1
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Belyayev L, Kang J, Sadat M, Loh K, Patil D, Muralidaran V, Khan K, Kaufman S, Subramanian S, Gusev Y, Bhuvaneshwar K, Ressom H, Varghese R, Ekong U, Matsumoto CS, Robson SC, Fishbein TM, Kroemer A. Suppressor T helper type 17 cell responses in intestinal transplant recipients with allograft rejection. Hum Immunol 2024:110773. [PMID: 38494386 DOI: 10.1016/j.humimm.2024.110773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Intestinal transplant (ITx) rejection is associated with memory T helper type 17 cell (Th17) infiltration of grafted tissues. Modulation of Th17 effector cell response is facilitated by T regulatory (Treg) cells, but a phenotypic characterization of this process is lacking in the context of allograft rejection. METHODS Flow cytometry was performed to examine the expression of surface receptors, cytokines, and transcription factors in Th17 and Treg cells in ITx control (n = 34) and rejection patients (n = 23). To elucidate key pathways guiding the rejection biology, we utilized RNA sequencing (RNAseq) and assessed epigenetic stability through pyrosequencing of the Treg-specific demethylated region (TSDR). RESULTS We found that intestinal allograft rejection is characterized by Treg cellular infiltrates, which are polarized toward Th17-type chemokine receptor, ROR-γt transcription factor expression, and cytokine production. These Treg cell subsets have maintained epigenetic stability, as defined by FoxP3-TSDR methylation status, but displayed upregulation of functional Treg and purinergic signaling genes by RNAseq analysis such as CD39, in keeping with suppressor Th17 properties. CONCLUSION We show that ITx rejection is associated with increased polarized cells that express a Th17-like phenotype concurrent with regulatory purinergic markers.
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Affiliation(s)
- Leonid Belyayev
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA; Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20814, USA
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA; Department of Biochemistry and Molecular & Cellular Biology, Georgetown University, Washington, DC 20007, USA
| | - Mohammed Sadat
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Katrina Loh
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Digvijay Patil
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Vinona Muralidaran
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Stuart Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Yuriy Gusev
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, 2115 Wisconsin Ave NW, Suite 110, Washington, DC 20075, USA
| | - Krithika Bhuvaneshwar
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, 2115 Wisconsin Ave NW, Suite 110, Washington, DC 20075, USA
| | - Habtom Ressom
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20008, USA
| | - Rency Varghese
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20008, USA
| | - Udeme Ekong
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Simon C Robson
- Center for Inflammation Research, Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA.
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2
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Hussan E, Kroemer A, Elsabbagh AM, Khan KM, Yazigi NA, Ekong UD, Subramanian S, Ghobrial SS, Guerra JF, Fishbein TM, Matsumoto CS, Kaufman SS. Idiopathic Ileal Ulceration After Intestinal Transplantation. Transplant Direct 2023; 9:e1529. [PMID: 37899780 PMCID: PMC10602531 DOI: 10.1097/txd.0000000000001529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/09/2023] [Accepted: 06/19/2023] [Indexed: 10/31/2023] Open
Abstract
Background Idiopathic ileal ulceration after intestinal transplantation (ITx) has been discussed infrequently and has an uncertain natural history and relation to graft rejection. Herein, we review our experience with this pathology. Methods We retrospectively reviewed 225 ITx in 217 patients with minimum 1 y graft survival. Routine graft endoscopy was conducted up to twice weekly within the first 90 d after ITx, gradually decreasing to once yearly. Risks for ulceration over time were evaluated using Cox regression. Results Of 93 (41%) patients with ulcers, 50 were found within 90 d after ITx mostly via ileoscopy; delayed healing after biopsy appeared causal in the majority. Of the remaining 43 patients with ulcers found >90 d after ITx, 36 were after ileostomy closure. Multivariable modeling demonstrated within 90-d ulcer associations with increasing patient age (hazard ratio [HR], 1.027; P < 0.001) and loop ileostomy (versus Santulli ileostomy; HR, 0.271; P < 0.001). For ulcers appearing after ileostomy closure, their sole association was with absence of graft colon (HR, 7.232; P < 0.001). For ulcers requiring extended anti-microbial and anti-inflammatory therapy, associations included de novo donor-specific antibodies (HR, 3.222; P < 0.007) and nucleotide oligomerization domain mutations (HR, 2.772; P < 0.016). Whole-cohort post-ITx ulceration was not associated with either graft rejection (P = 0.161) or graft failure (P = 0.410). Conclusions Idiopathic ulceration after ITx is relatively common but has little independent influence on outcome; risks include ileostomy construction, colon-free ITx, immunologic mutation, and donor sensitization.
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Affiliation(s)
- Elsadig Hussan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Ahmed M. Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Udeme D. Ekong
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | | | - Juan-Francisco Guerra
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC
- Georgetown University School of Medicine, Washington, DC
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3
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Ekong UD, Reddy S, Yazigi N, Khan K, Kaufman S, Chapman KA, Leon E, Mew NA, Regier D, MacLeod E, Kroemer A, Girlanda R, Hawksworth J, Matsumoto CS, Fishbein TM. Domino liver transplantation: Expanding the liver donor pool to the pediatric recipient. Liver Transpl 2022; 28:1947-1950. [PMID: 35689402 DOI: 10.1002/lt.26526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/19/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Udeme D Ekong
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Sahithi Reddy
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Nada Yazigi
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Khalid Khan
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Stuart Kaufman
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Kimberly A Chapman
- Department of Genetics, Children's National Hospital, Washington, District of Columbia, USA
| | - Eyby Leon
- Department of Genetics, Children's National Hospital, Washington, District of Columbia, USA
| | - Nicholas Ah Mew
- Department of Genetics, Children's National Hospital, Washington, District of Columbia, USA
| | - Debra Regier
- Department of Genetics, Children's National Hospital, Washington, District of Columbia, USA
| | - Erin MacLeod
- Department of Genetics, Children's National Hospital, Washington, District of Columbia, USA
| | - Alexander Kroemer
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Raffaelle Girlanda
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jason Hawksworth
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Cal S Matsumoto
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Thomas M Fishbein
- Department of Surgery, Medstar Georgetown Transplant Institute, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
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4
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Girlanda R, Liggett JR, Jayatilake M, Kroemer A, Guerra JF, Hawksworth JS, Radkani P, Matsumoto CS, Zasloff M, Fishbein TM. The Microbiome and Metabolomic Profile of the Transplanted Intestine with Long-Term Function. Biomedicines 2022; 10:biomedicines10092079. [PMID: 36140180 PMCID: PMC9495872 DOI: 10.3390/biomedicines10092079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 11/25/2022] Open
Abstract
We analyzed the fecal microbiome by deep sequencing of the 16S ribosomal genes and the metabolomic profiles of 43 intestinal transplant recipients to identify biomarkers of graft function. Stool samples were collected from 23 patients with stable graft function five years or longer after transplant, 15 stable recipients one-year post-transplant and four recipients with refractory rejection and graft loss within one-year post-transplant. Lactobacillus and Streptococcus species were predominant in patients with stable graft function both in the short and long term, with a microbiome profile consistent with the general population. Conversely, Enterococcus species were predominant in patients with refractory rejection as compared to the general population, indicating profound dysbiosis in the context of graft dysfunction. Metabolomic analysis demonstrated significant differences between the three groups, with several metabolites in rejecting recipients clustering as a distinct set. Our study suggests that the bacterial microbiome profile of stable intestinal transplants is similar to the general population, supporting further application of this non-invasive approach to identify biomarkers of intestinal graft function.
