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Sachan D, Rajakumar A, Krishna G D, Rajalingam R, Rela M. Living Donor Liver transplantation in an alloimmunised patient: Immunological challenges and Management in Indian Settings. Transpl Immunol 2023; 79:101854. [PMID: 37210014 DOI: 10.1016/j.trim.2023.101854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/30/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
Liver transplantation (LT) is often associated with hematological abnormalities with immune or non-immune etiologies and require timely diagnosis and interventions. We report a case of a patient suffering from non-alcoholic steato-hepatitis (NASH) related end stage liver disease (ESLD) with multiple red cell antibodies who underwent LT surgery. In postoperative phase, she developed immune hemolysis as well as acute antibody mediated rejection (AMR) which was managed with therapeutic plasma exchange and IVIG. The case highlights the need to develop an algorithm for red cell and HLA antibody screening in high-risk patients for timely detection and management.
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Affiliation(s)
- Deepti Sachan
- Department of Transfusion Medicine, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamilnadu, India
| | - Akila Rajakumar
- Liver Anesthesia & Intensive care, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamilnadu, India
| | - Deepthi Krishna G
- Department of Transfusion Medicine, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamilnadu, India.
| | - Rajesh Rajalingam
- HPB Surgery & Liver Transplantation, Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamilnadu, India
| | - Mohamed Rela
- HPB Surgery & Liver Transplantation, Institute of Liver Disease and Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education and Research, Chennai, Tamilnadu, India
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Cohn C, Dumont L, Lozano M, Marks D, Johnson L, Ismay S, Bondar N, T'Sas F, Yokoyama A, Kutner J, Acker J, Bohonek M, Sailliol A, Martinaud C, Pogłód R, Antoniewicz-Papis J, Lachert E, Pun P, Lu J, Cid J, Guijarro F, Puig L, Gerber B, Alberio L, Schanz U, Buser A, Noorman F, Zoodsma M, van der Meer P, de Korte D, Wagner S, O'Neill M. Vox Sanguinis International Forum on platelet cryopreservation. Vox Sang 2017; 112:e69-e85. [DOI: 10.1111/vox.12532] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
| | | | | | - D.C. Marks
- Australian Red Cross Blood Service; 17 O'Riordan Street Alexandria NSW 2015 Australia
| | - L. Johnson
- Australian Red Cross Blood Service; 17 O'Riordan Street Alexandria NSW 2015 Australia
| | - S. Ismay
- Australian Red Cross Blood Service; 17 O'Riordan Street Alexandria NSW 2015 Australia
| | - N. Bondar
- Australian Red Cross Blood Service; 17 O'Riordan Street Alexandria NSW 2015 Australia
| | - F. T'Sas
- HMRA - Service Militaire de Transfusion Sanguine; Rue Bruyn 1 1120 Bruxelles Belgique
| | - A.P.H. Yokoyama
- Departamento de Hemoterapia; Hospital Israelita Albert Einstein; Av. Albert Einstein, 627 Sao Paulo SP 05651-901 Brazil
| | - J.M. Kutner
- Departamento de Hemoterapia; Hospital Israelita Albert Einstein; Av. Albert Einstein, 627 Sao Paulo SP 05651-901 Brazil
| | - J.P. Acker
- Canadian Blood Services; 8249-114 Street Edmonton AB T6G 2R8 Canada
| | - M. Bohonek
- Department of Hematology and Blood Transfusion; Military University Hospital Prague; U Vojenske nemocnice 1200 Prague 169 02 Czech Republic
| | - A. Sailliol
- French Military Blood Institute; 1 rue de Lieutenant Batany Clamart 92140 France
| | - C. Martinaud
- French Military Blood Institute; 1 rue de Lieutenant Batany Clamart 92140 France
| | - R. Pogłód
- Zakład Transfuzjologii; Instytut Hematologii i Transfuzjologii; ul. I. Gandhi 14 Warszawa 02-776 Poland
