The influence of rejection on graft motility after intestinal transplantation in swine: the possibility of using this method for the real-time monitoring of acute cellular rejection.

BACKGROUND: We have previously reported that rejected allografts show dysmotility, which can be detected by real-time monitoring in swine. We examined the correlation between the motility and the mucosal histology to detect rejection at an early stage by real-time monitoring. METHODS: Intestinal transplantation was performed orthotopically using FK506. The distal segment of the allograft measuring about 20 cm was isolated and exteriorized as "Thiry-Vella" stoma for biopsies. Strain-gage force transducers were attached on a graft for the real-time monitoring of graft motility. The pigs without intestinal transplantation were used as controls (C). The rejection was classified into 4 groups based on the histologic findings: nonrejection, mild rejection, moderate rejection, and severe rejection. Migrating motor complex (MMC) phase 3 was estimated by the following parameters: duration, amplitude, interval, motility index, velocity, and frequency of the propagation. RESULTS: In the nonrejection group, all parameters were almost the same as in C group. In contrast, in the moderate rejection and severe rejection groups, most of the parameters were significantly lower than those in the C group. In the mild rejection group, the contractility of the MMC was not significantly altered, but the frequency of the propagation decreased significantly. CONCLUSIONS: The graft motility detected by the real-time strain-gage method correlated closely to the grade of mucosal histology. This method is therefore considered to be useful for detecting rejection at an early stage by examining the frequency of MMC propagation.

Successful prolonged rituximab treatment for post-transplant lymphoproliferative disorder following living donor liver transplantation in a child.

PTLD is a serious complication of immunosuppression in solid organ transplant recipients. The incidence of PTLD is significantly higher in pediatric recipients than in adult because children are often EBV-seronegative and they may develop primary EBV infection after transplantation. We herein describe a case of GI-PTLD who achieved a complete remission by prolonged rituximab, a chimeric monoclonal antibody against CD20, mono-therapy. A one-yr-old female underwent a LDLT for liver failure after having previously undergone the Kasai procedure for biliary atresia. At sixty days following the transplantation, GI-PTLD developed. Withdrawal of immunosuppression and a surgical resection were thus performed. A histopathological examination of tumor revealed atypical medium to large cell lymphoid proliferation with strong CD20 immunopositivity indicating their B-cell origin. Polymorphic PTLD was diagnosed. Rituximab was administered at a dose of 375 mg/m2 once a week, and the monotherapy resulted in a complete remission after 34 administrations. Based on this case, rituximab appears to be beneficial as a first-line therapy for PTLD.

Experimental study concerning safety dosage of OK-432 for intrauterine treatment.

OBJECTIVE: Clinical intrauterine treatment for fetal cystic hygroma has so far been performed in a few patients; however, it is still difficult to evaluate the results. The aim of this study is to establish the safe dosage of OK-432 in the intrauterine treatment of fetal cystic hygroma. METHODS: OK-432 was injected either subcutaneously behind the neck of the fetuses or into the amniotic cavity through the uterine wall of pregnant Japanese white rabbits at 27 days of gestation. Saline was administered to the controls. The dosage and the site of injection were as follows: group 1, OK-432, 0.01 KE (0.25 KE/kg) in 0.2 mL saline per fetus, subcutis; group 2, OK-432, 0.02 KE (0.5 KE/kg) in 0.2 mL saline per fetus, subcutis; group 3, OK-432, 0.04 KE (1 KE/kg) in 0.2 mL saline per fetus, subcutis; group 4, OK-432, 0.01 KE in 0.2 mL saline per fetus, amniotic cavity; group 5, OK-432, 0.04 KE in 0.2 mL saline per fetus, amniotic cavity; group 6, saline, 0.2 mL per fetus, subcutis; group 7, saline, 0.2 mL per fetus, amniotic cavity. All fetuses were delivered at 29 days of gestation. RESULTS: The mother's rectal temperature was mostly in the normal range throughout the experiment. There was no significant difference between any of the seven groups in fetal body weight. The C reactive protein values of all fetuses were negative. The appearance of the skin of all the fetuses was normal. The histopathological findings of the skin in the OK-432 groups showed a moderate infiltration of monocytes and plasma cells. No pathological changes were observed in the heart, lung, liver or kidneys of any of the fetuses. CONCLUSION: Based on this rabbit experiment, we determined that OK-432 may be safely used at a dose of up to 1 KE/1 kg of fetal body weight as an intrauterine treatment for fetal cystic hygroma.

Safe techniques for inserting the hickman catheter in pediatric patients.