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Affiliation(s)
- Raffaelle Girlanda
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
- Correspondence:
| | - Jedson R. Liggett
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
- Department of Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23704, USA
| | - Meth Jayatilake
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC 20007, USA
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Juan Francisco Guerra
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Jason Solomon Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20812, USA
| | - Pejman Radkani
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Michael Zasloff
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Center for Translational Transplant Medicine, Georgetown University, Washington, DC 20007, USA
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5
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Fortunato AC, Pinheiro RS, Matsumoto CS, Arantes RM, Rocha-Santos V, Nacif LS, Waisberg DR, Ducatti L, Martino RB, Carneiro-D’Albuquerque L, Andraus W. Techniques for Closing the Abdominal Wall in Intestinal and Multivisceral Transplantation: A Systematic Review. Ann Transplant 2022; 27:e934595. [PMID: 35228508 PMCID: PMC8897964 DOI: 10.12659/aot.934595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/13/2022] [Indexed: 11/09/2022] Open
Abstract
Short bowel syndrome is the most common etiology of intestinal failure, resulting from either resections of different intestinal segments or a congenital condition. Due to the absence or considerable reduction of intestinal loops in the abdominal cavity, patients with short bowel syndrome present with atrophy and muscle retraction of the abdominal wall, which leads to loss of abdominal domain and elasticity. This complication is an aggravating factor of intestinal transplantation since it can prevent the primary closure of the abdominal wall. A vast array of surgical techniques to overcome the challenges of the complexity of the abdominal wall have been described in the literature. The aim of our study was to review the modalities of abdominal wall closure in intestinal/multivisceral transplantation. Our study consisted of a systematic review following the methodological instructions described in the PRISMA guidelines. Duplicate studies and studies that did not meet the criteria for the systematic review were excluded, especially those without relevance and an explicit relationship with the investigated theme. After this step, 63 articles were included in our study. The results obtained with these techniques have been encouraging, but a high incidence of wound complications in some reports has raised concerns. There is no consensus among transplantation centers regarding which technique would be ideal and with higher success rates and lower rates of complications.
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Affiliation(s)
- Allana C. Fortunato
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Rafael S. Pinheiro
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Rubens M. Arantes
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Vinicius Rocha-Santos
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Lucas S. Nacif
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Daniel R. Waisberg
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Liliana Ducatti
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | - Rodrigo B. Martino
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
| | | | - Wellington Andraus
- Department of Gastroenterology, Clinics Hospital of the University of São Paulo, São Paulo, SP, Brazil
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6
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Ivanics T, Vianna R, Kubal CA, Iyer KR, Mazariegos GV, Matsumoto CS, Mangus R, Beduschi T, Abouljoud M, Fridell JA, Nagai S. Impact of the acuity circle model for liver allocation on multivisceral transplant candidates. Am J Transplant 2022; 22:464-473. [PMID: 34403552 DOI: 10.1111/ajt.16803] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/22/2021] [Accepted: 08/11/2021] [Indexed: 01/25/2023]
Abstract
Liver allocation was updated on February 4, 2020, replacing a Donor Service Area (DSA) with acuity circles (AC). The impact on waitlist outcomes for patients listed for combined liver-intestine transplantation (multivisceral transplantation [MVT]) remains unknown. The Organ Procurement and Transplantation Network/United Network for Organ Sharing database was used to identify all candidates listed for both liver and intestine between January 1, 2018 and March 5, 2021. Two eras were defined: pre-AC (2018-2020) and post-AC (2020-2021). Outcomes included 90-day waitlist mortality and transplant probability. A total of 127 adult and 104 pediatric MVT listings were identified. In adults, the 90-day waitlist mortality was not statistically significantly different, but transplant probability was lower post-AC. After risk-adjustment, post-AC was associated with a higher albeit not statistically significantly different mortality hazard (sub-distribution hazard ratio[sHR]: 8.45, 95% CI: 0.96-74.05; p = .054), but a significantly lower transplant probability (sHR: 0.33, 95% CI: 0.15-0.75; p = .008). For pediatric patients, waitlist mortality and transplant probability were similar between eras. The proportion of patients who underwent transplant with exception points was lower post-AC both in adult (44% to 9%; p = .04) and pediatric recipients (65% to 15%; p = .002). A lower transplant probability observed in adults listed for MVT may ultimately result in increased waitlist mortality. Efforts should be taken to ensure equitable organ allocation in this vulnerable patient population.
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Affiliation(s)
- Tommy Ivanics
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA.,Department of Surgical Sciences, Akademiska Sjukhuset, Uppsala University, Uppsala, Sweden
| | - Rodrigo Vianna
- Division of Liver/GI Transplant, Department of Surgery, Miami Transplant Institute, Jackson Memorial Hospital/University of Miami, Miami, Florida, USA
| | - Chandrashekhar A Kubal
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kishore R Iyer
- Recanati-Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, USA
| | - George V Mazariegos
- Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Cal S Matsumoto
- Medstar Georgetown University Hospital, Medstar Georgetown Transplant Institute, Washington, DC, USA
| | - Richard Mangus
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thiago Beduschi
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Marwan Abouljoud
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
| | - Jonathan A Fridell
- Division of Abdominal Transplant Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shunji Nagai
- Division of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Michigan, USA
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7
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Weiner J, Svetlicky N, Kang J, Sadat M, Khan K, Duttargi A, Stovroff M, Moturi S, Kara Balla A, Hyang Kwon D, Kallakury B, Hawksworth J, Subramanian S, Yazigi N, Kaufman S, Pasieka HB, Matsumoto CS, Robson SC, Pavletic S, Zasloff M, Fishbein TM, Kroemer A. CD69+ resident memory T cells are associated with graft-versus-host disease in intestinal transplantation. Am J Transplant 2021; 21:1878-1892. [PMID: 33226726 PMCID: PMC10364625 DOI: 10.1111/ajt.16405] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 09/30/2020] [Accepted: 11/13/2020] [Indexed: 01/25/2023]
Abstract
Graft-versus-host disease (GvHD) is a common, morbid complication after intestinal transplantation (ITx) with poorly understood pathophysiology. Resident memory T cells (TRM ) are a recently described CD69+ memory T cell subset localizing to peripheral tissue. We observed that T effector memory cells (TEM ) in the blood increase during GvHD and hypothesized that they derive from donor graft CD69+TRM migrating into host blood and tissue. To probe this hypothesis, graft and blood lymphocytes from 10 ITx patients with overt GvHD and 34 without were longitudinally analyzed using flow cytometry. As hypothesized, CD4+ and CD8+CD69+TRM were significantly increased in blood and grafts of GvHD patients, alongside higher cytokine and activation marker expression. The majority of CD69+TRM were donor derived as determined by multiplex immunostaining. Notably, CD8/PD-1 was significantly elevated in blood prior to transplantation in patients who later had GvHD, and percentages of HLA-DR, CD57, PD-1, and naïve T cells differed significantly between GvHD patients who died vs. those who survived. Overall, we demonstrate that (1) there were significant increases in TEM at the time of GvHD, possibly of donor derivation; (2) donor TRM in the graft are a possible source; and (3) potential biomarkers for the development and prognosis of GvHD exist.