| | - J. Antoniewicz-Papis
- Institute of Hematology and Transfusion Medicine; Indiry Gandhi 14 Warsaw 02-776 Poland
| | - E. Lachert
- Institute of Hematology and Transfusion Medicine; Indiry Gandhi 14 Warsaw 02-776 Poland
| | - P.B.L. Pun
- Defence Medical & Environmental Research Institute; DSO National Laboratories (Kent Ridge); 27 Medical Drive Singapore 117510
| | - J. Lu
- Defence Medical & Environmental Research Institute; DSO National Laboratories (Kent Ridge); 27 Medical Drive Singapore 117510
| | - J. Cid
- Apheresis Unit; Department of Hemotherapy and Hemostasis; ICMHO; Hospital Clínic; Villarroel 170 Barcelona Catalonia 08036 Spain
| | - F. Guijarro
- Apheresis Unit; Department of Hemotherapy and Hemostasis; ICMHO; IDIBAPS; Hospital Clínic; University of Barcelona; Barcelona Spain
| | - L. Puig
- Banc de Sang i Teixits de Catalunya; Transfusion Safety Laboratory; Barcelona Spain
| | - B. Gerber
- Division of Hematology; Oncology Institute of Southern Switzerland; Bellinzona CH-6500 Switzerland
| | - L. Alberio
- Division of Hematology and Central Hematology Laboratory; CHUV; Lausanne University Hospital; Lausanne Switzerland
| | - U. Schanz
- Division of Hematology; University and University Hospital Zurich; Zurich Switzerland
| | - A. Buser
- Hematology; University Hospital Basel; Basel Switzerland
| | - F. Noorman
- Military Blood Bank; Plesmanlaan 1c 2333 BZ The Netherlands
| | - M. Zoodsma
- Military Blood Bank; Plesmanlaan 1c 2333 BZ The Netherlands
| | - P.F. van der Meer
- Department of Product and Process Development; Sanquin Blood Bank; Plesmanlaan 125 Amsterdam 1066 CX The Netherlands
| | - D. de Korte
- Sanquin Blood Bank North West Region; Plesmanlaan 125 Amsterdam 1066 CX The Netherlands
| | - S. Wagner
- Transfusion Innovation Dept.; American Red Cross Holland Lab; 15601 Crabbs Branch Way Rockville MD 20855 USA
| | - M. O'Neill
- American Red Cross Medical Office; 180 Rustcraft Rd Dedham MA 020206 USA
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GRG profiles: Professor Ignazio Marino. Dig Dis Sci 2014; 59:2033-5. [PMID: 25142168 DOI: 10.1007/s10620-014-3301-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Affiliation(s)
- Yoogoo Kang
- Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Muro M, Marin L, Miras M, Moya-Quiles R, Minguela A, Sánchez-Bueno F, Bermejo J, Robles R, Ramírez P, García-Alonso A, Parrilla P, Alvarez-López MR. Liver recipients harbouring anti-donor preformed lymphocytotoxic antibodies exhibit a poor allograft survival at the first year after transplantation: experience of one centre. Transpl Immunol 2005; 14:91-7. [PMID: 15935299 DOI: 10.1016/j.trim.2005.03.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2005] [Accepted: 03/28/2005] [Indexed: 12/20/2022]
Abstract
In this retrospective study, we analyzed the effect of the presence of anti-donor preformed alloantibodies in 268 liver allograft transplants. Crossmatches were performed by complement-dependent cytotoxicity (CDC) assay and HLA antibody screening by flow cytometry (FlowPRA). Positive anti-donor crossmatch was detected in 5.2% of transplants. Acute rejection frequency in +CDC crossmatch patients was not different from that observed in -CDC crossmatch patients. None of the patients transplanted with +CDC crossmatch developed chronic rejection, but they showed a significantly lower allograft survival rate, and the majority of them had allograft failures before the end of the first post-transplant year, mainly within the 3 first months. Indeed, positive FlowPRA determination was concordant with data from the CDC assay. In conclusion, these findings show a direct correlation between the presence of anti-donor preformed antibodies and a poor allograft survival in liver transplant.
