Quality of life and problems affecting recipients more than 10 years after living donor liver transplantation.

BACKGROUND: We initiated living donor liver transplantation (LDLT) in 1991, allowing us to examine issues related to long-term survival. The aim of this study was to review the long-term outcomes of LDLT in children. PATIENTS AND METHODS: We performed 116 LDLT from 1991 to present, including 17 recipients who survived >10 years. They were evaluated for growth, immunosuppressive therapy, complications, and quality of life (QOL). RESULTS: The average age at LDLT was 5.4 years (range, 6 months to 17 years), with a present average age of 17.2 years (range, 11-28 years). At the time of LDLT, 6 recipients had growth retardation with body weights low for age by 2 standard deviations (SD). However, 4 of 6 recipients who underwent LDLT before age of 2 years caught up, reaching average heights and body weights for their ages. Among 6 recipients who were diagnosed with acute rejections by biopsy >5 years after LDLT, 5 improved after steroid pulse therapy. One recipient with a steroid-resistant acute rejection was administered deoxyspergualin after steroids. Chronic rejection was not observed in this series. One recipient has not required immunosuppressive therapy for >4 years with a good present condition. CONCLUSION: The majority of LDLT recipients achieved a good QOL during long-term survival; they are pursuing normal studies.

The use of recipient superficial femoral vein as a venous graft for portal vein reconstruction in right lobe living donor liver transplantation.

In living donor liver transplantation (LDLT), portal vein thrombosis (PVT) in the recipient is frequently regarded as a contraindication. To reconstruct the PV of a right-lobe liver graft (RLG) using an interposition or jump graft from the splenomesenteric junction, various vein grafts and technical modifications have been introduced. The internal jugular, external iliac, or great saphenous veins have been utilized in such reconstructive procedures. However, the superficial femoral vein (SFV) is preferable to the autologous vein grafts in terms of caliber, wall thickness, and length. We employed the recipient SFV to reconstruct PVT among 40 adult LDLT using RLG. Thirty-three were reconstructed by single end-to-end anastomosis with the right or left recipient PV. Three patients were transplanted with a RLG using 2 separated PVs reconstructed by double anastomoses with both the right and left PVs of the recipient. The remaining 4 patients required venous grafting for portal reconstruction. We used the recipient SFV as an interposition or jump graft from the splenomesenteric junction to the graft PV. There were 2 cases of anastomotic PV stenosis; 1 in portal reconstruction without a venous graft and the other with a SFV graft. Both were treated successfully by balloon angioplasty. The recipient SFV is an excellent size match for the PV reconstruction as a long interposition or jump conduit when the venous system from the deceased donor is not available. The indication for LDLT in patients with complete PVT should be carefully decided before transplantation in terms of portal reconstruction.

Management of living donor liver transplant patients using twice-daily 4-hour intravenous cyclosporine therapy.

Oral administration of cyclosporine (CsA) is the currently favored route in most liver transplant centers. From October 1998 to January 2008, 86 living donor liver transplantations (LDLTs) were performed in 85 patients (46 adults and 39 children) at our institution. Seventy-three patients received tacrolimus (Tac), and 12 intravenous CsA twice daily at a dose of 3 mg/kg/d as a 4-hour continuous infusion. Thirteen of 73 Tac-based patients were switched to CsA because of side effects. Five were switched to intravenous CsA because they were unable to take the drug orally because of severe Tac-related complications. The remaining eight patients switched to oral CsA. We evaluated patients (11 adults and three children), including 12 with induction therapy and two with conversion therapy within 2 weeks of LDLT. The patients were given a 4-hour intravenous infusion of CsA at an initial dose of 3 mg/kg/d. Stable and adequate blood CsA concentrations were achieved by 4-hour intravenous CsA administration. Among several factors, only graft-to-recipient weight ratio (r = .743, P < .0001) showed significant correlations with initial blood CsA concentration. No adverse effects were observed after intravenous CsA. No patients developed biopsy-proven acute cellular rejection (ACR) during intravenous CsA administration, whereas two patients had histopathologically diagnosed episodes of ACR after conversion from intravenous to oral CsA. Our findings suggest that immediate administration of a 4-hour intravenous infusion of CsA at an initial dose of 3 mg/kg/d is practical and effective for routine clinical use.

Foliar anatomy and microscopy of six Brazilian species of Baccharis (Asteraceae).

