided the best long-term graft survival rate, probably due to a decreased incidence of graft loss from rejection. 3. We could achieve good long-term graft survival in LURD kidney transplantation compared with that of HLA-haploidentical LRD kidney transplantation. 4. Because of the striking discrepancy between organ donation and the increasing demand for transplantation, distant relative donors and LURDs, including swap donors, should be considered as an alternative way to increase the number of available donors when accompanied by a careful evaluation process.