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Affiliation(s)
- Manuel Muro
- Immunology Service, University Hospital Virgen de la Arrixaca, Murcia 30120, Spain.
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Affiliation(s)
- Yves Ozier
- Departement d'Anesthesie-Reanimation Chirurgicale, Hôpital Cochin, Paris, France
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Abstract
Profound and complex coagulation disorders are encountered during liver transplantation. They include preoperative coagulation disorders related to the liver disease and haemostatic changes related to the procedure itself. They commonly lead to increased intraoperative bleeding, especially due to increased fibrinolysis, the contribution of which can be demonstrated by the relative efficacy of antifibrinolytics. Given the multifactorial nature of bleeding in liver transplantation, preoperative coagulation tests cannot predict blood loss even if some statistical relationship is occasionally found. Preoperative correction of coagulation defects has not been shown to be effective in reducing intraoperative bleeding. Throughout the procedure, a rapid and sensitive method for monitoring coagulation is necessary in order to guide the rational use of blood components and pharmacological agents. The usefulness of such a method to assist management of blood loss or blood component requirements is poorly documented and controversial.
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Chatzipetrou MA, Tsaroucha AK, Weppler D, Pappas PA, Kenyon NS, Nery JR, Khan MF, Kato T, Pinna AD, O'Brien C, Viciana A, Ricordi C, Tzakis AG. Thrombocytopenia after liver transplantation. Transplantation 1999; 67:702-6. [PMID: 10096525 DOI: 10.1097/00007890-199903150-00010] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Thrombocytopenia after orthotopic liver transplantation (OLT) is a well recognized and prevalent early postoperative complication. The etiology, as well as the effect of this phenomenon on transplant outcome, however, are vague. The aims of this study are to identify factors contributing to thrombocytopenia and to ascertain whether there is any correlation with early rejection and ultimate survival. METHODS This study examines 541 OLTs (541 grafts in 494 patients) that were transplanted at the University of Miami during the 3-year period from June 1994 to September 1997. The patients with severe postoperative thrombocytopenia (nadir platelet count [PLT] < 20,000/mm3), as well as the whole group of patients, were analyzed. The preoperative PLT, intra-operative platelet transfusion requirements, cross-match, recipient and donor cytomegalovirus (CMV) status, infusion of donor bone marrow cells (DBMC), occurrence of early rejection episodes (in the first posttransplant month), and re-transplantation were factors examined for any association with thrombocytopenia. Total bilirubin (TB) and direct bilirubin (dB), hematocrit, white blood cell count (WBC), aspartate aminotransferase and alanine aminotransferase, determined on the day that platelets reached a nadir (nadir day), were also analyzed. RESULTS In 90.9% of the cases, there was a 56.5%+/-23.5% fall in platelets in the immediate posttransplant period (first 2 weeks), but the mean PLT exceeded preoperative levels during the 3rd and 4th postoperative weeks. The nadir of the drop in the PLT most commonly occurred on posttransplant day 4. For preoperative PLT, platelet transfusions during the operation, re-transplantation, early rejection, cross-match, and recipient CMV status, there was significant statistical correlation with any degree of postoperative thrombocytopenia. Four of these factors, preoperative PLT, intra-operative platelet transfusions, re-transplantation, and early rejection, were found to be independently associated with thrombocytopenia in general. None of them was found to be independently correlated with severe thrombocytopenia. A statistically significant correlation between bilirubin and WBC on the nadir day and the degree of thrombocytopenia was observed. No correlation was found between infusion of DBMC or donor CMV serology and thrombocytopenia. Both the nadir PLT and the percentage of the platelet fall were independent predictive factors (p<0.01 and 0.005, respectively) of patient and graft survival. CONCLUSIONS Thrombocytopenia in the immediate posttransplant period is correlated with low preoperative PLT, massive platelet transfusions, and re-transplantation. These factors reflect a poor preoperative condition. There is also a correlation with allograft dysfunction, rejection, and poorer patient and graft survival. A rise in the mean PLT after the 2nd postoperative week reflects proper graft function.