We report for the first time the presence of cluster crystals of calcium oxalate within the glandular trichomes and oil bodies in the mesophyll for Baccharis species. Moreover, the comparative leaf anatomy and micro-morphology of six species of Baccharis, namely B. illinita, B. microdonta, B. pauciflosculosa, B. punctulata, B. reticularioides, and B. sphenophylla is investigated by light and scanning electron microscopy. The studied species exhibited differences in their leaf anatomical features such as the morphology of the cuticle, type and occurrence of the stomata, presence or absence of glandular trichomes, shape of the flagelliform trichomes, and the arrangement of the mesophyll tissues. These differences can be helpful in the species identification and classification and could represent informative characters for the reconstruction of the evolution of the genus.

Continuous low-dose human atrial natriuretic peptide promotes diuresis in oliguric patients after living donor liver transplantation.

Human atrial natriuretic peptide (ANP) is beneficial for the prophylaxis of acute renal failure (ARF) after liver transplantation (OLT). We evaluated renal function in OLT patients with or without ARF, describing cases unresponsive to loop diuretics successfully treated with continuous low-dose ANP infusion without hemodialysis. Twenty-seven consecutive adult-to-adult living donor liver transplantations (LDLTs) were performed in 26 patients. One case was excluded due to the need for continuous hemodialysis (HD) during the operation. Of the 26 cases, 6 (23%, group 2) developed ARF in the first 30 days after LDLT; the other 20 were ARF-free (group 1). The median follow-up was 24 months. No patient required either continuous or intermittent HD. Only one patient died due to multiple liver abscesses. Mean preoperative serum creatinine (sCr) value and intraoperative blood loss in group 2 were significantly higher than those in group 1. Three cases in group 2 failed to improve on high-dose loop diuretics with low-dose dopamine, exhibiting fluid overload. The remaining three cases in group 2 responded to conventional diuretic treatments. Continuous low-dose ANP was started 2, 4, or 5 days after LDLT, and urine output significantly increased after ANP administration. The serum creatinine values were 1.1, 1.2, and 1.1 at 1 month and 1.0, 0.9, and 0.6 mg/dL at 6 months after LDLT. Massive blood loss during the operation caused ARF, but did not affect renal function after LDLT. Continuous low-dose ANP improved renal function and diuresis for oliguric ARF patients, preventing the need for HD or continuous venovenous hemodialysis.

Immortalization of human lymphocytes by co-cultivation with lethally irradiated autologous T-cell lines harbouring human T-cell leukaemia virus-I.

Human adult peripheral blood lymphocytes were successfully immortalized by co-cultivation with irradiated autologous and homologous T-cell lines harbouring human T-cell leukaemia virus-I (HTLV-I). The efficiency of transformation was the same in both cases. The participation of alloantigen stimulation in co-cultivation procedures is discussed, and it is stressed that factors other than alloantigen stimulation might be required for the efficient immortalization of human T-lymphocytes in vitro by HTLV.

Treatment of small hepatocellular carcinoma.

Of the 692 patients with hepatocellular carcinoma (HCC) who were admitted to our hospital between 1976 and 1990, 60 (8.8%) had small HCC with a maximal diameter of below 2 cm. The outcome of these 60 cases was analyzed after they had been divided into 4 groups based on the therapeutic method used: operation group (17 cases), percutaneous ethanol injection therapy (PEIT) group (20 cases), transcatheter arterial embolization (TAE) group (13 cases), and oral anticancer drug therapy (per os) group (10 cases). The 1-, 2-, 3-, 4-, and 5-year survival values obtained for the operation group (100%, 87.5%, 87.5%, 87.5%, and 87.5%, respectively) were significantly higher than those found for the per os group (P < 0.01). The best therapeutic results were achieved in the operation group. Although the follow-up period for the PEIT group was short, the 2-year survival of this group was nearly equal to that of the operation group. Whereas the duration of survival tended to increase in inverse proportion to the severity of the underlying liver cirrhosis, the survival values did not differ between solitary and multiple tumors or among the different histological grades of HCC. In this series, 20 patients died; 9 deaths (45.0%) were due to progressive disease and 3 deaths (15.0%) were attributed to hepatic failure. Because the operation group included many patients who displayed relatively good liver function, we cannot rule out the possibility that their excellent outcome may have been associated with this background factor. Therefore, further prospective investigation is necessary to compare the efficacy of various therapies in patient groups with a homogeneous background.

Endoscopic injection sclerotherapy for esophageal variceal hemorrhage in a patient with idiopathic myelofibrosis.

