The recipients were all in a critical clinical situation; that is, all were types 1 or 2 of the U... more The recipients were all in a critical clinical situation; that is, all were types 1 or 2 of the UNOS classification6 Two were on mechanical ventilation; three had hepatorenal syndrome, two had previous spontaneous bacterial peritonitis, and one was grade III encephalopathic. Such recipients represented 11.4% of the GLT cases performed in our program during this time. Liver transplantation was realized with preservation of the recipient caval vein ("piggy-back") without venovenous bypass. We analyzed the following parameters: age of donors; etiology of death; Maastricht classification; time from cardiac arrest to start of cardiopulmonary resucitation (CPR); type of management from death to harvesting; and ALT (glutamicoxalacetic transaminase) peak within the first 3 days after OLT.
Introduction. The demand for liver transplantation has increasingly exceeded the supply of cadave... more Introduction. The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. The outcome of 20 liver transplants from Maastricht category 2 NHBD was compared with that of 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support with simultaneous application of chest and abdominal compression (CPS; n ϭ 6) or cardiopulmonary bypass (CPB; n ϭ 14) was used to maintain the donors. Results. At a minimum follow-up of 2 years, actuarial patient and graft survival rates with livers from Maastricht category 2 NHBD were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with organs from HBDs. The graft survival rates was 83% for livers from NHBDs preserved with CPS and 42% in those maintained with CPB. MATERIALS AND METHODS Donor Characteristics Livers from Maastricht category 2 NHBDs were harvested at 2 hospitals: Hospital Juan Canalejo, La Coruña (n ϭ 6), and Hospital Clínico San Carlos, Madrid (n ϭ 14).
The American Society of Transplant Surgeons and the American Society of Transplantation jointly s... more The American Society of Transplant Surgeons and the American Society of Transplantation jointly sponsored their third American Transplant Congress on May 30-June 4, 2003. The meeting, which took place in Washington, D.C., U.S.A., thoroughly reviewed the different immunosuppressive protocols for every kind of transplantation. Also presented were the immunological and nonimmunological factors influencing the success or failure of transplants from the point of view of genetics, the place of new investigative agents and the current status of various therapeutic protocols intended to induce tolerance or normal function of grafts in the absence of immunosuppressive treatment. Presentations on renal, liver, heart, lung, multivisceral and islet transplantation are covered in this report, as well as aspects of new immunosuppressive agents, genomics in transplantation and tolerance induction in allotransplantation.
Anti-alpha-galactosyl antibodies (anti-Gal) seemingly mediate rejection of pig organs transplante... more Anti-alpha-galactosyl antibodies (anti-Gal) seemingly mediate rejection of pig organs transplanted into humans and Old World monkeys. These natural antibodies appear to be produced by a subpopulation of B cells residing in the peritoneum. Therefore, peritoneal dialysis (PD) may have an impact on anti-Gal levels. In this cross-sectional study, blood anti-Gal levels were quantified by ELISA in 17 patients undergoing PD and 18 patients undergoing hemodialysis (HD), and the results were compared with those from a control group of 30 healthy blood donors. The effects of the mode of dialysis therapy and other epidemiologic variables on anti-Gal levels were also evaluated. The PD and HD patients were comparable with regards to age, sex, percentage having diabetes, time on dialysis, distribution of blood groups, and total serum levels of immunoglobulins A (IgA), G (IgG), and M (IgM). In patients and controls, IgG anti-Gal levels were not significantly different, but IgM anti-Gal levels were significantly lower in both PD and HD patients compared with controls. A nonsignificant trend toward lower IgM anti-Gal levels in PD patients compared with HD patients was also observed. IgG anti-Gal levels correlated positively with time on dialysis in the HD patients, but not in the PD patients. IgG anti-Gal levels also were found to be markedly elevated in three patients with chronic liver disease, but no other scrutinized variable appeared to influence IgG or IgM anti-Gal levels.