The placement of the Hickman catheter in the central veins is thought to be an effective method for providing venous access in various clinical situations in children. The catheter is usually inserted by the percutaneous approach, but in some cases various troublesome complications can occur, such as sheath introducer kinking or damage, in addition to other major ones. Therefore, some modified techniques, using vascular dilators, both to dilate the route and to avoid such complications, have been developed and investigated to obtain a smooth and safe percutaneous insertion of the Hickman catheter in children. A total of 41 Hickman catheters were inserted by the percutaneous method in 41 pediatric patients from 1996 to 2004 in our department. Sixteen catheters were inserted by means of a standard method, using the manufacturer's insertion kit, and 25 catheters were inserted by means of a modified method, namely, using various sized vascular dilators. The length of time for the procedure, the complication rate, and the changes in the serum C-reactive reaction (CRP) levels were then compared between the standard and the modified methods. Those parameters were also compared between a right-side and left-side approach using both methods, to clarify which side was better for the insertion of this catheter. The length of time for the catheter replacement procedure in the standard group was significantly longer than that in modified one. The occurrence rate for both the kinking and small damage to the sheath introducer in the standard group was higher than that in the modified one. The peak of serum CRP in the modified group was significantly lower than that in the standard one. When comparing a right-side and left-side approach, 7 catheters out of 16 were inserted by the right-side approach in the standard group, while 10 catheters out of 25 were done by the right-side approach in the modified group. The length of time for the procedure for the left-side approach was significantly shorter than that for the right-side one in both groups. No difference in technical complications was observed between the two different approaches in the modified group, while complications when using the right-side approach often occurred in the standard group. The peak of serum CRP in the left-side approach was lower than that in the right-side one in both groups. The use of the modified percutaneous method, using various sized vascular dilators and the left-side approach, was therefore found to be useful for the safe and smooth placement of the Hickman catheter in children.

Auxiliary partial orthotopic living donor liver transplantation for a child with congenital absence of the portal vein.

Congenital absence of the portal vein (CAPV) is a rare malformation of the mesenteric vasculature in which visceral venous blood bypasses the liver, completely draining into the systemic circulation through a congenital porto-systemic shunt. Liver transplantation has rarely been indicated for patients with this disease. We present a child with CAPV who was managed successfully by living donor auxiliary partial orthotopic liver transplantation (APOLT), while preserving the right lobe of the native liver. In conclusion, APOLT for patients with CAPV is a feasible and ideal procedure because portal vein (PV) diversion is not necessary.

Effect of a valine-rich diet on a rat model of short bowel syndrome.

It has been recently reported that valine, which was one of the branched chain amino acids, enhanced liver regeneration after a hepatectomy in rats. The aim of this study is to investigate the effect of enteral valine supplementation on the intestinal adaptation of short bowel syndrome using a rat model. Seven-week-old male Lewis rats underwent a 90% small bowel resection. The rats were randomly divided into two groups; Group V (valine-rich diet which contains valine, five times as the normal amount of valine as that found in standard rat chow) and Group S (standard rat chow), according to the diet each group received. The rats were killed and evaluated at the operative day, and postoperative days (POD) 7, 14, 30, and 60, respectively. The parameters of estimation were body weight (BW), a blood amino acids analysis, a urine organic acids analysis and a morphological examination of the residual small intestines. The BW and the intestinal wet weight, jejunal crypt depth and proliferating cell nuclear antigen positive cells in Group V at POD 7 were significantly higher than in Group S, while those in the Group V at POD 30 and 60 were smaller than in Group S. The urine methylmalonic acid (MMA) level in Group V at POD 30 and 60 was much higher than in Group S. The valine-rich diet was thus found to enhance intestinal regeneration after a small bowel resection in the acute phase. However, the long-term valine-rich diet supplementation was found to disturb the intestinal adaptation, which might be caused by the high production of MMA due to the valine-rich diet. This is the first report in which valine was used as a promoter of intestinal adaptation.

Fatty liver caused by portal vein thrombosis after living donor liver transplantation: a case report.

Portal vein thrombosis (PVT) is a rare complication that occurs after liver transplantation: however, it cannot be ignored as a cause of graft loss and death. We herein report a pediatric case of PVT that caused a fatty change in the graft after living donor liver transplantation. The portal vein was successfully reconstructed using the left great saphenous vein of the same donor. Moreover, the fatty liver recovered after the operation. Our case suggests that the finding of fatty liver is an important marker of PVT and immediate portal reconstruction is performed.

Immune tolerance induced by donor antigen and cyclophosphamide in rat fetal small bowel transplantation.