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Affiliation(s)
- Joshua Weiner
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Nina Svetlicky
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Mohammed Sadat
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Anju Duttargi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Merrill Stovroff
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Sangeetha Moturi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Abdalla Kara Balla
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Dong Hyang Kwon
- Department of Pathology, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Bhaskar Kallakury
- Department of Pathology, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Nada Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Stuart Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Helena B Pasieka
- Division of Dermatology, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Simon C Robson
- Departments of Anesthesiology and Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Steven Pavletic
- National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland
| | - Michael Zasloff
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, District of Columbia
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8
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Kroemer A, Belyayev L, Khan K, Loh K, Kang J, Duttargi A, Dhani H, Sadat M, Aguirre O, Gusev Y, Bhuvaneshwar K, Kallakury B, Cosentino C, Houlihan B, Diaz J, Moturi S, Yazigi N, Kaufman S, Subramanian S, Hawksworth J, Girlanda R, Robson SC, Matsumoto CS, Zasloff M, Fishbein TM. Rejection of intestinal allotransplants is driven by memory T helper type 17 immunity and responds to infliximab. Am J Transplant 2021; 21:1238-1254. [PMID: 32882110 PMCID: PMC8049508 DOI: 10.1111/ajt.16283] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 02/06/2023]
Abstract
Intestinal transplantation (ITx) can be life-saving for patients with advanced intestinal failure experiencing complications of parenteral nutrition. New surgical techniques and conventional immunosuppression have enabled some success, but outcomes post-ITx remain disappointing. Refractory cellular immune responses, immunosuppression-linked infections, and posttransplant malignancies have precluded widespread ITx application. To shed light on the dynamics of ITx allograft rejection and treatment resistance, peripheral blood samples and intestinal allograft biopsies from 51 ITx patients with severe rejection, alongside 37 stable controls, were analyzed using immunohistochemistry, polychromatic flow cytometry, and reverse transcription-PCR. Our findings inform both immunomonitoring and treatment. In terms of immunomonitoring, we found that while ITx rejection is associated with proinflammatory and activated effector memory T cells in the blood, evidence of treatment efficacy can only be found in the allograft itself, meaning that blood-based monitoring may be insufficient. In terms of treatment, we found that the prominence of intra-graft memory TNF-α and IL-17 double-positive T helper type 17 (Th17) cells is a leading feature of refractory rejection. Anti-TNF-α therapies appear to provide novel and safer treatment strategies for refractory ITx rejection; with responses in 14 of 14 patients. Clinical protocols targeting TNF-α, IL-17, and Th17 warrant further testing.
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Affiliation(s)
- Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Leonid Belyayev
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Katrina Loh
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Gastroenterology, Hepatology and Nutrition, Children’s National Medical Center, Washington, DC
| | - Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Anju Duttargi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Harmeet Dhani
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Mohammed Sadat
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Oswaldo Aguirre
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Yuriy Gusev
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, Washington, DC
| | - Krithika Bhuvaneshwar
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, Washington, DC
| | - Bhaskar Kallakury
- Department of Pathology, MedStar Georgetown University Hospital, Washington, DC
| | - Christopher Cosentino
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Brenna Houlihan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Jamie Diaz
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Sangeetha Moturi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Nada Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Stuart Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Sukanya Subramanian
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC,Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Raffaele Girlanda
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Simon C. Robson
- Departments of Anesthesiology and Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Michael Zasloff
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, Washington, DC
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9
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Kang J, Loh K, Belyayev L, Cha P, Sadat M, Khan K, Gusev Y, Bhuvaneshwar K, Ressom H, Moturi S, Kaiser J, Hawksworth J, Robson SC, Matsumoto CS, Zasloff M, Fishbein TM, Kroemer A. Type 3 innate lymphoid cells are associated with a successful intestinal transplant. Am J Transplant 2021; 21:787-797. [PMID: 32594614 PMCID: PMC8049507 DOI: 10.1111/ajt.16163] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 06/19/2020] [Accepted: 06/19/2020] [Indexed: 01/25/2023]
Abstract
Although innate lymphoid cells (ILCs) play fundamental roles in mucosal barrier functionality and tissue homeostasis, ILC-related mechanisms underlying intestinal barrier function, homeostatic regulation, and graft rejection in intestinal transplantation (ITx) patients have yet to be thoroughly defined. We found protective type 3 NKp44+ ILCs (ILC3s) to be significantly diminished in newly transplanted allografts, compared to allografts at 6 months, whereas proinflammatory type 1 NKp44- ILCs (ILC1s) were higher. Moreover, serial immunomonitoring revealed that in healthy allografts, protective ILC3s repopulate by 2-4 weeks postoperatively, but in rejecting allografts they remain diminished. Intracellular cytokine staining confirmed that NKp44+ ILC3 produced protective interleukin-22 (IL-22), whereas ILC1s produced proinflammatory interferon-gamma (IFN-γ) and tumor necrosis factor-alpha (TNF-α). Our findings about the paucity of protective ILC3s immediately following transplant and their repopulation in healthy allografts during the first month following transplant were confirmed by RNA-sequencing analyses of serial ITx biopsies. Overall, our findings show that ILCs may play a key role in regulating ITx graft homeostasis and could serve as sentinels for early recognition of allograft rejection and be targets for future therapies.
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Affiliation(s)
- Jiman Kang
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
| | - Katrina Loh
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007,Children’s National Medical Center, 111 Michigan Avenue NW, Washington DC, 20010
| | - Leonid Belyayev
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007,Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda MD, 20814
| | - Priscilla Cha
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007,Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda MD, 20814
| | - Mohammed Sadat
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
| | - Khalid Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
| | - Yuriy Gusev
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, 2115 Wisconsin Ave NW, Suite 110, Washington DC, 20007
| | - Krithika Bhuvaneshwar
- Innovation Center for Biomedical Informatics (ICBI), Georgetown University Medical Center, 2115 Wisconsin Ave NW, Suite 110, Washington DC, 20007
| | - Habtom Ressom
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 4000 Reservoir Road NW, Washington DC, 20007
| | - Sangeetha Moturi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
| | - Jason Kaiser
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007,Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda MD, 20814
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007,Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda MD, 20814
| | - Simon C. Robson
- Departments of Anesthesiology and Medicine, CLS 612, 330 Brookline Avenue, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA, 02115
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
| | - Michael Zasloff
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital and the Center for Translational Transplant Medicine, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington DC, 20007
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10
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Kroemer A, Khan K, Kaufman SS, Kang J, Weiner J, Duttargi A, Belyayev L, Ashokkumar C, Sindhi R, Timofeeva OA, Zasloff M, Matsumoto CS, Fishbein TM. Operational tolerance in intestinal transplantation. Am J Transplant 2021; 21:876-882. [PMID: 32721092 PMCID: PMC8274367 DOI: 10.1111/ajt.16224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/29/2020] [Accepted: 07/15/2020] [Indexed: 01/25/2023]
Abstract
By presenting the first case report of true operational tolerance in an intestinal transplant patient, we aim to demonstrate that tolerance is possible in a field that has been hampered by suboptimal outcomes. Although operational tolerance has been achieved in liver and kidney transplantation, and some intestinal transplant patients have been able to decrease immunosuppression, this is the first instance of true operational tolerance after complete cessation of immunosuppression. A patient received a deceased-donor small intestinal and colon allograft with standard immunosuppressive treatment, achieving excellent graft function after overcoming a graft-versus-host-disease episode 5 months posttransplant. Four years later, against medical advice, the patient discontinued all immunosuppression. During follow-up visits 2 and 3 years after cessation of immunosuppression, the patient exhibited normal graft function with full enteral autonomy and without histological or endoscopic signs of rejection. Mechanistic analysis demonstrated immune competence against third party antigen, with in vitro evidence of donor-specific hyporesponsiveness in the absence of donor macrochimerism. This proof of principle case can stimulate future mechanistic studies on diagnostic and therapeutic strategies, for example, cellular therapy trials, that can lead to minimization or elimination of immunosuppression and, it is hoped, help revitalize the field of intestinal transplantation.