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Affiliation(s)
- M A Chatzipetrou
- Department of Surgery, University of Miami School of Medicine/Jackson Memorial Hospital, Florida 33136, USA
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Recent advances in transplantation anesthesia and intensive care medicine. Acta Anaesthesiol Scand 1997. [DOI: 10.1111/j.1399-6576.1997.tb04887.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cacciarelli TV, Keeffe EB, Moore DH, Burns W, Chuljian P, Busque S, Concepcion W, So SK, Esquivel CO. Primary liver transplantation without transfusion of red blood cells. Surgery 1996; 120:698-704; discussion 704-5. [PMID: 8862380 DOI: 10.1016/s0039-6060(96)80019-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study examines factors associated with the performance of orthotopic liver transplantation (OLT) without red blood cell (RBC) transfusion. METHODS Between January 1992 and December 1994, 306 primary OLTs were performed with recipients divided into two groups: group 1 patients (61 recipients, 20% of total) underwent transplantation without packed RBCs, and group 2 patients (245 recipients, 80% of cases) received a transfusion of at least 1 unit of RBCs during operation. RESULTS Recipients in group 1 compared with group 2 had less advanced liver disease (20% hospitalized and 48% Child's class C versus 58% hospitalized and 73% Child's class C, p < 0.01) and lower frequency of right upper quadrant surgery (13% versus 25%, p < 0.05). Group 1 recipients also had significantly higher preoperative hematocrits (38% versus 33%, p < 0.01), lower prothrombin times (15.4 versus 16.7 seconds, p < 0.001) and partial thromboplastin times (36.9 versus 42.2 seconds, p < 0.01), a greater proportion of patients transplanted by piggyback technique (87% versus 59%, p < 0.001), and shorter operative times (7.9 hours versus 9.2 hours, p < 0.001). Moreover, a greater percentage of patients underwent OLT without RBC transfusion in each successive year: 9% in 1992, 21% in 1993, and 31% in 1994 (p < 0.001). Logistic regression analysis showed the following factors to be independent predictors of OLT without RBC transfusion. Preoperative Hct, United Network of Organ Sharing status, piggyback technique, operative time, and year of transplantation. CONCLUSIONS OLT can be performed without transfusion of RBCs in recipients with less advanced liver disease, and surgical technique, along with increased experience by the transplant team, are important factors.