PREFORMED donor-reactive antibodies in kidney transplantation predispose to accelerated or precip... more PREFORMED donor-reactive antibodies in kidney transplantation predispose to accelerated or precipitous graft failure, sometimes within hours after transplantation (hyperacute rejection). 1 However, liver allografts have been shown to be resistant to this form of injury. 2 Improvements in surgical techniques, preservation methods, patient selection and management, 3 as weli as the introduction of the new immunosuppressant, FK 506, 4 have improved early liver allograft survival, reducing many of the nonimmunologic causes of early graft dysfunction.
Severe lithium poisoning is a frequent condition in the intoxicated intensive care unit populatio... more Severe lithium poisoning is a frequent condition in the intoxicated intensive care unit population. Dialysis is the treatment of choice, but no clinical markers predicting higher requirement for dialysis have been identified to date. We analyze the characteristics of lithium overdose patients needing dialysis to improve lithium clearance, and identify the ones associated with higher dialysis requirement. This is an observational, retrospective study of 14 patients with lithium poisoning admitted from 2004 to 2009. Median age was 41.8 Ϯ 16.1 years. Poisonings were acute in 7.1%, acute-onchronic in 64.28%, and chronic in 28.5% of cases. Comparing clinical and biochemical data in patients requiring more than one dialysis session with those requiring only one session, the univariate analysis showed differences at admission in creatinine clearance (40.5 Ϯ 23 vs. 73.3 Ϯ 24.9 mL/min, P = 0.025), white blood cells (17528 Ϯ 3530 vs. 11580 Ϯ 3360 cells/L, P = 0.007), and blood sodium concentration (134.8 Ϯ 5.9 vs. 141.8 Ϯ 8.4 mmol/L, P=0.035). We measured the degree of association between the number of sessions and the variables with partial correlations. High lithium levels (P = 0.006, r = 0.69), low creatinine clearance (P = 0.04, r =-0.55), and low blood sodium concentration (P = 0.024, r =-0.59) were associated with a greater number of dialysis sessions. The correlation remained significant for blood sodium concentration (P = 0.016, r =-0.67) after adjustment for creatinine clearance and initial lithium levels. Presence on admission of low creatinine clearance, low blood sodium concentration, and/or high lithium levels correlated with a higher number of dialysis sessions in severe lithium poisoning. These factors, especially low blood sodium concentration, are associated with higher dialysis requirements in severe lithium intoxication.
Twenty-two consecutive liver allograft recipients, who tested positive for immunoglobulin G (lgG)... more Twenty-two consecutive liver allograft recipients, who tested positive for immunoglobulin G (lgG) lymphocytotoxicity were subjected to pretransplantion and posttransplantation immunologic monitoring of antidonor IgG Iymphocytotoxic antibody titers. total hemolytic complement activity (CH.oo), circulating immune complexes (CIC), and platelet counts in an effort to improve our understanding of the preformed antibody state in clinical hepatic transplantation. Ten contemporaneous liver transplant recipients whose crossmatch results were negative and who experienced severe hepatocellular damage early after transplantation were included as controls. Crossmatch test results were negative 1 day after transplantation and during the 1 month follow-up remained negative in 14 of 22 (64%) sensitized recipients, most of whom had relatively low (:s 1:16) antidonor IgG antibody titers before transplantation. After transplantation, this group and the control group experienced no thrombocytopenia. no increase of CIC, and a gradual increase in CH.oo activity that reached normal levels within 1 week. A strong negative correlation between prothrombin time (PT) and CHuII) activity in these groups of patients suggested that changes in CH.oo activity (P < .0005) were tightly linked to liver synthetic function. In contrast. the crossmatch test results remained positive after transplantation in 8 of 22 (36%) sensitized recipients. all of whom had relatively high (>1:32 to 1024) pre transplantation titers of anti-donor IgG antibodies. After transplantation these patients developed a syndrome that was characterized by decreased CH.oo activity and increased CIC compared with pretrans-AbbreVIations: IgG. immunoglobulin G; CIC. cm:ulatlOg Immune com• plexes; AST. aspartate transammase; CH" ... hemolvtlc complement actiVIty; I'GE,. prostaj!landlO E,; PT. prothrombin time.