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Affiliation(s)
- Alexander Kroemer
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Khalid Khan
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Stuart S Kaufman
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Jiman Kang
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Joshua Weiner
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Anju Duttargi
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Leonid Belyayev
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Chethan Ashokkumar
- The Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rakesh Sindhi
- The Hillman Center for Pediatric Transplantation, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Olga A Timofeeva
- Department of Pathology and Laboratory Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Michael Zasloff
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Cal S Matsumoto
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Thomas M Fishbein
- Center for Translational Transplant Medicine, MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Georgetown University Medical Center, Washington, District of Columbia, USA
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11
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Elsabbagh AM, Hawksworth J, Khan KM, Kaufman SS, Yazigi NA, Kroemer A, Smith C, Fishbein TM, Matsumoto CS. Long-term survival in visceral transplant recipients in the new era: A single-center experience. Am J Transplant 2019; 19:2077-2091. [PMID: 30672105 PMCID: PMC6591067 DOI: 10.1111/ajt.15269] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 12/31/2018] [Accepted: 01/14/2019] [Indexed: 02/06/2023]
Abstract
There is a paucity of data on long-term outcomes following visceral transplantation in the contemporary era. This is a single-center retrospective analysis of all visceral allograft recipients who underwent transplant between November 2003 and December 2013 with at least 3-year follow-up data. Clinical data from a prospectively maintained database were used to assess outcomes including patient and graft survival. Of 174 recipients, 90 were adults and 84 were pediatric patients. Types of visceral transplants were isolated intestinal transplant (56.3%), combined liver-intestinal transplant (25.3%), multivisceral transplant (16.1%), and modified multivisceral transplant (2.3%). Three-, 5-, and 10-year overall patient survival was 69.5%, 66%, and 63%, respectively, while 3-, 5-, and 10-year overall graft survival was 67%, 62%, and 61%, respectively. In multivariable analysis, significant predictors of survival included pediatric recipient (P = .001), donor/recipient weight ratio <0.9 (P = .008), no episodes of severe acute rejection (P = .021), cold ischemia time <8 hours (P = .014), and shorter hospital stay (P = .0001). In conclusion, visceral transplantation remains a good option for treatment of end-stage intestinal failure with parenteral nutritional complications. Proper graft selection, shorter cold ischemia time, and improvement of immunosuppression regimens could significantly improve the long-term survival.
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Affiliation(s)
- Ahmed M. Elsabbagh
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt,St. Vincent Abdominal Transplant Center, St. Vincent Hospital, Indianapolis, Indiana
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC,Department of Surgery, Organ Transplant Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Nada A. Yazigi
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Coleman Smith
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
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12
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Walters ET, Han KD, Howell AC, DeFazio MV, Falola R, Sher SR, Fishbein TM, Matsumoto CS, Evans KK. Management of Complex Abdominal Wall Defects in the Intestinal Transplant and Multivisceral Transplant Populations: Review of Our Multidisciplinary Experience. Am Surg 2018; 84:e494-e497. [PMID: 30747664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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13
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Walters ET, Han KD, Howell AC, Defazio MV, Falola R, Sher SR, Fishbein TM, Matsumoto CS, Evans KK. Management of Complex Abdominal Wall Defects in the Intestinal Transplant and Multivisceral Transplant Populations: Review of Our Multidisciplinary Experience. Am Surg 2018. [DOI: 10.1177/000313481808401121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elliot T. Walters
- Department of Plastic and Reconstructive Surgery Center for Wound Healing and Hyperbaric Medicine MedStar Georgetown University Hospital Washington, DC
| | - Kevin D. Han
- Department of Surgery Division of Plastic Surgery Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts
| | - Anna C. Howell
- Division of Plastic and Reconstructive Surgery University of Southern California Medical Center Los Angeles, California
| | - Michael V. Defazio
- Department of Plastic and Reconstructive Surgery Center for Wound Healing and Hyperbaric Medicine MedStar Georgetown University Hospital Washington, DC
| | - Reuben Falola
- Department of Plastic and Reconstructive Surgery Center for Wound Healing and Hyperbaric Medicine MedStar Georgetown University Hospital Washington, DC
| | - Sarah R. Sher
- Department of Plastic and Reconstructive Surgery Center for Wound Healing and Hyperbaric Medicine MedStar Georgetown University Hospital Washington, DC
| | - Thomas M. Fishbein
- MedStar Transplant Institute MedStar Georgetown University Hospital Washington, DC
| | - Cal S. Matsumoto
- MedStar Transplant Institute MedStar Georgetown University Hospital Washington, DC
| | - Karen K. Evans
- Department of Plastic and Reconstructive Surgery Center for Wound Healing and Hyperbaric Medicine MedStar Georgetown University Hospital Washington, DC
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14
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Kaufman SS, Zhong XS, Elsabbagh AM, Bailey D, Yazigi NA, Khan KM, Matsumoto CS. Fecal pancreatic elastase-1 in the evaluation of pancreatic function after pediatric intestinal transplantation. Pediatr Transplant 2018; 22:e13247. [PMID: 29927031 DOI: 10.1111/petr.13247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2018] [Indexed: 12/13/2022]
Abstract
Fat malabsorption is common after SBT. To identify whether anatomic variant transplants differ in occurrence of exocrine pancreatic insufficiency that could contribute to fat malabsorption, we measured FPE repeatedly in 54 recipients of a SBT, ages 6.2 to 320 months. FPE determination most distant from SBT was 6.1 years. Of the 54, 39% received an isolated intestinal graft (native pancreas only), 48% received an en bloc liver-intestinal-pancreas graft (native and graft pancreas), and 13% received a multivisceral graft (graft pancreas only). Initial FPE was normal (>200 μg/g) in 15 of the 54 at a median of 22 (11-61) days after SBT. Recipients of a liver-intestine-pancreas transplant were more likely to have normal FPE within 30 days after SBT than were isolated intestinal or multivisceral transplant recipients (47%, 19%, and 0%, respectively, P = .049). Of the remaining 39 patients, 34 eventually demonstrated a normal FPE at a median of 168 (31-943) days after SBT. Type of SBT did not influence the likelihood of achieving a normal FPE level or time when it occurred. Five (9%) patients failed to achieve normal FPE, including 3 who died within 2 years after SBT. In conclusion, possessing both graft and native pancreas as in transplantation of an en bloc liver-intestinal-pancreas graft facilitates early normalization of FPE that eventually occurs in most patients irrespective of transplant type. Failure to recover normal pancreatic function may be associated with severe post-transplant complications.
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Affiliation(s)
- Stuart S Kaufman
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Xiaogang Simon Zhong
- Department of Biostatistics and Bioinformatics, Georgetown University, Washington, DC, USA
| | - Ahmed M Elsabbagh
- Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Dominique Bailey
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Nada A Yazigi
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Khalid M Khan
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
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15
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Hawksworth JS, Desai CS, Khan KM, Kaufman SS, Yazigi N, Girlanda R, Kroemer A, Fishbein TM, Matsumoto CS. Visceral transplantation in patients with intestinal-failure associated liver disease: Evolving indications, graft selection, and outcomes. Am J Transplant 2018; 18:1312-1320. [PMID: 29498797 PMCID: PMC5992069 DOI: 10.1111/ajt.14715] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/11/2017] [Accepted: 02/04/2018] [Indexed: 01/25/2023]
Abstract
Intestinal failure (IF)-associated liver disease (IFALD) is widely recognized as a lethal complication of long-term parenteral nutrition. The pathophysiology of IFALD is poorly understood but appears to be multifactorial and related to the inflammatory state in the patient with IF. Visceral transplant for IFALD includes variants of intestine, liver, or combined liver-intestine allografts. Graft selection for an individual patient depends on the etiology of IF, abdominal and vascular anatomy, severity of IFALD, and potential for intestinal rehabilitation. The past decade has witnessed dramatic improvement in the management of IFALD, principally due to improved lipid emulsion formulations and the multidisciplinary care of the patient with IF. As the recognition and treatment of IFALD continue to improve, the requirement of liver-inclusive visceral grafts appears to be decreasing, representing a paradigm shift in the care of the patient with IF. This review highlights the current indications, graft selection, and outcomes of visceral transplantation for IFALD.