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Affiliation(s)
- T V Cacciarelli
- Liver Transplant Program, Stanford University Medical Center, Palo Alto, Calif. 94304, USA
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Starzl TE, Valdivia LA, Murase N, Demetris AJ, Fontes P, Rao AS, Manez R, Marino IR, Todo S, Thomson AW. The biological basis of and strategies for clinical xenotransplantation. Immunol Rev 1994; 141:213-44. [PMID: 7868154 PMCID: PMC3005617 DOI: 10.1111/j.1600-065x.1994.tb00879.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Recent discoveries have suggested that the exchange of multiple leukocyte lineages between grafts and host and subsequent long-term chimerism in both is the seminal mechanism of the acceptance of organs transplanted from the same (allografts) or different species (xenografts). This insight suggests new strategies which may allow xenotransplantation, the principal obstacle to which has been humoral rejection. We have defined humoral rejection as a family of complement activation syndromes afflicting allografts and xenografts in which there is a strong (but not invariable) association with performed antigraft antibodies, invariable evidence of complement activation, histopathologic stigmas of vascular endothelial damage, and a concomitant local or systemic coagulopathy. The generic descriptive term hyperacute rejection is a misnomer because a slow-motion version of the same "humoral" process can occur with some allografts and is the rule with the so-called concordant species xenotransplantations. The pathway of experience and discovery leading to this conclusion shows clearly that the distinction frequently made between allograft versus xenograft humoral rejection does not actually exist in principle, but only in details and intensity. Breaking down this barrier to xenotransplantation, whether or not it is associated with antibodies, is unrealistic. However, the possibility of avoiding the barrier has been exposed by showing that animal organs can be humanized, with a mixed donor and recipient cell population similar to the chimerism seen in long surviving allografts or even with complete leukocyte replacement. Pilot experiments in rodents suggest that organs from fully xenogeneic chimeras can be made into xenogeneic targets that are no more provocative of complement activation than allografts when they are transplanted into the donor bone marrow species. Although the validity of this concept of organ xenograft preparation is only at the pilot stage of verification, there is reason to suspect that the complement trigger of humoral rejection can be thereby disarmed. If this can be accomplished, independent evidence suggests that cellular rejection can be controlled with conventional T-cell directed immunosuppression, perhaps even with surprising ease. The potential subtle liability of synthetic products of xenogeneic parenchymal cells is not yet known.
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Affiliation(s)
- T E Starzl
- Pittsburgh Transplantation Institute, University of Pittsburgh Medical Center, PA 15213
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Ramos HC, Todo S, Kang Y, Felekouras E, Doyle HR, Starzl TE. Liver transplantation without the use of blood products. ARCHIVES OF SURGERY (CHICAGO, ILL. : 1960) 1994; 129:528-32; discussion 532-3. [PMID: 8185476 PMCID: PMC3022432 DOI: 10.1001/archsurg.1994.01420290074011] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To examine the techniques and the outcome of liver transplantation with maximal conservation of blood products and to analyze the potential benefits or drawbacks of blood conservation and salvage techniques. DESIGN Case series survey. SETTING Tertiary care, major university teaching hospital. PATIENTS AND METHODS Four patients with religious objections to blood transfusions who were selected on the basis of restrictive criteria that would lower their risk for fatal hemorrhage, including coagulopathy, a thrombosed splanchnic venous system requiring extensive reconstruction, active bleeding and associated medical complications. All patients were pretreated with erythropoietin to increase production of red blood cells. All operations were performed at the same institution, with a 36-month follow-up. INTERVENTIONS Orthotopic liver transplantation that used blood salvage, plateletpheresis, and autotransfusion and the withholding of the use of human blood products with the exception of albumin. MAIN OUTCOME MEASURES Survival and postoperative complications, with the effectiveness of erythropoietin and plateletpheresis as secondary measures. RESULTS All patients are alive at 36 months after orthotopic liver transplantation. One patient, a minor (13 years of age), was transfused per a state court ruling. Erythropoietin increased the production of red blood cells as shown by a mean increase in hematocrit levels of 0.08. Platelet-pheresis allowed autologous, platelet-rich plasma to be available for use after allograft reperfusion. Three major complications were resolved or corrected without sequelae. Only one patient developed postoperative hemorrhage, which was corrected surgically. The mean charge for bloodless surgery was $174,000 for the three patients with United Network for Organ Sharing (UNOS) status 3 priority for transplantation. This result was statistically significant when these patients were compared with all the patients with UNOS status 3 priority during the same period who met the same restrictive guidelines (P < .05). Only 19 of 1009 orthotopic liver transplantations performed at our institution were similar according to the UNOS status and the fulfillment of the guidelines. The mean charge for these comparison patients was $327,000, 3.8% of which was related to transfusions. CONCLUSIONS Orthotopic liver transplantation without the use of blood products is possible. Blood conservation techniques do not increase morbidity or mortality and can result in fewer transfusion-related, in-hospital charges.