A 74-year-old female with idiopathic myelofibrosis (IMF) was admitted to our hospital because of massive hematemesis and melena. Immediate upper gastrointestinal endoscopy revealed an intermittent spurting hemorrhage from extensive esophageal varices. Endoscopic injection sclerotherapy (EIS) was carried out and the bleeding ceased. After five courses of EIS, all the esophageal varices were eradicated. About 15 months later, the patient died, due to a cerebral hemorrhage, without further variceal bleeding. A postmortem examination was carried out and the portal hypertension was considered to be due not only to extramedullary hematopoiesis in the sinusoids, but also to increased splenic blood flow. We are confident that EIS is an effective therapeutic procedure for patients with IMF showing esophageal variceal hemorrhage. EIS should be the preferred choice of treatment for esophageal varices in patients with IMF, since it is less invasive than splenectomy.

Significance of early measurement of serum hepatitis C virus RNA in predicting response to interferon therapy in patients with chronic hepatitis C.

BACKGROUND: Interferon can induce complete clearance of hepatitis C virus (HCV) in some patients with chronic hepatitis C. However, various side effects often require cessation of administration during the treatment period. Early prediction of response to interferon would be helpful. We evaluated measurement of serum HCV RNA 2 weeks after starting interferon as a predictor of response. METHODS: The presence of HCV RNA was measured in serum 2 weeks after starting therapy in 85 patients receiving natural interferon a (total 480 MU). RESULTS: Twenty-seven of 38 patients (71.1%) in whom serum HCV RNA had disappeared at 2 weeks achieved a sustained response. Only two out of 47 patients (4.3%) in whom serum HCV RNA had not disappeared at 2 weeks achieved a sustained response. Of 42 patients with pre-treatment HCV RNA concentrations less than 1 x 10(6) eq/ml, 26 of 30 patients (86.7%) whose HCV RNA had disappeared at 2 weeks achieved a sustained response, while only one of 12 patients (8.3%) whose HCV RNA was still detectable at 2 weeks had a sustained response. CONCLUSION: Clearance of serum HCV RNA after 2 weeks of treatment with interferon was more likely in patients with lower pre-treatment HCV RNA concentrations and they had a high likelihood of achieving a sustained response. In patients in whom serum HCV RNA was still detectable after 2 weeks of interferon therapy, a sustained response was most unlikely.

Detection of HLA-D-region-associated antigens on the surface of adult T-cell leukemia virus particles by immunoelectron microscopy.

To search for lymphocyte marker antigens on the surface of human T-cell leukemia virus (HTLV), an immunoelectron microscopic study was performed on a HTLV-producing human T-cell line, MT-2, using monoclonal antibodies, such as anti-Leu-1, -Leu-2b, -Leu-3a, -Leu-5, -Leu-10 and -HLA-DR and OKIal. The reactivity of each antibody with MT-2 cells was tested by the immunoperoxidase method at the light microscopic level. OKIal, anti-HLA-DR and -Leu-10 gave positive results. At the ultrastructural level, the surface of HTLV as well as the plasma membranes of MT-2 cells were labeled with ferritin by the monoclonal antibodies OKIal, anti-HLA-DR and -Leu-10, but not by anti-Leu-1 and -Leu-3a. These findings suggest that HLA-D region -associated antigens are common antigenic determinants shared by the surface of HTLV and the plasma membranes of MT-2 cells. These antigens on the virus surface are probably picked up selectively from the plasma membranes and may play an important role in the interaction of HTLV and target T-cells.

Metaplastic bone formation in a hyperplastic polyp of the stomach: a case report.

Metaplastic bony tissue along with hyperplastic mucosal epithelium showing no atypism was detected in biopsy materials from a Yamada type I gastric polyp. The tissue was metaplastic woven bone associated with calcification. Histogenesis of the bone formation is as yet unknown. This is the first reported case of the presence of metaplastic bone accompanied by hyperplastic gastric mucosa so far.

Intrapulmonary sequestration with arterial supply from the left internal thoracic artery: a case report.

Pulmonary sequestration is uncommon in the upper lobe. Its arterial supply from the internal thoracic artery is very rare. Reported here is a case of a 20-year-old male whose presenting symptom was recurrent pneumonia. Helical computed tomography (CT) and three-dimensional reconstruction images showed that aberrant arteries arising from the left internal thoracic artery were supplying the area of sequestration and draining into the pulmonary vein. Selective intra-arterial digital substraction angiogram also showed left internal thoracic artery supplying the area of the sequestration. Helical three-dimensional CT is noninvasive and provides as accurate three-dimensional information of the aberrant vascular supply in intrapulmonary sequestration as the angiography.