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Affiliation(s)
- Jason S. Hawksworth
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA,Walter Reed National Military Medical Center, Department of Surgery, Organ Transplant Service, Bethesda, MD USA
| | - Chirag S. Desai
- University of North Carolina, Department of Surgery, Division of Abdominal Transplant, Chapel Hill, NC USA
| | - Khalid M. Khan
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Stuart S. Kaufman
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Nada Yazigi
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Raffaele Girlanda
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Alexander Kroemer
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Thomas M. Fishbein
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
| | - Cal S. Matsumoto
- MedStar Georgetown University Hospital, MedStar Georgetown Transplant Institute, Washington, DC USA
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16
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Elsabbagh AM, Girlanda R, Hawksworth J, Pichert MD, Williams C, Pozzi A, Kroemer A, Nookala A, Smith C, Matsumoto CS, Fishbein TM. Impact of early reoperation on graft survival after liver transplantation: Univariate and multivariate analysis. Clin Transplant 2018; 32:e13228. [PMID: 29478256 DOI: 10.1111/ctr.13228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Data on rate, risk factors, and consequences of early reoperation after liver transplantation are still limited. STUDY DESIGN Single-center retrospective analysis of data of 428 patients, who underwent liver transplantation in period between January 2009 and December 2014. Univariate and multivariate analysis were used to study the risk factors of early reoperation and its impact on graft survival. RESULTS Of 428 patients, 74 (17.3%) underwent early reoperation. Of them, 46 (62.2%) underwent reoperation within the first week and 28 (37.8%) underwent reoperation later than 1 week after transplantation. With multivariate analysis, significant risk factors of early reoperation included pretransplant ICU admission, previous abdominal surgery and diabetes. Early reoperation itself was not found to be an independent predictor of graft loss. However, early reoperation later than 7 days from transplant was found to be independent predictor of graft loss (odds ratio [OR] = 5.125; 95% CI, 1.358-19.552; P = .016). In our series, other independent predictors of graft loss were MELD score (P = .010) and operative time (P = .048). CONCLUSIONS This analysis demonstrates that early reoperations later than a week appear to negatively impact the graft survival. The timing of early reoperation should be a focus of additional studies.
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Affiliation(s)
- Ahmed M Elsabbagh
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA.,Gastroenterology Surgical Center, Department of Surgery, Mansoura University, Mansoura, Egypt
| | - Raffaele Girlanda
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Matthew D Pichert
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Cassie Williams
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Agostino Pozzi
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Anupama Nookala
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Coleman Smith
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
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Kwon YK, Llore N, Kaufman SS, Matsumoto CS, Fishbein TM, Girlanda R. The use of vascular homografts in pediatric small bowel transplantation: Single-center experience over a decade. Pediatr Transplant 2018; 22:10.1111/petr.13137. [PMID: 29356317 PMCID: PMC6445255 DOI: 10.1111/petr.13137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2017] [Indexed: 01/08/2023]
Abstract
Intestinal transplantation in children has evolved with more isolated small intestine transplants being performed compared to combined liver-intestine transplants. Consequently, surgical techniques have changed, frequently requiring the use of vascular homografts of small caliber to revascularize the isolated small intestine, the impact of which on outcomes is unknown. Among 106 pediatric intestine and multivisceral transplants performed at our center since 2003, 33 recipients of an isolated small intestine graft were included in this study. Outcome parameters were thrombotic complications, graft, and patient survival. A total of 29 of 33 (87.9%) patients required arterial and/or venous homografts from the same donor, mainly iliac or carotid artery and iliac or innominate vein, respectively (donor's median age 1.1 years [2 months to 23 years], median weight 10 kg [14.7-48.5]). Post-transplant, there were three acute arterial homograft thromboses and one venous thrombosis resulting in two peri-operative graft salvages and two graft losses. Three of four thromboses occurred in patients with primary hypercoagulable state, including the two graft losses. Overall, at a median of 4.1 years (1-10.2) from transplant, 29 of 33 (88%) patients are alive with 26 of 33 (79%) functioning grafts. The procurement of intact, size-matched donor vessels and the management of effective post-transplant anticoagulation are critical.
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Affiliation(s)
- Yong K. Kwon
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Nathaly Llore
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Stuart S. Kaufman
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Raffaele Girlanda
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
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18
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Elsabbagh AM, Hawksworth J, Khan KM, Yazigi N, Matsumoto CS, Fishbein TM. World's smallest combined en bloc liver-pancreas transplantation. Pediatr Transplant 2018; 22:10.1111/petr.13082. [PMID: 29139617 PMCID: PMC6433131 DOI: 10.1111/petr.13082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2017] [Indexed: 11/30/2022]
Abstract
We present a case of a 2-year-old child who underwent a combined en bloc liver and pancreas transplant following complications of WRS. WRS is characterized clinically through infantile insulin-dependent diabetes mellitus, neutropenia, recurrent infections, propensity for liver failure following viral infections, bone dysplasia, and developmental delay. Usually, death occurs from fulminant liver and concomitant kidney failure. Few cases with WRS are reported in the literature, mostly from consanguineous parents. To the best of our knowledge, combined en bloc liver and pancreas transplant has not been performed in small children.
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Affiliation(s)
- Ahmed M. Elsabbagh
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Khalid M. Khan
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Nada Yazigi
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Cal S. Matsumoto
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
| | - Thomas M. Fishbein
- MedStar Georgetown Transplant Institute; Georgetown University Hospital; Washington DC USA
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19
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Elsabbagh AM, Williams C, Girlanda R, Hawksworth J, Kroemer A, Matsumoto CS, Fishbein TM. The impact of intercenter sharing on the outcomes of pediatric split liver transplantation. Clin Transplant 2017; 31. [PMID: 29032604 DOI: 10.1111/ctr.13138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Split liver transplantation allows for expansion of the pool of organs available for pediatric liver transplantation. The impact of sharing segments of the same liver between centers has not been studied. STUDY DESIGN Retrospective analysis of 24 pediatric split liver transplant cases in a recent cohort. We evaluated the outcomes of pediatric recipients who shared organs with adult patients in our own center (group A) compared to recipients who shared organs with adult patients in other centers. (group B). RESULTS One-, 3-, and 5-year graft survival for group A was 100%, 100%, and 100% vs 83%, 71%, and 57% for group B (P = .039). Postoperative complications included biliary complications (41.7% in group A vs 50% in group B, P = .682), vascular complications (8.3% in group A vs 41.7% in group B, P = .059), and postoperative bleeding (16.7% in group A vs 25% in group B, P = .615). High-grade Clavien-Dindo complications were 0% in group A vs 33.3% in group B, P = .028. CONCLUSIONS Organ sharing between centers appears to be associated with significantly poorer graft survival. Possible explanations include greater procurement-related injury or suboptimal vessel distribution. Future larger studies focused on this area may be helpful to formulate policy considerations.
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Affiliation(s)
- Ahmed M Elsabbagh
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Cassie Williams
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Raffaele Girlanda
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Alexander Kroemer
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, United States
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20
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Abstract
Intestinal transplantation is the most immunologically complex of all abdominal organ transplants. Understanding the role both humoral and innate and adaptive cellular immunity play in intestinal transplantation is critical to improving outcomes and increasing indications for patients suffering from intestinal failure. Recent findings highlighting the impact of donor-specific antibodies on intestinal allografts, the role of NOD2 as a key regulator of intestinal immunity, the protective effects of innate lymphoid cells, and the role of Th17 in acute cellular rejection are reviewed here.