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Affiliation(s)
- H C Ramos
- Department of Surgery, University of Pittsburgh, School of Medicine. Pa
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Saidman SL, Duquesnoy RJ, Demetris AJ, McCauley J, Ramos H, Mazariegos G, Shapiro R, Starzl TE, Fung JJ. Combined liver-kidney transplantation and the effect of preformed lymphocytotoxic antibodies. Transpl Immunol 1994; 2:61-7. [PMID: 8081794 PMCID: PMC2956073 DOI: 10.1016/0966-3274(94)90080-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Thirty-eight sequentially placed liver and kidney allografts were evaluated with respect to patient and graft survival, and the influence of preformed lymphocytotoxic antibodies was analysed. The results suggest that the survival rate of combined liver and kidney transplantation is similar to the survival rate of liver transplantation alone. Sequentially placed kidney allografts may be protected from hyperacute rejection in the presence of donor specific lymphocytotoxic antibodies, but not in all instances. Both patient and kidney allograft survival was lower in positive crossmatch patients (33% and 17% respectively) than in negative crossmatch patients (78% and 75%). High levels of panel reactive antibodies (> 10%) also appeared to have a deleterious effect on survival, although the majority of the patients who failed also had a positive crossmatch. Although performed lymphocytotoxic antibodies are not an absolute contraindication to combined liver-kidney transplantation, they do appear to have a deleterious effect on long-term graft survival. However, more correlation with clinical parameters is needed.
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Affiliation(s)
- S L Saidman
- Department of Pathology, University of Pittsburgh School of Medicine
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Smith O, Hazlehurst G, Brozovic B, Rolles K, Burroughs A, Mallett S, Dawson K, Mehta A. Impact of aprotinin on blood transfusion requirements in liver transplantation. Transfus Med 1993; 3:97-102. [PMID: 7690641 DOI: 10.1111/j.1365-3148.1993.tb00046.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A retrospective study was carried out to ascertain the blood bank provision required to support a liver transplant programme and to assess the effect of intraoperative aprotinin on blood product requirements in liver transplant recipients with cirrhosis. Sixty patients with end-stage liver disease underwent 62 consecutive orthotopic liver transplants between October 1988 and January 1991. The total and intraoperative requirements of red cells, platelets and fresh frozen plasma (FFP) were analysed for three groups of liver transplant recipients, those without cirrhosis (n = 15), those with cirrhosis (n = 25) and those with cirrhosis who received intraoperative aprotinin (n = 20). Fifteen without cirrhosis had mean total requirements of 15 units of red cells, 18 units of platelets and 16 units of FFP. Twenty patients with cirrhosis who received intraoperative aprotinin had broadly similar requirements. However, blood product requirements for 25 patients with cirrhosis were significantly greater (46 units of red cells, 41 units of platelets, 43 units of FFP, excluding the seven patients with primary biliary cirrhosis). We conclude that a liver transplant programme can be supported by a teaching hospital blood bank. The use of intraoperative aprotinin significantly reduces blood product requirements.