Acute traumatic dissection and blunt rupture of the thoracic descending aorta: A case report.

Rupture of the thoracic aorta following blunt trauma is increasing in incidence and remains a highly lethal injury. Blunt traumatic rupture and acute dissection of the thoracic aorta is very rare. A 50-year-old man involved in a motor vehicle accident on March 3, 1998 was admitted to our hospital one and a half hours following the accident. On admission, he was alert and his hemodynamics were stable. Chest roentgenogram demonstrated a widened mediastinum and multiple left-sided rib fractures. Enhanced chest CT revealed a periaortic hematoma just distal to the isthmus, dissection of the descending thoracic aorta and mediastinal hematoma. With the diagnosis of thoracic aortic rupture and acute DeBakey type IIIB dissection, an emergency operation was performed. Intraoperative transesophageal echocardiogram showed a mobile intimal flap and diminished caliber of the proximal descending aorta. Disruption and dissection of the descending thoracic aorta were found. Prosthetic graft interposition was accomplished with the aid of left atrium-left femoral artery bypass using a centrifugal pump and heparin-coated circuits and a blood collection device for blood conservation. The weak dissected aortic wall was glued and reapproximated with Gelatine-Resorcine-Formol glue. The postoperative course was uneventful.

Treatment of chronic hepatitis C with interferon-alpha: sustained absence of hepatitis C virus RNA from serum after four courses of therapy.

A patient with chronic hepatitis type C, confirmed by the detection of hepatitis C virus RNA (HCV RNA) in the serum and by histological examination of the liver biopsy specimen, was treated with four courses of interferon-alpha (IFN-alpha). For the first three courses of IFN-alpha the patient's serum alanine aminotransferase (ALT) level normalized during the administration of IFN-alpha but rose again after its cessation; similarly, HCV RNA was absent from the serum by the end of each course of treatment but could be detected once again after treatment stopped. The fourth course of IFN-alpha therapy, however, produced a sustained normalization of the ALT level and sustained absence of HCV RNA from the serum for 20 months after the end of treatment. This case suggests that patients with the potential for an eventual complete response to IFN-alpha therapy may show a normalization of serum ALT levels during IFN-alpha administration and the absence of HCV RNA in the serum by the end of each course of treatment (even if that particular course of treatment does not produce a sustained response).

Disruption in the intrathoracic trachea due to blunt trauma.

Intrathoracic tracheal disruption by blunt trauma is rare and potentially life threatening. Here report 3 cases of intrathoracic tracheal disruption due to blunt trauma. Two cases, each 43 year old, involved an unrestrained male driver who suffered a head-on crash, while the other, 63 year old, involved a male who suffered compression. Chest roentgenograms on admission showed remarkable deep cervical and mediastinal emphysema in Cases 1 and 2 and mediastinal emphysema alone in Case 3. Bronchoscopy revealed disruption in the trachea. Primary repair was performed through a right posterolateral thoracotomy in Cases 1 and 3 and through a median sternotomy in Case 2. In all cases the postoperative course was uneventful.

Terminal warm blood cardioplegia improves the recovery of myocardial electrical activity. A retrospective and comparative study.

OBJECTIVE: The effect of terminal warm blood cardioplegia was analyzed in 191 patients undergoing either coronary artery bypass grafting (CABG) or prosthetic heart valve replacement between Jan. 1990 and Dec. 1995. METHODS: Patients were subdivided into 3 historical cohorts based on the method of myocardial protection: Group A (n = 106), multidose cold crystalloid glucose-potassium cardioplegia, alone; Group B (n = 37), cold crystalloid glucose-potassium cardioplegia plus terminal warm blood cardioplegia, Group C (n = 48), cardioplegia induction with cold crystalloid glucose-potassium cardioplegia, maintenance with multidose cold blood cardioplegia, and terminal warm blood cardioplegia. RESULTS: Of patients undergoing CABG, 5.6% of group A, 70.4% of group B, and 86.7% of group C spontaneously resumed sinus rhythm after aortic declamping, as did 9.1% of group A, 60.0% of group B, and 55.6% of group C of patients undergoing prosthetic heart valve replacement. The incidence of spontaneous recovery was significantly better in groups B and C than in group A (p < 0.05). Over 90% of patients without terminal warm blood cardioplegia developed ventricular fibrillation or tachycardia requiring electrical cardioversion (p < 0.05). Postoperatively, patients without terminal warm blood cardioplegia required temporary epicardial pacing more frequently than those with terminal warm blood cardioplegia (p < 0.05). In patients undergoing prosthetic heart valve replacement, groups B and C, the incidence of postoperative atrial fibrillation was significantly lower than in group A. CONCLUSION: Terminal warm blood cardioplegia thus promoted better postoperative electrophysiological cardiac recovery.