BACKGROUND/PURPOSE: Donor specific immune tolerance is thought to be the ideal state for the recipient after organ transplantation. The administration of donor antigens and cyclophosphamide has been reported to induce donor specific immune tolerance in heart or liver transplantation. However, the effectiveness of this method for small bowel transplantation has not yet been studied. We assessed the cyclophosphamide induced immune tolerance on rat fetal small bowel transplantation. METHODS: Lewis rats (RT1(1), n=99) were used as recipients while either F344 (RT1(1), n=44) or WKAM (RT1(u), n=47) rats were used as donors. The combination of F344 and Lewis rats produces an immunologically low responder, while that of WKAM and Lewis rat produces a high responder. Bone marrow and spleen cells were harvested from the donor rats and 3x10(8)/kg of each were administrated to the recipient rats intravenously on day 0. Next, cyclophosphamide was given either divisionally or bolously. The fetal small bowel of the same strain as the donor was transplanted into the rectus muscle of the recipient abdominal wall on day 10. On day 17, all grafts were taken out and graft survival was thereafter evaluated. The body weight of recipient was also assessed. RESULTS: Most of the grafts (87.5%) survived in the F344-Lewis rat (low responder) combination using the divisional administration of 120 mg/kg of cyclophosphamide. Histologically, most of them showed the whole layers of the intestinal architectureto be well preserved. The weight loss of the recipient was minimal after divisional administration. In contrast, no graft survived in the WKAM-Lewis rat (high responder) combination. CONCLUSIONS: Immune tolerance is considered to be induced by the administration of donor specific antigen and cyclophosphamide in an immunologically low responder combination. Therefore, this method is expected to be useful as an adjuvant therapy and may also be able to reduce the dose of immunosuppressive agents in living-related clinical small intestinal transplantation.

Effect of liver transplantation on multiple bone fractures in an infant with end-stage biliary atresia: a case report.

Osteodystrophy is frequently found in children with chronic cholestatic liver disease. We herein report an end-stage case of biliary atresia that was associated with multiple bone fractures and severe growth retardation. The patient, an 8-month-old female, underwent a living-related liver transplantation and thereafter showed a dramatic improvement in growth and decrease in bone fractures. A correction of the liver function is therefore considered to be a key factor in treating osteodystrophy that is related to chronic cholestatic liver disease. It is also essential to perform liver transplantation at the most appropriate time to enhance and support the growth of these patients.

Efficacy of real-time monitoring to determine motility in porcine small intestinal transplantation.

Orthotropic small intestinal transplantation (SIT) was performed in outbred 20 pigs. The interdigestive motor patterns were evaluated using strain gage (SG) force transducers. Seven pigs without SIT were treated as control (C) group. Based on the obtained data, the group, which could be detected the migrating motor complex (MMC) in the graft and alive with adequate oral feeding, was regarded as functional graft (FG) group, whereas the group which had available data recorded within 10 days before the death due to rejection was regarded as rejection (R) group. The MMC was analyzed using following parameters: duration; amplitude; and interval. In group FG, all parameters were almost same as group C, thus suggesting that the allograft in group FG had a normal motor function. In contrast, all parameters in group R were significantly lower than those in group FG, suggesting that the motility in group R was impaired. The SG method could monitor the real-time motility and was efficient for detecting the rejection of SIT.

Effect of a nucleoside/nucleotide-free diet in rat allogenic small intestinal transplantation.

The aim of this study is to estimate the effect of nucleoside (NS) and nucleotide (NT) on the recipient and graft immune response after rat allogenic small intestinal transplantation. Seven-week-old Lewis rats were randomly assigned to two groups, including the NS/NT free group ( n=6) and the NS/NT supplemented group ( n=6), according to the diet received. The recipient Lewis rats were each given diet for 12 days, and then, on the nineteenth day of gestation, a 2 cm jejunum from the donor fetal Fischer rat was transplanted into the abdominal wall of the recipient rats using a non-vascular anastomotic technique. The recipient rats were killed on day 2 after transplantation, and then the recipient plasma interleukin-2 (IL-2) level was measured. In addition, the histological findings of the graft were analyzed. The IL-2 level of the NS/NT free group was significantly lower than that of the NS/NT supplemented group. In order to determine the grade of rejection, the morphological findings were blindly graded on a scale of 0-4. The mean grade of the NS/NT free group was also significantly lower than that of the NS/NT supplemented group. The NS/NT free diet is therefore considered to have an immunosuppressive effect on rat allogenic small intestinal transplantation based on the recipient plasma IL-2 levels and the histological findings of the grafts.

