Dual-graft adult living donor liver transplantation with ABO-incompatible graft: short-term and long-term outcomes.

ABO-incompatible (ABOi) dual-graft (DG) adult living donor liver transplantation (ALDLT) is not commonly performed due to its inherently intricate surgical technique and immunological complexity. Therefore, data are lacking on the short- and long-term clinical outcomes of ABOi DG ALDLT. We performed a retrospective study by reviewing the medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. Additionally, computed tomography volumetric analysis was conducted to assess the graft regeneration rate. The mean age of a total of 28 recipients was 50.2 ± 8.5 years, and the mean model for end-stage liver disease score was 12.2 ± 4.6. The 1-, 3-, and 5-year patient survival rate was 96.4% during the mean follow-up period of 57.0 ± 22.4 months. The 1-, 3-, and 5-year graft survival rate was 96.4%, 94.2%, and 92.0%, respectively, and no significant differences were observed between ABO-compatible (ABOc) and ABOi grafts (P = .145). The biliary complication rate showed no significant difference (P = .195) between ABOc and ABOi grafts. Regeneration rates of ABOi grafts were not significantly different from those of ABOc grafts. DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks.

Adult Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure in High-Model for End-Stage Liver Disease Score Patients.

The large volume of adult living donor liver transplantations (ALDLTs) at our center affords a unique opportunity to examine the impact of acute-on-chronic liver failure (ACLF) among high-Model for End-Stage Liver Disease MELD score patients. From February 1998 to March 2010, 1958 cirrhotic recipients were analyzed to study the relationship between MELD scores and ALDLT outcomes. A total of 327 high-MELD score recipients were categorized into ACLF and non-ACLF groups, and their outcomes were compared. The 5-year graft and patient survival in the high-MELD group were 75.2% and 76.4%, respectively, which were significantly worse than the low and intermediate MELD groups. The presence of ACLF associated with higher MELD scores appeared to be the dominant factor responsible for the inferior results of patients with MELD score of 30-34 points. The 5-year graft survivals in the ACLF group was 70.5% and in the non-ACLF group it was 81.0% (p = 0.035). Therefore, ALDLT should be performed as soon as possible in high-MELD score patients prior to ACLF development. Moreover, ACLF patients should be separately categorized when analyzing the outcomes of ALDLT. ALDLT for ACLF patients should not be discouraged because favorable outcomes can be expected through timely ALDLT and comprehensive management.

Acute Graft-vs-Host Disease After Liver Transplantation: Experience at a High-volume Liver Transplantation Center in Korea.

BACKGROUND: Acute graft-vs-host disease (GVHD) is a rare but life-threatening complication of orthotopic liver transplantation (OLT). We present 6 cases of GVHD after OLT. METHODS: Among our 4294 OLT recipients, we identified 6 patients (0.14%) who were diagnosed with GVHD. Their medical records were reviewed retrospectively. RESULTS: Liver graft types included deceased donor whole liver graft (n = 3) and right liver graft from son (n = 3). Mean recipient and donor ages were 57.2 ± 6.6 years and 32.7 ± 10.8 years, respectively. Onset of GVHD symptoms occurred 14 to 32 days after OLT, and initial symptoms were skin rash (n = 5) and fever (n = 1). GVHD was pathologically confirmed by skin or rectal biopsy. Chimerism of donor lymphocytes was identified in all 3 patients who underwent the short tandem repeat polymerase chain reaction assay. Attempts were made to treat the GVHD in all 6 patients by corticosteroids with or without low-dose calcineurin inhibitor, but we had to stop early or reduce these agents due to aggravation of pancytopenia and septic complications. Ultimately, 5 patients died 6 to 106 days after the onset of GVHD, and only 1 patient recovered. This surviving patient was diagnosed earlier and had been administered the recommended dosage of corticosteroid for a longer period with aggressive infection prophylaxis compared to the other cases. CONCLUSIONS: Because of very poor outcomes of GVHD after OLT, early diagnosis and vigorous treatment should be emphasized, although no effective treatment modality has been established yet. We strongly suggest performing aggressive infection prophylaxis during GVHD treatment.