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Affiliation(s)
- Alexander Kroemer
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA.
| | - Christopher Cosentino
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Jason Kaiser
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Cal S Matsumoto
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, 2PHC, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC, 20007, USA
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21
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22
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Kaufman SS, Matsumoto CS. Management of pediatric intestinal failure. Minerva Pediatr 2015; 67:321-340. [PMID: 25752806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Intestinal failure (IF) is defined as the state of the intestinal tract where the function is below the minimum required for the absorption of macronutrients, water, and electrolytes. The etiology may be a multitude of causes, but short bowel syndrome (SBS) remains the most common. The successful management and prognosis of SBS in infants and children depends a multitude of variables such as length, quality, location, and anatomy of the remaining intestine. Prognosis, likewise, depends on these factors, but also is dependent on the clinical management of these patients. Strategies for a successful outcome and the success of therapeutic interventions are dependent upon understanding each individual's remaining intestinal function. Medical intervention success is defined by a graduated advancement of enteral nutrition (EN) and a reduction of parenteral nutrition (PN). Complications of IF and PN include progressive liver disease, bacterial overgrowth, dysmotility, renal disease, catheter related bloodstream infections, and loss of venous access. Surgical interventions such as bowel lengthening procedures show promise in carefully selected patients. Intestinal transplantation is reserved for those infants and children suffering from life-threatening complications of PN.
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Affiliation(s)
- S S Kaufman
- Center for Intestinal Care and Transplant, Medstar Georgetown Transplant Institute, Washington, DC, USA -
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23
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Matsumoto CS, Kaufman SS, Island ER, Kallakury B, Yazigi NA, Khan KM, Fishbein TM. Hepatic explant pathology of pediatric intestinal transplant recipients previously treated with omega-3 fatty acid lipid emulsion. J Pediatr 2014; 165:59-64. [PMID: 24793206 DOI: 10.1016/j.jpeds.2014.03.034] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 02/14/2014] [Accepted: 03/19/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate and compare the biochemical and histologic effect of parenteral fish oil lipid emulsion that is rich in omega-3 polyunsaturated fatty acids (O3FAs), Omegaven (Fresenius Kabi AG, Bad Homburg, Germany) with standard omega-6 polyunsaturated fatty acid (O6FA) parenteral nutrition. STUDY DESIGN Comparison of hepatic explant pathology and biochemical outcome on pediatric patients with intestinal failure treated with either parental O3FA or O6FA who had received a liver-inclusive intestine transplant. RESULTS Seven liver-inclusive intestinal transplants were performed in 7 patients who received O3FA for a mean of 62% ± 13% of total patient life-span (16.1 ± 7.0 months) before transplant. Median total bilirubin fell from 6.9 mg/dL at the start of treatment to 0.7 mg/dL at the time transplant (P < .02), which was a significant decrease compared with the similarly matched O6FA cohort (P = .012). All 7 of the 03FA-treated patients received a liver-inclusive intestinal transplant had advanced fibrosis (stage 3 or 4) noted on explant pathologic examination, despite a resolution of cholestasis at the time of transplant. Histologic inflammatory scores were lower (P = .056) in the 03FA group with similar degrees of advanced fibrosis as in the O6FA group. CONCLUSIONS In a matched comparison of patients undergoing intestinal transplantation with a history of extended O3FA lipid emulsion therapy that successfully reversed hyperbilirubinemia, significant hepatic fibrosis was present in the explanted livers despite a reduction in inflammation. This result confirms concern that the use of O3FA may have a limited role in altering the development of hepatic fibrosis from parenteral nutrition.
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Affiliation(s)
- Cal S Matsumoto
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC.
| | - Stuart S Kaufman
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Eddie R Island
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Bhaskar Kallakury
- Department of Pathology, MedStar Georgetown University Hospital, Washington, DC
| | - Nada A Yazigi
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Khalid M Khan
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
| | - Thomas M Fishbein
- MedStar Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC
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24
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Primeggia J, Matsumoto CS, Fishbein TM, Karacki PS, Fredette TM, Timpone JG. Infection among adult small bowel and multivisceral transplant recipients in the 30-day postoperative period. Transpl Infect Dis 2013; 15:441-8. [PMID: 23809406 DOI: 10.1111/tid.12107] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Revised: 08/13/2012] [Accepted: 01/08/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intestinal transplantation is a potential option for patients with short gut syndrome (SGS), and infection is common in the postoperative period. The aim of our study was to identify the incidence and characteristics of bacterial and fungal infections of adult small bowel or multivisceral (SB/MV) transplantation recipients in the 30-day postoperative period. METHODS This retrospective chart review assessed the incidence and characteristics of bacterial and fungal infections in patients who underwent SB/MV transplant at our center between April 2004 and November 2008. Patient data were retrieved from computerized databases, flow-charts, and medical records. RESULTS A total of 40 adult patients with a mean age of 38.7 ± 13.4 years received transplants during this period: 27 patients received isolated SB, 12 received MV, and 1 received SB and kidney. Our immunosuppressive regimen included basiliximab for induction, and tacrolimus, sirolimus, and methylprednisolone for maintenance therapy. The most common indications for transplant were SGS, intestinal ischemia, Crohn's disease, trauma, motility disorders, and Gardner's syndrome. We report a 30-day postoperative infection rate of 57.5% and mean time to first infection of 10.78 ± 8.99 days. A total of 36 infections were documented in 23 patients. Of patients who developed infections, 56.5% developed 1 infection, 30.4% developed 2 infections, and 13% developed 3 infections. The most common site of infection was the abdomen, followed by blood, urine, lung, and wound infection. The isolates were gram-negative bacteria in 49.3%, gram-positive bacteria in 39.4%, and 11.3% were fungi. The most common organisms were Pseudomonas (19%), Enterococcus (15%), and Escherichia coli (13%). Overall, 47% of infections were due to drug-resistant pathogens; 31% of E. coli and Klebsiella species were extended-spectrum beta-lactamase-producing organisms, 36% of Pseudomonas was multidrug resistant (MDR), 75% of Enterococcus was vancomycin resistant, and 100% of Staphylococcus aureus was methicillin resistant. CONCLUSION These findings demonstrate that bacterial and fungal infections remain an important complication in SB/MV transplant recipients within the early postoperative period. Infections due to MDR organisms have emerged as an important clinical problem in this patient population.
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Affiliation(s)
- J Primeggia
- Division of Infectious Diseases, Department of Internal Medicine, Georgetown University Hospital, Washington, DC, USA
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25
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Girlanda R, Cheema AK, Kaur P, Kwon Y, Li A, Guerra J, Matsumoto CS, Zasloff M, Fishbein TM. Metabolomics of human intestinal transplant rejection. Am J Transplant 2012; 12 Suppl 4:S18-26. [PMID: 22759354 DOI: 10.1111/j.1600-6143.2012.04183.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Surveillance endoscopy with biopsy is the standard method to monitor intestinal transplant recipients but it is invasive, costly and prone to sampling error. Early noninvasive biomarkers of intestinal rejection are needed. In this pilot study we applied metabolomics to characterize the metabolomic profile of intestinal allograft rejection. Fifty-six samples of ileostomy fluid or stool from 11 rejection and 45 nonrejection episodes were analyzed by ultraperformance liquid chromatography in conjunction with Quadrupole time-of-flight mass spectrometry (UPLC-QTOFMS). The data were acquired in duplicate for each sample in positive ionization mode and preprocessed using XCMS (Scripps) followed by multivariate data analysis. We detected a total of 2541 metabolites in the positive ionization mode (mass 50-850 Daltons). A significant interclass separation was found between rejection and nonrejection. The proinflammatory mediator leukotriene E4 was the metabolite with the highest fold change in the rejection group compared to nonrejection. Water-soluble vitamins B2, B5, B6, and taurocholate were also detected with high fold change in rejection. The metabolomic profile of rejection was more heterogeneous than nonrejection. Although larger studies are needed, metabolomics appears to be a promising tool to characterize the pathophysiologic mechanisms involved in intestinal allograft rejection and potentially to identify noninvasive biomarkers.