28. :\liki T. Bottaro DP. Flemmg TP. et al. Determination of ligandbinding speCIficity by alterna... more 28. :\liki T. Bottaro DP. Flemmg TP. et al. Determination of ligandbinding speCIficity by alternative splicing: two distinct growth factor receptors encoded by a single gene. Proc Nat! Acad Sci eSA 1993: 89: 246. 29. GospodaroWlCZ D. Neufeld G. Schwelgerer L. Molecular and biologlcal characterization of FGF. an angIogeruc factor which also controls the proliferation and differentlation of mesodermand neuroectodenn-deriyed cells. Cell Diff Dey 1986: 91: 1. 10. GospodaroWlcz D. Massogtia S. Cheng J. Fujii OK. Effect of fibroblast growth factor and lipoprotems on the proliferatlon of endothelial cells denved from bovme adrenal corteX. bram cortex and corpus lutewn caplilaries. J Cell PhyslOl 1986: 127: 121. >1. Thomas KA. Rios-Candelore M. Gimenez-Gallego G. Pure bralndcnved aCIdIC tlbroblast growth factor IS a potent anglogemc 1\04\-\:1:17/95/5907• 10\0503.0010 TRANSPLA.'1TATION ('"pvn~nt 11.. 1995 bv Williams & Wilkms vascular endothelial cell mitogen Wlth sequence homology to interleukin-l.
Xenotransplantation of genetically engineered porcine chondrocytes may benefit many patients who ... more Xenotransplantation of genetically engineered porcine chondrocytes may benefit many patients who suffer cartilage defects. In this work, we sought to elucidate the molecular bases of the cellular response to xenogeneic cartilage. To this end, we isolated pig costal chondrocytes (PCC) and conducted a series of functional studies. First, we determined by flow cytometry the cell surface expression of multiple immunoregulatory proteins in resting conditions or after treatment with human TNF-α, IL-1α, or IL-1β, which did not induce apoptosis. TNF-α and to a lesser extent IL-1α led to a marked upregulation of SLA I, VCAM-1, and ICAM-1 on PCC. SLA II and E-selectin remained undetectable in all the conditions assayed. Notably, CD86 was constitutively expressed at moderate levels, whereas CD80 and CD40 were barely detected. To assess their function, we next studied the interaction of PCC with human monoblastic U937 and Jurkat T cells. U937 cells adhered to resting and in a greater proportion to cytokine-stimulated PCC. Consistent with its expression pattern, pig VCAM-1 was key, mediating the increased adhesion after cytokine stimulation. We also conducted coculture experiments with U937 and PCC and measured the release of pig and human cytokines. Stimulated PCC secreted IL-6 and IL-8, whereas U937 secreted IL-8 in response to PCC. Finally, coculture of PCC with Jurkat in the presence of PHA led to a marked Jurkat activation as determined by the increase in IL-2 secretion. This process was dramatically reduced by blocking pig CD86. In summary, CD86 and VCAM-1 on pig chondrocytes may be important triggers of the xenogeneic cellular immune response. These molecules together with TNF could be considered potential targets for intervention in order to develop xenogeneic therapies for cartilage repair.
Epstein-Barr virus (EBV) infection is recognized as the principal aetiological factor in the path... more Epstein-Barr virus (EBV) infection is recognized as the principal aetiological factor in the pathogenesis of post-transplant lymphoproliferative disease (PTLD), particularly when primary EBV infection occurs after transplantation. We analysed, using a time-dependent proportional hazards model, the factors associated with development of PTLD in 40 adult liver transplant recipients who were seronegative for EBV prior to transplantation. Of 40 patients, 13 (33%) had a tissue diagnosis of PTLD at a median time of 126 days after transplantation. The multivariate analysis showed that prior CMV disease, the number of steroid boluses given and the number of units of RBC and FFP transfused were significant risk factors for development of PTLD.