ABO-Incompatible Adult Living Donor Liver Transplantation Under the Desensitization Protocol With Rituximab.

ABO incompatibility is no longer considered a contraindication for adult living donor liver transplantation (ALDLT) due to various strategies to overcome the ABO blood group barrier. We report the largest single-center experience of ABO-incompatible (ABOi) ALDLT in 235 adult patients. The desensitization protocol included a single dose of rituximab and total plasma exchange. In addition, local graft infusion therapy, cyclophosphamide, or splenectomy was used for a certain time period, but these treatments were eventually discontinued due to adverse events. There were three cases (1.3%) of in-hospital mortality. The cumulative 3-year graft and patient survival rates were 89.2% and 92.3%, respectively, and were comparable to those of the ABO-compatible group (n = 1301). Despite promising survival outcomes, 17 patients (7.2%) experienced antibody-mediated rejection that manifested as diffuse intrahepatic biliary stricture; six cases required retransplantation, and three patients died. ABOi ALDLT is a feasible method for expanding a living liver donor pool, but the efficacy of the desensitization protocol in targeting B cell immunity should be optimized.

Donor Safety and Recipient Liver Function After Right-Lobe Liver Transplantation From Living Donors With Gilbert Syndrome.

BACKGROUND: Donor safety is the most important aspect in living-donor liver transplantation (LDLT). Gilbert syndrome is an autosomal recessive condition that is a common cause of isolated unconjugated hyperbilirubinemia, and its prevalence is not negligibly low in the general population. This study intended to assess donor safety and recipient liver function after LDLT with the use of right liver grafts from living donors with Gilbert syndrome. METHODS: Among 2,140 right liver transplantations performed from January 2002 to December 20113 at our institution, we identified 12 living donors (0.6%) who showed a preoperative serum total bilirubin level of ≥2 mg/dL. These donors were clinically diagnosed with Gilbert syndrome. The clinical outcomes of these donors and their recipients were analyzed retrospectively. RESULTS: The mean donor age was 24.6 ± 7.1 years, and 11 donors were male. All subjects met the preoperative evaluation conditions for right liver donation except for the level of unconjugated hyperbilirubinemia. The mean serum total bilirubin level of the donors was 2.23 ± 0.20 mg/dL before and 1.79 ± 0.61 mg/dL 1 year after right liver donation. The preoperative donor direct bilirubin level was 0.43 ± 0.19 mg/dL. The preoperative indocyanine green retention rate at 15 minutes was 8.2 ± 2.8%. All donors and recipients recovered uneventfully and were alive at the time of writing. The recipient serum total bilirubin level was 1.29 ± 0.47 mg/dL 1 year after LDLT. CONCLUSIONS: We suggest that LDLT with living donors with Gilbert syndrome can be safely performed, but that a meticulous preoperative evaluation is vital to maximize donor safety.

Updated status of deceased-donor liver graft allocation for high-urgency adult patients in a Korean high-volume liver transplantation center.

BACKGROUND: The number of deceased organ donors in Korea has been gradually increased to reach 8 per million population. This study intended to analyze the updated status of urgent deceased-donor liver transplantation in a Korean high-volume liver transplantation center. METHODS: A retrospective study was performed with a 4-year study period from 2010 to 2013. RESULTS: During the study period, 328 adult patients were enrolled at the Asan Medical Center for urgent orthotopic liver transplantation (OLT) with Korean Network for Organ Sharing status 1 in 56 (17.1%) and status 2A in 272 (82.9%). Of them, 201 (61.3%) were allocated for OLT and 195 (58.2%) actually underwent OLT after exclusion of 6 cases of spontaneous withdrawal. In KONOS status 1, liver grafts were initially allocated to 33 (58.9%), but 6 were withdrawn owing to clinical improvement, so 27 (48.2%) actually underwent OLT. In status 2A, 168 (61.8%) underwent OLT within 2 weeks of priority waiting period. According to ABO blood groups in recipients, the allocation probability was 68% (68 of 100) in group A, 60.6% (60 of 99) in group B, 64.1% (25 of 39) in group AB, and 53.3% (48 of 90) in group O. Mean waiting period for OLT was 5.7 ± 2.1 days. CONCLUSIONS: Deceased donor incidence of ∼8 per million population contributed to meeting ∼60% of the demand for urgent deceased-donor liver transplantation in a Korean transplantation center, so further increasing deceased organ donor numbers is necessary to improve the current status of organ shortage.