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Affiliation(s)
- R Girlanda
- Georgetown Transplant Institute, Washington, DC, USA.
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26
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Hawksworth JS, Rosen-Bronson S, Island E, Girlanda R, Guerra JF, Valdiconza C, Kishiyama K, Christensen KD, Kozlowski S, Kaufman S, Little C, Shetty K, Laurin J, Satoskar R, Kallakury B, Fishbein TM, Matsumoto CS. Successful isolated intestinal transplantation in sensitized recipients with the use of virtual crossmatching. Am J Transplant 2012; 12 Suppl 4:S33-42. [PMID: 22947089 DOI: 10.1111/j.1600-6143.2012.04238.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We evaluated virtual crossmatching (VXM) for organ allocation and immunologic risk reduction in sensitized isolated intestinal transplantation recipients. All isolated intestine transplants performed at our institution from 2008 to 2011 were included in this study. Allograft allocation in sensitized recipients was based on the results of a VXM, in which the donor-specific antibody (DSA) was prospectively evaluated with the use of single-antigen assays. A total of 42 isolated intestine transplants (13 pediatric and 29 adult) were performed during this time period, with a median follow-up of 20 months (6-40 months). A sensitized (PRA ≥ 20%) group (n = 15) was compared to a control (PRA < 20%) group (n = 27) to evaluate the efficacy of VXM. With the use of VXM, 80% (12/15) of the sensitized patients were transplanted with a negative or weakly positive flow-cytometry crossmatch and 86.7% (13/15) with zero or only low-titer (≤ 1:16) DSA. Outcomes were comparable between sensitized and control recipients, including 1-year freedom from rejection (53.3% and 66.7% respectively, p = 0.367), 1-year patient survival (73.3% and 88.9% respectively, p = 0.197) and 1-year graft survival (66.7% and 85.2% respectively, p = 0.167). In conclusion, a VXM strategy to optimize organ allocation enables sensitized patients to successfully undergo isolated intestinal transplantation with acceptable short-term outcomes.
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Affiliation(s)
- J S Hawksworth
- Georgetown Transplant Institute, Georgetown University Hospital, Washington, DC, USA
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27
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Kaufman SS, Pehlivanova M, Fennelly EM, Rekhtman YM, Gondolesi GE, Little CA, Matsumoto CS, Fishbein TM. Predicting liver failure in parenteral nutrition-dependent short bowel syndrome of infancy. J Pediatr 2010; 156:580-5.e1. [PMID: 20097357 DOI: 10.1016/j.jpeds.2009.11.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 08/28/2009] [Accepted: 11/02/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To test the hypothesis that early trends in common blood tests may delineate risks of liver failure (LF) in infants with parenteral nutrition-associated liver disease (PNALD) from short bowel syndrome and suggest criteria for transplant referral. STUDY DESIGN Total levels of bilirubin, gamma-glutamyl transferase, albumin, alanine aminotransferase, platelet count, and absolute neutrophil count were recorded every 3 months for 61 infants with PNALD who were being considered for intestinal transplant starting at age 3 months until death without transplant (n = 12), LF with transplant (n = 35), or liver recovery without transplant (n = 14). Probabilities of LF were determined with logistic regression. RESULTS Independent predictors of LF were, in descending order, total bilirubin level (odds ratio [OR] = 1.195), platelet count (OR = 0.992), and albumin level (OR = 0.248). Predicted probabilities of eventual LF varied from 36% to 38% at ages 3 to 6 months when the total bilirubin level was 6.0 mg/dL, platelet count was 220 x 10(3)/microL, and albumin level was 3.5 g/dL to 83% to 84% when the total bilirubin level was 11.7 mg/dL, platelet count was 168 x 10(3)/microL, and albumin level was 3.0 g/dL. CONCLUSIONS Transplant referral for a total bilirubin level of 6 mg/dL between 3 to 6 months of age is appropriate, because the probability of LF is at least 36%.
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Affiliation(s)
- Stuart S Kaufman
- Department of Pediatrics, Georgetown University School of Medicine, Institute of Transplantation, Georgetown University Hospital, Washington, DC 20007, USA.
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28
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Abstract
We report the case of a successful multivisceral transplant in which both donor and recipient presented aberrant anatomy of the celiac-mesenteric axis requiring five separate arterial anastomoses to reconstruct the blood inflow to the graft.
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Affiliation(s)
- R Girlanda
- Transplant Institute, Georgetown University Hospital, Washington, DC
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29
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Abstract
A common requirement of multivisceral transplantation has been removal of the native duodenum, pancreas and spleen in the process of abdominal exenteration. Oftentimes, though, the indication for their removal has not been underlying disease states in those organs. In order to avoid adverse sequelae of pancreas and splenic removal for purely anatomic reasons, we have designed a new approach and have performed a multivisceral transplantation with splenopancreatic preservation. In this modified multivisceral technique, the native spleen and pancreas are preserved with venous outflow through a native portocaval shunt, and native pancreatic exocrine drainage is established to the donor jejunum. Risk of transplant pancreatic insufficiency, posttransplant lymphoproliferative disorder, and postsplenectomy sepsis may be avoided utilizing this technique. This new modification of multivisceral transplantation allows pancreaticosplenic preservation while facilitating stomach replacement for those patients requiring intestinal replacement therapy. It represents another step towards minimizing morbidities associated with these lifesaving transplants.
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Affiliation(s)
- Cal S Matsumoto
- Center for Intestinal Care and Transplant, Georgetown University Hospital, Washington, DC, USA
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30
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Fishbein TM, Matsumoto CS. Intestinal replacement therapy: timing and indications for referral of patients to an intestinal rehabilitation and transplant program. Gastroenterology 2006; 130:S147-51. [PMID: 16473063 DOI: 10.1053/j.gastro.2005.12.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2005] [Accepted: 09/21/2005] [Indexed: 12/02/2022]
Abstract
Current treatment options for patients suffering from intestinal insufficiency include all forms of intestinal replacement therapy (IRT). Parenteral nutrition has achieved extended success for the majority of patients requiring interval treatment, however, complications leading to failure of this treatment increases with the duration of therapy. There is currently no consensus as to the appropriate timing for transplantation of the intestine or the timing of referral for evaluation at a center experienced with this therapy. Certain patient characteristics warrant evaluation. Those patients with no jejunoileum who have guaranteed lifelong parenteral dependence, both adult and pediatric, should be immediately referred to a transplant center due to the high likelihood of the development of liver disease. Patients with metastatic infectious complications from catheter sepsis, patients with cholestasis seen intermittently with sepsis episodes, patients who are not successfully weaning and who demonstrate progressive thrombocytopenia, and patients with motility disorder experiencing deterioration should also warrant early referral to an intestinal rehabilitation and transplant program. The objective of evaluation is to maximize the opportunities for rehabilitation while not missing the critical window of opportunity for successful transplantation when needed. We favor an aggressive directed approach to rehabilitation, coupled with psychological preparation for both transplantations and other options. Early referral requires trust between the patient, referring physician, and the transplant team to assure that a rush to judgment will not lead to a premature transplant. The current wait list mortality is high, mandating early referral and listing with an approach aimed at maximizing both the success of gastrointestinal support, as well as of transplantation when necessary.
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Affiliation(s)
- Thomas M Fishbein
- Small Bowel & Pediatric Liver Transplantation, Georgetown University Hospital, Washington, DC 20007, USA.