Anti-endothelial cell antibodies in the sera of patients with mixed connective tissue disease--the clinical significance.

To determine the clinical significance of anti-endothelial cell antibodies in mixed connective tissue disease (MCTD), we measured the titers of antibodies to both untreated and cytokine-treated endothelial cells (EC) in the sera of the MCTD patients by means of an enzyme linked immunosorbent assay. The mean titer of antibodies to untreated EC (aEC) in the sera of the MCTD patients was significantly higher than that for the healthy subjects. The mean titer of antibody to EC treated with IFN gamma, IL1 (aIL1-EC) or TNF alpha (aTNF-EC) was significantly higher than that of aEC in the sera of the MCTD patients with proteinuria, and the mean titer of aTNF-EC was significantly higher than that of aEC in the sea of the MCTD patients with pulmonary fibrosis. Furthermore, the mean titers of aIL1-EC and aTNF-EC in the sera of the MCTD patients with pulmonary fibrosis were significantly higher than those of aIL1-EC and aTNF-EC in the sera of the MCTD patients without pulmonary fibrosis. These results suggest that antibodies to cytokine-treated EC may play a more important role in the manifestation of renal or pulmonary lesions in MCTD patients than aEC.

[Mass-screenings for osteoporosis using computed X-ray densitometry (CXD): in a mobile unit].

The early diagnosis and treatment of osteoporosis is considered to be important for the prevention of fractures which often cause elderly to become bed-ridden. Computed X-ray densitometry (CXD), a method to measure bone mineral content in the metacarpus II utilizing a simple X-ray image, has been used for mass-screening of osteoporosis, because of its utility and reliability. However, due to its requiring adequate X-ray equipment, this method is often unsuitable for use in small facilities in a remote mountain areas. The use of CXD for osteoporosis screening, was attempted in a mobile unit for tuberculosis screening, by our public health center. The results showed that it is possible to use CXD in combination with a mobile unit, correcting the obtained values according to the radiographic conditions. With this set-up, CXD was used for mass-screening of osteoporosis in a total of 1150 subjects living in mountainous areas of Yoshino-gun, Nara prefecture, and CXD was found to be convenient and effective for mass-screening. The use of CXD in a mobile chest X-ray unit can be expected to be useful for mass-screening of osteoporosis especially in remote mountainous areas having inadequate X-ray equipment.

[Clinical decision analysis and ROC curve].

This workshop was planned to teach the importance of clinical decision analysis and the ROC curve in clinical medicine. A pre-workshop test and post-workshop test were given before and after the workshop. In the clinical decision analysis a heart disease case was shown, a decision tree was made, and the chance node and expected value were calculated. The ROC curve was prepared from the results of urine analysis of patients with renal and urinary tract infections, and the cut-off points were changed variously. There were 27 participants. Twelve of them took both the pre-workshop test and post-workshop test, and about half of them answered that they understood how to perform the analysis. There tended to be more participants who understood how to make the clinical decision analysis than the ROC curve.

[Ultramicroassay of red cell group using Terasaki-plate].

In order to simplify the testing-method of blood groups (ABO, Rh, MN, Ss, P, I, Lewis, Duffy, Kidd and Diego) and the assay of glycosyl transferases activity, we have developed a new method using Terasaki plate (T-plate method), and examined its usefulness in the routine examination. As results followings were obtained: 1) The sensitivity of T-plate method was equal or superior than that of the common method using test-tube. 2) Samples used for T-plate method were smaller in volume compared with those for the common tube test method. 3) The percent of coincidence between T-plate method and tube test method was 100% for ABO, Rh, MN, Ss, P, I, Duffy, Kidd and Diego grouping. They were 98% for Lewis(a) and 96% for Lewis(b) grouping, respectively. These results indicate the superiority of T-plate method than the common method using test-tubes in respects of smaller volume of samples, lower price and handling of a large amount of samples.