The dermal stem cell factor and c-kit are overexpressed in melasma.

BACKGROUND: The pathogenesis of melasma has not yet been clearly demonstrated. We tried to determine whether the stem cell factor (SCF) and its receptor c-kit are involved in the mechanism of hyperpigmentation of melasma because this factor is highly implicated in the stimulation of melanocyte function in vitro and in vivo. OBJECTIVES: The present study was conducted to investigate the expression of SCF and c-kit on the lesions of melasma compared with nonlesional skin. PATIENTS/METHODS: Skin samples were obtained from lesional and nonlesional facial skin of 60 Korean women with melasma. Immunohistochemistry and reverse transcriptase-polymerase chain reaction (RT-PCR) analysis was performed to determine the expression of SCF and c-kit in melasma. RESULTS: The expression of SCF was significantly increased at the lesional dermis compared with nonlesional dermis. However, there was no significant difference in the expression of SCF in lesional and nonlesional epidermis. The expression of c-kit was significantly increased at lesional epidermis compared with nonlesional skin. RT-PCR of SCF and c-kit mRNAs demonstrated increased expression of both types of transcripts in the lesional skin compared with nonlesional skin. CONCLUSIONS: These results suggest that the increased expression of SCF in the dermis and of c-kit in the epidermis play an important role in the mechanism of hyperpigmentation in melasma.

Expression and function of peroxisome proliferator-activated receptors in human melanocytes.

BACKGROUND: Peroxisome proliferator-activated receptors (PPARs) belong to the superfamily of nuclear receptors that heterodimerize with the retinoic X receptor. Agonists of PPAR have been known to play an important role in cellular responses including proliferation and differentiation. The expression and function of PPARs have not been investigated in human melanocytes, although they have been widely demonstrated in keratinocytes of the skin. OBJECTIVES: To investigate the expression of PPARs in human melanocytes and the effects of PPAR activators on melanocyte growth and melanogenesis. METHODS: We used immunocytochemistry and Western blot analysis to determine whether PPARs are expressed in melanocytes. To investigate further expression of PPAR subtypes, reverse transcriptase-polymerase chain reaction analysis was performed using PPAR subtype-specific oligonucleotides. The cell proliferation was measured using the Coulter counter. The effects on pigmentation were investigated with measurement of melanin contents, tyrosinase activity and its expression. RESULTS: The mRNA of all three PPAR subtypes, PPAR-alpha, PPAR-beta/delta and PPAR-gamma, were expressed in melanocytes. Activators for PPAR-alpha (WY-14643) and PPAR-gamma (ciglitazone) inhibited proliferation of melanocytes in a dose-dependent manner, whereas bezafibrate, a preferential activator for PPAR-beta/delta, had no effect. This growth inhibition was accompanied by the morphological change of the melanocytes to an activated form with an increased number of dendrites and enlarged cell area compared with the control. The WY-14643 and ciglitazone also appeared to stimulate the melanin synthesis of melanocytes. This increase in pigmentation was due to stimulation of the tyrosinase activity without an increase in the expression of tyrosinase. CONCLUSIONS: PPARs are expressed in human melanocytes and PPAR-alpha and PPAR-gamma activators inhibit melanocyte growth and stimulate melanogenesis.