Renal tubular acidosis secondary to FK506 in living donor liver transplantation: a case report.

FK506 is an immunosuppressant that is thought to be less nephrotoxic than cyclosporine A. However, complications due to renal tubular acidosis (RTA) have recently been reported. We report a case of RTA secondary to FK506 administration in liver transplantation. A 6-month-old girl was treated with FK506 after undergoing living donor liver transplantation for fulminant hepatitis. On postoperative day 17, she demonstrated hyperkalaemia and metabolic acidosis; she was diagnosed to have hyperkalaemic distal RTA with aldosterone deficiency (type IV). Intravenous sodium bicarbonate and furosemide, and intrarectal calcium polystyrenesulfonate were administered to correct the acidosis and promote potassium secretion. Thereafter, the FK506 concentration in whole blood gradually decreased, and the hyperkalaemia and metabolic acidosis following RTA improved. RTA is one type of nephrotoxicity induced by FK506, and it is reversible in mild cases when appropriately treated. The mechanism of RTA induced by FK506 has not yet been clearly elucidated. Surgeons and physicians should therefore be aware of the potential for RTA to occur with FK506 after any organ transplantation. The treatment for acidosis and hyperkalaemia should be started as soon as RTA is diagnosed, and the dosage of FK506 should also be reduced if possible.

Prenatally diagnosed cystic neuroblastoma: a report of two cases.

We report two cases of prenatally diagnosed cystic neuroblastoma (PDCN). In the first case, prenatal ultrasonography (US) at 33 weeks' gestation showed a 30 x 20 mm cyst at the upper pole of the right kidney. The size and content of the mass demonstrated no change during pregnancy. Postnatal US showed no change in the cystic mass 4 weeks after birth compared to the prenatal findings. The infant underwent total resection of the tumour at 28 days of age. In the second case, a left cystic mass measuring 50 x 40 mm was detected in a fetus in the 37th week of pregnancy. Postnatal US showed a cystic mass in the left adrenal gland. The US findings showed no change 18 days after birth and the infant underwent total resection of the tumour at 19 days of age. In both cases, pathological examination revealed a neuroblastoma and all of the biological prognostic factors were favourable. Surgical intervention was necessary for a final histological and biological diagnosis to be made. We recommend that prenatally suspected neuroblastomas should normally undergo surgical intervention, unless tumour size decreases within about 1 month after birth.

The efficacy of autologous cord-blood transfusions in neonatal surgical patients.

PURPOSE: Allogenic blood transfusions have a risk of infection owing to unknown organisms, graft-versus-host reaction, and immunosupression; however, the use of autologous blood has been reported to be safe. Cord blood has been reported to be useful as a source of stem cell transplantation for the treatment of leukemia and genetic disease. Furthermore, autologous cord-blood transfusions (ACBT) have been reported to be effective for the treatment of anemia in premature infants. The authors examined the efficacy of ACBT in neonatal surgical patients. METHODS: Autologous cord-blood was stored from 12 infants at delivery, including 2 transvaginal and 10 cesarean section deliveries, from 1998 to 2001. All infants had surgically correctable malformations diagnosed antenatally. The mean gestational age was 37.2 +/- 1.6 weeks, and the birth weight was 2,597 +/- 1.6 g. The results of the blood count, serum electrolyte, and liver function tests of the patients who underwent ACBT only (group 1, n = 7) were compared with those of the 7 neonates who underwent an allogenic transfusion during the same period (group 2, n = 7). RESULTS: The mean volume of the stored blood was 64 +/- 35.6 g (range, 20 to 100). Eleven of the 12 patients underwent transfusions. Ten of 11 patients received autologous cord blood. A mean of 44.1 +/- 37.3 g of cord blood was used. Three of 10 cases also required an allotransfusion because of ECMO circuit preparation and a shortage of the stored blood. One patient underwent allotransfusion only. As a result, 7 of 11 babies (64%) who required transfusion were able to avoid an allotransfusion. The blood potassium levels were lower in group 1 than in group 2. No significant complications were recognized clinically. CONCLUSIONS: ACBT is considered beneficial because it enables neonatal surgical patients to avoid allotransfusions. Therefore, autologous cord-blood storage should be considered in the patients antenatally diagnosed to have surgical malformations. However, the storage volume varies for each case. Improved techniques to obtain an adequate amount of blood also should be developed.

Cortisol and cytokine responses after surgery in different age groups of pediatric patients.