The recipients were all in a critical clinical situation; that is, all were types 1 or 2 of the U... more The recipients were all in a critical clinical situation; that is, all were types 1 or 2 of the UNOS classification6 Two were on mechanical ventilation; three had hepatorenal syndrome, two had previous spontaneous bacterial peritonitis, and one was grade III encephalopathic. Such recipients represented 11.4% of the GLT cases performed in our program during this time. Liver transplantation was realized with preservation of the recipient caval vein ("piggy-back") without venovenous bypass. We analyzed the following parameters: age of donors; etiology of death; Maastricht classification; time from cardiac arrest to start of cardiopulmonary resucitation (CPR); type of management from death to harvesting; and ALT (glutamicoxalacetic transaminase) peak within the first 3 days after OLT.
Introduction. The demand for liver transplantation has increasingly exceeded the supply of cadave... more Introduction. The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. The outcome of 20 liver transplants from Maastricht category 2 NHBD was compared with that of 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support with simultaneous application of chest and abdominal compression (CPS; n ϭ 6) or cardiopulmonary bypass (CPB; n ϭ 14) was used to maintain the donors. Results. At a minimum follow-up of 2 years, actuarial patient and graft survival rates with livers from Maastricht category 2 NHBD were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with organs from HBDs. The graft survival rates was 83% for livers from NHBDs preserved with CPS and 42% in those maintained with CPB. MATERIALS AND METHODS Donor Characteristics Livers from Maastricht category 2 NHBDs were harvested at 2 hospitals: Hospital Juan Canalejo, La Coruña (n ϭ 6), and Hospital Clínico San Carlos, Madrid (n ϭ 14).
The American Society of Transplant Surgeons and the American Society of Transplantation jointly s... more The American Society of Transplant Surgeons and the American Society of Transplantation jointly sponsored their third American Transplant Congress on May 30-June 4, 2003. The meeting, which took place in Washington, D.C., U.S.A., thoroughly reviewed the different immunosuppressive protocols for every kind of transplantation. Also presented were the immunological and nonimmunological factors influencing the success or failure of transplants from the point of view of genetics, the place of new investigative agents and the current status of various therapeutic protocols intended to induce tolerance or normal function of grafts in the absence of immunosuppressive treatment. Presentations on renal, liver, heart, lung, multivisceral and islet transplantation are covered in this report, as well as aspects of new immunosuppressive agents, genomics in transplantation and tolerance induction in allotransplantation.
Anti-alpha-galactosyl antibodies (anti-Gal) seemingly mediate rejection of pig organs transplante... more Anti-alpha-galactosyl antibodies (anti-Gal) seemingly mediate rejection of pig organs transplanted into humans and Old World monkeys. These natural antibodies appear to be produced by a subpopulation of B cells residing in the peritoneum. Therefore, peritoneal dialysis (PD) may have an impact on anti-Gal levels. In this cross-sectional study, blood anti-Gal levels were quantified by ELISA in 17 patients undergoing PD and 18 patients undergoing hemodialysis (HD), and the results were compared with those from a control group of 30 healthy blood donors. The effects of the mode of dialysis therapy and other epidemiologic variables on anti-Gal levels were also evaluated. The PD and HD patients were comparable with regards to age, sex, percentage having diabetes, time on dialysis, distribution of blood groups, and total serum levels of immunoglobulins A (IgA), G (IgG), and M (IgM). In patients and controls, IgG anti-Gal levels were not significantly different, but IgM anti-Gal levels were significantly lower in both PD and HD patients compared with controls. A nonsignificant trend toward lower IgM anti-Gal levels in PD patients compared with HD patients was also observed. IgG anti-Gal levels correlated positively with time on dialysis in the HD patients, but not in the PD patients. IgG anti-Gal levels also were found to be markedly elevated in three patients with chronic liver disease, but no other scrutinized variable appeared to influence IgG or IgM anti-Gal levels.