Melasma: histopathological characteristics in 56 Korean patients.

BACKGROUND: Melasma is a common acquired symmetrical hypermelanosis characterized by irregular light to dark brown macules and patches on sun-exposed areas of the skin. Its histopathological characteristics are not fully understood. OBJECTIVES: To characterize the histopathological features of facial melasma skin in comparison with adjacent normal skin. METHODS: Biopsies were taken from both melasma lesional skin and adjacent perilesional normal skin in 56 Korean women with melasma. The sections were stained using haematoxylin and eosin, Fontana-Masson, diastase-resistant periodic acid-Schiff, Masson trichrome and Verhoeff-van Gieson stains, and immunostaining for melanocytes. Data on the changes in number of melanocytes and melanin contents of the epidermis were analysed by a computer-assisted image analysis program. The ultrastructure of the skin was also examined. RESULTS: The amount of melanin was significantly increased in all epidermal layers in melasma skin. The staining intensity and number of epidermal melanocytes increased in melasma lesions. Lesional skin showed more prominent solar elastosis compared with normal skin. Melanosomes increased in number and were more widely dispersed in the keratinocytes of the lesional skin. Lesional melanocytes had many more mitochondria, Golgi apparatus, rough endoplasmic reticulum and ribosomes in their cytoplasm. A dihydroxyphenylalanine reaction was apparent in the cisternae and vesicles of the trans-Golgi network in melanocytes from lesional skin. CONCLUSIONS: Melasma is characterized by epidermal hyperpigmentation, possibly caused both by an increased number of melanocytes and by an increased activity of melanogenic enzymes overlying dermal changes caused by solar radiation.

Negative regulation of filamentous growth and flocculation by Lkh1, a fission yeast LAMMER kinase homolog.

We have isolated a full-length cDNA clone that encodes for a Schizosaccharomyces pombe homolog of the dual-specificity protein kinase of the LAMMER family, lkh1 (lammer kinase homolog). The proposed Lkh1 protein contains 575 amino acids. The lkh1(+) null mutant is viable, but exhibits flocculation upon reaching stationary phase in liquid media and filamentous adhesion growth on solid media. Analysis of the flocculation activity of the lkh1(+) null mutant indicates that asexual aggregation of S. pombe cells into floccules is divalent cation-dependent and galactose-specific. We also demonstrate that the Saccharomyces cerevisiae LAMMER kinase homolog, Kns1, can substitute for the Lkh1 function in S. pombe.

Absence of human papillomavirus DNA in nongenital seborrheic keratosis.

Seborrheic keratosis (SK) is a benign epidermal tumor of unknown etiology. Because of its wart-like morphology, human papillomavirus (HPV) has been suggested as a possible causative agent. Viral involvement, however, has not been confirmed yet despite extensive research. The aim of this study was to evaluate the presence of HPV 6/11, 31, 33 DNA in nongenital SK. We analyzed 40 biopsy specimens taken from patients with nongenital SK using in situ polymerase chain reaction (PCR) and PCR with tissue extracts. The SK specimens (n=40), analyzed by in situ PCR, were negative for all HPV probes tested (types 6/11, 31, 33). Control slides (condyloma acuminatum, n=3) were positive for type 6/11, 31, and 33 HPV probes tested. Melasma samples (n=4), the negative controls, were consistently negative. No HPV DNA band was detected by PCR with the tissue extracts from paraffin-embedded SK samples, while condyloma acuminatum, the positive controls, showed DNA bands of the correct molecular weights. Our results show that HPV type 6/11, 31, and 33 cannot be recognized as causative agents for nongenital SK, which is in contrast to the previous studies. Further studies are required to reveal the presence of other types (more than 90) of HPV DNA.

Application of computerized image analysis in pigmentary skin diseases.