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Affiliation(s)
- O Smith
- Department of Haematology, Royal Free Hospital and School of Medicine, London, U.K
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Nakamura K, Murase N, Becich MJ, Furuya T, Todo S, Fung JJ, Starzl TE, Demetris AJ. Liver allograft rejection in sensitized recipients. Observations in a clinically relevant small animal model. THE AMERICAN JOURNAL OF PATHOLOGY 1993; 142:1383-91. [PMID: 8494042 PMCID: PMC1886908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
A sequential analysis of liver allograft rejection in sensitized rats using immunopathological and ultrastructural microscopy is described. Lewis rats were primed with four ACI skin grafts and challenged with an arterialized ACI orthotopic liver allograft 14 to 17 weeks later. The sensitization resulted in a mix of IgG and IgM lymphocytotoxic antibodies at a titer of 1:512 at the time of transplantation. Specificity analysis of pretransplant immune sera revealed a predominance of IgG anti-class I major histocompatibility complex (RT1) antibodies with a minor IgG fraction showing apparent endothelial cell specificity (non-RT1). This level of sensitization was associated with accelerated graft failure in 3 to 5 days from mixed humoral and cellular rejection. Sequential analysis of serial posttransplant graft biopsies revealed diffuse vascular IgG deposition and platelet thrombi in portal veins and periportal sinusoids within 3 minutes after reperfusion. This was followed by endothelial cell hypertrophy and vacuolization, periportal hepatocyte necrosis, arterial spasm, focal large bile duct necrosis, and hilar mast cell infiltration and degranulation. However, the liver allografts did not fail precipitously and hyperacute rejection was not seen. Kupffer cell phagocytosis of the sinusoidal platelets began as early as 30 minutes posttransplant and by 24 hours, the platelet thrombi had decreased. Cholangioles appeared focally at the edge of the limiting plates by 2 to 3 days, apparently in response to earlier periportal hepatocyte damage. A mononuclear portal and perivenular infiltrate became evident at 3 days, and graft failure was attributed to both antibody and cell-mediated rejection (Furuya et al: Preformed lymphocytotoxic antibodies: Hepatology 1992, 16: 1415-1422). The model described resembles observations in crossmatch positive human liver allograft recipients. The mechanisms of hepatic graft resistance to antibody mediated rejection and the possible long term consequences of early damage to the biliary tree are discussed.
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Affiliation(s)
- K Nakamura
- Department of Pathology, University of Pittsburgh, PA 15213
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Demetris AJ, Nakamura K, Yagihashi A, Iwaki Y, Takaya S, Hartman GG, Murase N, Bronsther O, Manez R, Fung JJ. A clinicopathological study of human liver allograft recipients harboring preformed IgG lymphocytotoxic antibodies. Hepatology 1992; 16:671-81. [PMID: 1505910 PMCID: PMC2956418 DOI: 10.1002/hep.1840160310] [Citation(s) in RCA: 107] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Twenty-six adult patients with preformed IgG donor lymphocytotoxic antibodies received primary liver allografts under FK 506 immunosuppression. The effect of the crossmatch-positive state on early graft function and on the immunopathological and histopathological findings was compared with that of 52 crossmatch-negative control recipients. The presensitized (crossmatch-positive) patients had prolongation of early graft dysfunction, underwent more clinically indicated biopsies and had a higher incidence of cellular rejection, both overall (p less than 0.05) and within 10 days of transplantation (p less than 0.01). They also had a higher incidence of graft failure in the first 180 days (p less than 0.01). Hyperacute rejection with necrotizing or neutrophilic arteritis was not seen in the crossmatch-positive grafts. However, histological findings associated with presensitization included platelet margination in central veins and sinusoids in biopsy specimens 60 to 90 min after graft revascularization. Later biopsy specimens had neutrophilic portal venulitis followed by cholangiolar proliferation, acute cholangiolitis and centrilobular hepatocyte swelling that mimicked preservation injury, endothelial activation of arteries with medial changes and relapsing episodes of acute cellular rejection. These clinicopathological observations suggest that lymphocytotoxic antibodies can have a deleterious effect on liver allograft function and survival, even if they do not precipitate immediate or hyperacute rejection.
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Affiliation(s)
- A J Demetris
- Department of Pathology, University of Pittsburgh Health Sciences Center, PA 15213
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Affiliation(s)
- T E Starzl
- Department of Surgery, University of Pittsburgh School of Medicine, Pennsylvania
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Brayman KL, Morel P, Sutherland DE, Najarian JS, Payne WD. Liver transplantation: annotated references. Curr Opin Immunol 1989; 1:1236-40. [PMID: 2679762 DOI: 10.1016/0952-7915(89)90022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- K L Brayman
- Department of Surgery, University of Minnesota Hospital and Clinic, Minneapolis
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