We investigated the cortisol and cytokine responses to surgical stress in the different age groups of pediatric patients. This study included 19 neonates (0-6 days old, group I), 19 infants (1-11 months old, group II), and 20 pre-school children (1-5 years old, group III), undergoing major thoracic and abdominal surgery. We obtained blood samples preoperatively and 0, 3, 6, 12, and 24 h postoperatively to measure the plasma levels of C-reactive protein (CRP), cortisol, interleukin (IL)-6, and IL-10. The plasma CRP level in each group reached a peak value on postoperative day 2; however, the peak value was significantly lower in group I than in groups II or III (I vs II, III; p=0.0134, p=0.0017, respectively). The plasma cortisol level in each group reached a peak value just after surgery; however, the peak value was also significantly lower in group I than in groups II or III (I vs II, III; p<0.001, p=0.0104, respectively). The plasma IL-6 level in each group reached a peak level hours postoperatively; however, the peak values in groups I and II were higher than in group III (I, II vs III; p=0.003, p=0.0458, respectively). The plasma IL-10 level in each group reached a peak value just after surgery and did not differ among the three groups. The endocrine and cytokine responses to the surgical stress vary among the different age groups of pediatric patients.

Roles of nucleosides and nucleotide mixture in small bowel transplantation.

OBJECTIVES: We investigated the effect of nucleosides (NSs) and nucleotides (NTs) on the intestine and intestinal graft in a model of syngenic small bowel transplantation, with the fetal rat intestine as a graft. METHODS: Two-centimeter jejunal segments from Lewis rats at 19 d of gestation were transplanted into the abdominal walls of 5-wk-old Lewis rats by using a non-vascular anastomotic technique. After transplantation, the rats were assigned to one of two groups: group 1 did not receive NS or NT and group 2 was supplemented with NS and NT. The grafts and graft recipients were examined morphologically 14 d after transplantation according to conventional histologic and immunohistochemical studies of neurons and smooth muscles. RESULTS: Group 1 gained little body weight, even though both groups received similar amounts of food. The grafts in group 1 showed poor development in length, diameter, and wet weight. They also showed poor villi development, abnormalities in nerve distribution, and degeneration of muscle layer structure on histologic and immunohistochemical studies. CONCLUSIONS: We found that NS and NT are essential nutrients for intestinal growth and maintenance of structures in fetal small bowel transplantation.

Changing profile of parenteral nutrition in pediatric surgery: a 30-year experience at one institute.

BACKGROUND: Due to technical refinements and steady advances in the development of highly sophisticated nutrient solutions consisting of optimal combinations of macronutrients and micronutrients, parenteral nutrition (PN) is now playing an important role in patient management. However, some PN-associated complications, such as catheter-related sepsis (CRS) and cholestasis, continue at high incidence, particularly in neonates. The objective of this study was to investigate the changing profiles of PN over the past 30 years in our department. METHODS: The medical records of 893 children (225 neonates, 245 infants, 261 preschool-age children, and 162 school-age children) who were placed on PN for >7 days in our department were reviewed, and the following data were extracted: birth weight, underlying disease, indications for PN, PN delivery route, type of catheter used, duration of PN, substrate and energy intake, type of amino acid solution used, and incidence of complications including CRS and liver dysfunction. The results were analyzed by dividing the patients into 3 groups according to their basic stages in management of PN and consisted of group 1 (1970 to 1979), group 2 (1980 to 1989), and group 3 (1990 to 1999). The parameters were compared in each group. RESULTS: The total number of patients in each group showed no significant difference; however, the percentage of low birth-weight neonates increased in group 3. In group 1, 85% of PN was administered through the peripheral vein; in group 2, 51.2%; and in group 3, 9.7%. The total calorie and nutrient intake decreased in groups 2 and 3 compared with group 1, particularly regarding fat intake. In groups 1 and 2, commercially available amino acid solution based on the Food and Agriculture Organization/World Health Organization formula was usually used as the nitrogen source, but in group 3, it was changed to an amino acid solution for children. CRS decreased significantly, particularly in neonates, and occurred at a rate of 45.4% in group 1, 10.7% in group 2, and 1.5% in group 3. The incidence of liver dysfunction also showed a decrease: 35.7% in group 1, 22.3% in group 2, and 18.0% in group 3. A multivariate analysis showed a strong relationship between PN-related liver dysfunction and the duration of PN, the presence of infection, and the type of amino acid solution used. CONCLUSIONS: PN via central venous catheters has been regarded as safe and effective treatment in pediatric surgical patients. Over the past 30 years, the incidence of CRS has decreased. However, PN-related liver dysfunction remains a problem, particularly in patients receiving long-term PN.