BACKGROUND: Melanocyte number and the amount of melanin pigment are related to diagnosis and treatment of pigmentary skin diseases. Various histologic methods are used, such as Fontana-Masson stain for melanin pigment or immunohistochemical stain for melanocytes. Recently, computerized image analysis has been applied to many fields to avoid interobserver bias. In this study, we applied a computerized image analysis to assess the melanin content and melanocyte density of human epidermis. METHODS: We evaluated the skin biopsy specimens (paraffin blocks) from normal human skin (33 +/- 6.6, n = 11) and diseased skins; vitiligo (32 +/- 10.0, n = 8), melasma (35 +/- 8.6, n = 11), and lentigo senilis (40 +/- 7.2, n = 11) (mean age +/- SD). Each specimen was stained with Fontana-Masson for melanin pigments and immunohistochemical method for melanocytes. Quantitative analysis of melanin pigment and melanocyte number (density) were investigated through two methods: (1) two dermatologists measured the visual scales; and (2) computerized image analysis was used to measure melanin content indices (MCI). The data were evaluated using one-way ANOVA. RESULTS: The visual scale of the Fontana-Masson stain was the highest for lentigo senilis (3.8 +/- 0.40), followed by melasma (2.6 +/- 0.67), normal skin (1.8 +/- 0.60) and vitiligo (0) (P < 0.05). These findings were consistent with objective measurements made by computerized image analysis. MCI values were 120.3 +/- 20.74 for lentigo senilis, 81.1 +/- 19.27 for melasma, 45.5 +/- 16.92 for normal skin, and 0.3 +/- 0.30 for vitiligo in decreasing order (P < 0.05). MC/1E (melanocyte number per 1 mm epidermis) was about two fold larger in lentigo senilis (18.1 +/- 8.92) than melasma (9.7 +/- 2.40) or normal skin (9.3 +/- 2.67) (P < 0.05). MC/1B (melanocyte number per 1 mm basal layer) was about 1.5 fold higher in lentigo senilis (13.5 +/- 4.17), compared to normal skin (9.0 +/- 3.55) (P < 0.05). Melasma showed increased melanocyte numbers compared to normal skin, but it was not statistically significant (P > 0.05). CONCLUSION: We believe this computerized image analysis could be useful tool for diagnosis and comparison of interval changes in pigmentary diseases like melasma or lentigo senilis by quantifying melanin pigments or melanocytes in skin biopsy specimens.

Expression and function of ryanodine receptors in human melanocytes.

We investigated the expression of ryanodine receptors (RyRs) in cultured human melanocytes with immunocytochemistry and reverse transcriptase-polymerase chain reaction. With the use of a monoclonal antibody, RyR immunoreactivity was detected in the cytoplasm of melanocytes, and was further confirmed by RT-PCR assay. The PCR products were cut with restriction enzymes specific for each RyR isoform. Using the RyR1-specific restriction enzyme SacI yielded fragments of 300, 100, and 130 base pairs, consistent with the expression of RyR1 isoforms. The function of RyR in Ca(2+) signaling was investigated using single-cell fura-2 imaging. Ryanodine (1 to approximately 100 microM) induced significant elevation of cytoplasmic Ca(2+) in single human melanocytes in a dose-dependent manner. The ryanodine-induced [Ca(2+)](i) increase was inhibited by neomycin. Furthermore, ryanodine inhibited proliferation and stimulated pigmentation of human melanocytes. This study demonstrates that the RyR1 isoform is expressed in cultured human melanocytes, and suggests that the RyR may be involved in regulating the intracellular Ca(2+) responses involved in proliferation and pigmentation of cultured human melanocytes.

Secondary cutaneous amyloidosis in disseminated superficial porokeratosis: a case report.