PREFORMED donor-reactive antibodies in kidney transplantation predispose to accelerated or precip... more PREFORMED donor-reactive antibodies in kidney transplantation predispose to accelerated or precipitous graft failure, sometimes within hours after transplantation (hyperacute rejection). 1 However, liver allografts have been shown to be resistant to this form of injury. 2 Improvements in surgical techniques, preservation methods, patient selection and management, 3 as weli as the introduction of the new immunosuppressant, FK 506, 4 have improved early liver allograft survival, reducing many of the nonimmunologic causes of early graft dysfunction.
Severe lithium poisoning is a frequent condition in the intoxicated intensive care unit populatio... more Severe lithium poisoning is a frequent condition in the intoxicated intensive care unit population. Dialysis is the treatment of choice, but no clinical markers predicting higher requirement for dialysis have been identified to date. We analyze the characteristics of lithium overdose patients needing dialysis to improve lithium clearance, and identify the ones associated with higher dialysis requirement. This is an observational, retrospective study of 14 patients with lithium poisoning admitted from 2004 to 2009. Median age was 41.8 Ϯ 16.1 years. Poisonings were acute in 7.1%, acute-onchronic in 64.28%, and chronic in 28.5% of cases. Comparing clinical and biochemical data in patients requiring more than one dialysis session with those requiring only one session, the univariate analysis showed differences at admission in creatinine clearance (40.5 Ϯ 23 vs. 73.3 Ϯ 24.9 mL/min, P = 0.025), white blood cells (17528 Ϯ 3530 vs. 11580 Ϯ 3360 cells/L, P = 0.007), and blood sodium concentration (134.8 Ϯ 5.9 vs. 141.8 Ϯ 8.4 mmol/L, P=0.035). We measured the degree of association between the number of sessions and the variables with partial correlations. High lithium levels (P = 0.006, r = 0.69), low creatinine clearance (P = 0.04, r =-0.55), and low blood sodium concentration (P = 0.024, r =-0.59) were associated with a greater number of dialysis sessions. The correlation remained significant for blood sodium concentration (P = 0.016, r =-0.67) after adjustment for creatinine clearance and initial lithium levels. Presence on admission of low creatinine clearance, low blood sodium concentration, and/or high lithium levels correlated with a higher number of dialysis sessions in severe lithium poisoning. These factors, especially low blood sodium concentration, are associated with higher dialysis requirements in severe lithium intoxication.
Twenty-two consecutive liver allograft recipients, who tested positive for immunoglobulin G (lgG)... more Twenty-two consecutive liver allograft recipients, who tested positive for immunoglobulin G (lgG) lymphocytotoxicity were subjected to pretransplantion and posttransplantation immunologic monitoring of antidonor IgG Iymphocytotoxic antibody titers. total hemolytic complement activity (CH.oo), circulating immune complexes (CIC), and platelet counts in an effort to improve our understanding of the preformed antibody state in clinical hepatic transplantation. Ten contemporaneous liver transplant recipients whose crossmatch results were negative and who experienced severe hepatocellular damage early after transplantation were included as controls. Crossmatch test results were negative 1 day after transplantation and during the 1 month follow-up remained negative in 14 of 22 (64%) sensitized recipients, most of whom had relatively low (:s 1:16) antidonor IgG antibody titers before transplantation. After transplantation, this group and the control group experienced no thrombocytopenia. no increase of CIC, and a gradual increase in CH.oo activity that reached normal levels within 1 week. A strong negative correlation between prothrombin time (PT) and CHuII) activity in these groups of patients suggested that changes in CH.oo activity (P < .0005) were tightly linked to liver synthetic function. In contrast. the crossmatch test results remained positive after transplantation in 8 of 22 (36%) sensitized recipients. all of whom had relatively high (>1:32 to 1024) pre transplantation titers of anti-donor IgG antibodies. After transplantation these patients developed a syndrome that was characterized by decreased CH.oo activity and increased CIC compared with pretrans-AbbreVIations: IgG. immunoglobulin G; CIC. cm:ulatlOg Immune com• plexes; AST. aspartate transammase; CH" ... hemolvtlc complement actiVIty; I'GE,. prostaj!landlO E,; PT. prothrombin time.
28. :\liki T. Bottaro DP. Flemmg TP. et al. Determination of ligandbinding speCIficity by alterna... more 28. :\liki T. Bottaro DP. Flemmg TP. et al. Determination of ligandbinding speCIficity by alternative splicing: two distinct growth factor receptors encoded by a single gene. Proc Nat! Acad Sci eSA 1993: 89: 246. 29. GospodaroWlCZ D. Neufeld G. Schwelgerer L. Molecular and biologlcal characterization of FGF. an angIogeruc factor which also controls the proliferation and differentlation of mesodermand neuroectodenn-deriyed cells. Cell Diff Dey 1986: 91: 1. 10. GospodaroWlcz D. Massogtia S. Cheng J. Fujii OK. Effect of fibroblast growth factor and lipoprotems on the proliferatlon of endothelial cells denved from bovme adrenal corteX. bram cortex and corpus lutewn caplilaries. J Cell PhyslOl 1986: 127: 121. >1. Thomas KA. Rios-Candelore M. Gimenez-Gallego G. Pure bralndcnved aCIdIC tlbroblast growth factor IS a potent anglogemc 1\04\-\:1:17/95/5907• 10\0503.0010 TRANSPLA.'1TATION ('"pvn~nt 11.. 1995 bv Williams & Wilkms vascular endothelial cell mitogen Wlth sequence homology to interleukin-l.
Xenotransplantation of genetically engineered porcine chondrocytes may benefit many patients who ... more Xenotransplantation of genetically engineered porcine chondrocytes may benefit many patients who suffer cartilage defects. In this work, we sought to elucidate the molecular bases of the cellular response to xenogeneic cartilage. To this end, we isolated pig costal chondrocytes (PCC) and conducted a series of functional studies. First, we determined by flow cytometry the cell surface expression of multiple immunoregulatory proteins in resting conditions or after treatment with human TNF-α, IL-1α, or IL-1β, which did not induce apoptosis. TNF-α and to a lesser extent IL-1α led to a marked upregulation of SLA I, VCAM-1, and ICAM-1 on PCC. SLA II and E-selectin remained undetectable in all the conditions assayed. Notably, CD86 was constitutively expressed at moderate levels, whereas CD80 and CD40 were barely detected. To assess their function, we next studied the interaction of PCC with human monoblastic U937 and Jurkat T cells. U937 cells adhered to resting and in a greater proportion to cytokine-stimulated PCC. Consistent with its expression pattern, pig VCAM-1 was key, mediating the increased adhesion after cytokine stimulation. We also conducted coculture experiments with U937 and PCC and measured the release of pig and human cytokines. Stimulated PCC secreted IL-6 and IL-8, whereas U937 secreted IL-8 in response to PCC. Finally, coculture of PCC with Jurkat in the presence of PHA led to a marked Jurkat activation as determined by the increase in IL-2 secretion. This process was dramatically reduced by blocking pig CD86. In summary, CD86 and VCAM-1 on pig chondrocytes may be important triggers of the xenogeneic cellular immune response. These molecules together with TNF could be considered potential targets for intervention in order to develop xenogeneic therapies for cartilage repair.
Epstein-Barr virus (EBV) infection is recognized as the principal aetiological factor in the path... more Epstein-Barr virus (EBV) infection is recognized as the principal aetiological factor in the pathogenesis of post-transplant lymphoproliferative disease (PTLD), particularly when primary EBV infection occurs after transplantation. We analysed, using a time-dependent proportional hazards model, the factors associated with development of PTLD in 40 adult liver transplant recipients who were seronegative for EBV prior to transplantation. Of 40 patients, 13 (33%) had a tissue diagnosis of PTLD at a median time of 126 days after transplantation. The multivariate analysis showed that prior CMV disease, the number of steroid boluses given and the number of units of RBC and FFP transfused were significant risk factors for development of PTLD.
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