Disseminated superficial porokeratosis (DSP) is a rare cause of secondary cutaneous amyloidosis. An 83-year-old male patient showed an increase in both size and number of DSP lesions after contracting pulmonary tuberculosis. The DSP lesions of the patient consisted of numerous annular eruptions on both sun-exposed and sun-protected areas, which occurred over a period of 20 years. Multiple skin biopsies were taken from normal or lesional/sun-exposed or sun-protected skin samples. Histopathologic examination included routine H&E stains, Congo red stains, thioflavin-T stains and anticytokeratin antibodies (AE1, AE3). And the results were as follows; 1) Positive staining with Congo red and thioflavin-T indicated an amyloid nature for the deposits, 2) confinement of the amyloid deposition just below the lesional epidermis (while sparing the neighboring uninvolved or distant normal skin) indicated some role of the lesional epidermis, and 3) positive staining with AE3 further indicated an epidermal origin-type II epithelial keratin-of the amyloid. We present a case of DSP with a local amyloid deposit, characterized by association of positive familial background, severe pruritus and pulmonary tuberculosis.

Behavioral differences between donor site-matched adult and neonatal melanocytes in culture.

Little is known about the biologic behaviors of cultured melanocytes in relation to donor age. To investigate age-dependent differences, neonatal and adult melanocytes were isolated from the same anatomical site, the foreskin, and cultured in the same growth medium supplemented with cAMP inducers (choleratoxin and 3-isobutyl-methylxanthine). The morphology, melanin content, pattern of melanosome distribution, and growth rate were then compared. Neonatal melanocytes were bipolar in appearance, whereas adult melanocytes were highly dendritic in appearance. Image analysis showed that adult melanocytes were larger and longer, and had a greater number of dendrites than neonatal melanocytes. When the growth medium was replaced by a medium without cAMP inducers, adult melanocytes showed a change in their morphology from dendritic to spindle-shaped, while the morphology of neonatal melanocytes remained unchanged. Melanosomes of adult melanocytes were distributed singly along the dendrites, and extracellular secretion of melanosomes was also found. In contrast, melanosomes of neonatal melanocytes were aggregated near the nuclei. No age-dependent differences in melanin content and growth rate were noted in the donor site-matched cultured melanocytes. These results suggest that donor age is one of the factors involved in determining melanocyte dendricity and melanosome distribution, and that increased dendricity of adult melanocytes is due to increased sensitivity to cAMP inducers. In addition, the adult melanocytes established in our culture system, which resembled dendritic melanocytes in vivo, could be considered a desirable model for studying the mechanisms of adult-onset hyperpigmentary disorders and melanogenesis.

Expression of progesterone receptor in human keratinocytes.

Despite the various responses of human skin to female sex hormones, cellular and subcellular targets and the mechanisms of action of estrogen and progesterone in human skin are not well understood. The detection of estrogen receptor (ER) and progesterone receptor (PR) in the skin is of great importance to understand the effect of estrogen and progesterone. In primary cultures of human keratinocytes, expression of ER and PR was monitored by immunocytochemistry and reverse transcriptase polymerase chain reaction (RT-PCR). Paraffin embedded skin tissues were stained with monoclonal antibodies to human ER and PR by immunohistochemistry. Cultured human keratinocytes expressed cytoplasmic PR protein and PR mRNA transcripts. By contrast, ER was detected only at the mRNA level. Suprabasal keratinocytes from samples of pruritic urticarial papules, plaques of pregnancy (PUPPP) and psoriasis were stained positively only for PR, while those from samples of erythema nodosum were negative for both ER and PR. Lesional epidermis of PUPPP showed positive PR immunoreactivity, while nonlesional epidermis did not. No other cells in the normal human skin were stained with ER and PR. The present study suggests that by expressing PR human keratinocytes act as targets for progesterone action.

Macular amyloidosis presented as poikiloderma: a case report.

We report a 51-year-old Vietnam War veteran with an unusual variant of macular amyloidosis presenting as poikilodermatous skin lesions. The extensive mottled brown pigmentation was checkered with small hypopigmented or normal skin-colored spots and intermingled with telangiectasia. Skin biopsy revealed subepidermal amyloid deposits. There was no evidence of extracutaneous involvements. This case could be easily confused with other true poikiloderma lesions.