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31
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32
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Abbott KC, Bucci JR, Matsumoto CS, Swanson SJ, Agodoa LYC, Holtzmuller KC, Cruess DF, Peters TG. Hepatitis C and renal transplantation in the era of modern immunosuppression. J Am Soc Nephrol 2004; 14:2908-18. [PMID: 14569101 DOI: 10.1097/01.asn.0000090743.43034.72] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Kidneys from donors who are positive for hepatitis C virus (DHCV+) have recently been identified as an independent risk factor for mortality after renal transplantation. However, it has not been determined whether risk persists after adjustment for baseline cardiac comorbidity or applies in the era of modern immunosuppression. Therefore, a historical cohort study was conducted of US adult cadaveric renal transplant recipients from January 1, 1996, to May 31, 2001; followed until October 31, 2001. A total of 36,956 patients had valid donor and recipient HCV serology. Cox regression analysis was used to model adjusted hazard ratios for mortality and graft loss, respectively, adjusted for other factors, including comorbid conditions from Center for Medicare and Medicaid Studies Form 2728 and previous dialysis access-related complications. It was found that DHCV+ was independently associated with an increased risk of mortality (adjusted hazard ratio, 2.12, 95% confidence interval, 1.72 to 2.87; P < 0.001), primarily as a result of infection. Mycophenolate mofetil was associated with improved survival in DHCV+ patients, primarily related to fewer infectious deaths. Adjusted analyses limited to recipients who were HCV+, HCV negative, or age 65 and over, or by use of mycophenolate mofetil confirmed that DHCV+ was independently associated with mortality in each subgroup. It is concluded that DHCV+ is independently associated with an increased risk of mortality after renal transplantation adjusted for baseline comorbid conditions in all subgroups. Recipients of DHCV+ organs should be considered at high risk for excessive immunosuppression.
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Affiliation(s)
- Kevin C Abbott
- Nephrology Service, Walter Reed Army Medical Center (WRAMC), Washington, DC 20307, USA.
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33
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Bucci JR, Matsumoto CS, Swanson SJ, Agodoa LYC, Holtzmuller KC, Peters TG, Abbott KC. Donor hepatitis C seropositivity: clinical correlates and effect on early graft and patient survival in adult cadaveric kidney transplantation. J Am Soc Nephrol 2002; 13:2974-82. [PMID: 12444217 DOI: 10.1097/01.asn.0000034944.90425.75] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The impact of hepatitis C virus-positive donor kidneys on patient survival has not been analyzed in a national study. This study analyzed 20,111 adult (age, > or =16 yr) recipients having solitary cadaveric kidney transplants from adult donors with valid donor hepatitis C serologies from July 1, 1994, to June 30, 1998, in an historical cohort study (the 2000 United States Kidney Data System) of patient survival. Analysis was by the Cox proportional hazards models, which corrected for characteristics thought to affect outcomes. Of 484 kidneys positive for hepatitis C virus serology, 165 (34%) were given to recipients with confirmed negative hepatitis C serologies. Unadjusted 3-yr patient survival was 93% in all recipients of donor hepatitis C-negative kidneys versus 85% in all recipients of donor hepatitis C-positive kidneys (P = 0.01). Among hepatitis C-positive recipients, those who received hepatitis C-positive kidneys had worse survival than recipients of hepatitis C-negative kidneys. Among elderly hepatitis C-negative recipients, those who received hepatitis C-positive kidneys also had worse survival; in fact, all recipients of donor hepatitis C-positive kidneys had increased risk of mortality (P = 0.028). There were no significant interactions between donor hepatitis C positivity and either recipient hepatitis C positivity or older recipient age. The use of hepatitis C-positive kidneys in recipients who were hepatitis C-negative was fairly common and contrary to some current recommendations. Recipients of donor hepatitis C-positive kidneys were at independently increased risk of mortality, with no evidence that any subgroups were less affected.
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Affiliation(s)
- Jay R Bucci
- Nephrology Service, Walter Reed Army Medical Center (WRAMC), Washington, DC, USA
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Abstract
We examined a patient with an iron intraocular foreign body and recorded electroretinograms (ERGs) before and after the removal of the foreign body by vitrectomy. The amplitudes of the rod and cone ERGs and the oscillatory potentials (OPs) in the injured eye were reduced before the operation. In addition, the photopic on-responses (b wave) were more reduced than off-responses (d wave). One year after surgery, the amplitudes of the rod, cone and photopic on- and off-responses were markedly improved to within the low normal limit. However, the OP amplitudes remained unchanged with lower values. These findings suggest that iron retinotoxicity leads to a dysfunction of all layers but the changes may be reversible in the early period of the disease. The late period iron toxicity produces more severe damage to the inner retina than the outer retina.
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Affiliation(s)
- M Imaizumi
- Department of Ophthalmology, Oita Medical University, Oita, Japan
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Kimoto K, Yatsuka H, Matsumoto CS, Nakatsuka K. [A case of chronic iridocyclitis in young girls--surgery for complicated cataract and effect of cyclosporin A]. Nippon Ganka Gakkai Zasshi 1999; 103:658-62. [PMID: 10513206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
PURPOSE To report a case of chronic iridocyclitis in young girls and the effect of systemic cyclosporin A for inflammation following surgery for complicated cataract. CASE A 6-year-old girl presented with white uveitis, complicated cataract, and band keratopathy in both eyes. We diagnosed her as having chronic iridocyclitis in young girls. Eight months later, the anterior chamber in the left eye became flat. Ultrasound biomicroscopy (UBM) showed the presence of cyclitic membrane and adhesion of the ciliary body to the lens capsule. Phacoemulsification with pars plana vitrectomy was used to remove the lens, anterior vitreous, and cyclitic membrane. Severe inflammation and hypotony developed after surgery and persisted after systemic and topical corticosteroids. Systemic cyclosporin A induced rapid resolution of inflammation. CONCLUSION Systemic cyclosporin A was useful for postoperative inflammation in this case of uveitis of young girls.
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Affiliation(s)
- K Kimoto
- Department of Ophthalmology, Oita Medical University, Japan
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Matsumoto CS, Tatsukawa T, Imaizumi M, Nakatsuka K. Electroretinographic changes in eyes with idiopathic macular hole treated by vitrectomy. Doc Ophthalmol 1998; 94:341-54. [PMID: 9858094 DOI: 10.1007/bf02580859] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We recorded full-field electroretinograms before and after vitrectomy in 18 eyes of 18 patients with idiopathic macular hole. The results were compared between affected and fellow eyes in the preoperative and early (within 10 days) and late (3 to 6 months) postoperative periods. No significant changes between affected and control eyes were found in the amplitude of the rod electroretinogram, mixed cone-rod electroretinogram, cone electroretinogram a- and b-waves or 30-Hz flicker electroretinogram in all stages of the study. The peak implicit times of the cone electroretinogram (a- and b-wave) and dark- and light- adapted oscillatory potential (O1-O4), however, were delayed. Also, the amplitude of the oscillatory potentials (O1+O2+O3+O4) was significantly reduced in the early postoperative period. By the late period, all of these changes had resolved. We concluded that electrophysiologic changes were derived from a transitory dysfunction of the inner retina. The possible causes of the electroretinographic changes would include mechanical trauma of the surgery, intravitreous air tamponade or the changes in vitreous electrolytes after surgery. Oscillatory potentials were more sensitive than a- and b-waves in eliciting dysfunction of the inner retina in operate on eyes.
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Affiliation(s)
- C S Matsumoto
- Department of Ophthalmology, Oita Medical University, Japan
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Abstract
We describe a patient with an eyelid tumor that responded well to radiation therapy. The histopathological diagnosis was poorly differentiated sebaceous carcinoma. The patient received 52 Gy electron beam irradiation in a 5-week period; thereafter, the tumor diminished. The histopathological findings after radiation showed that most tumor cells underwent massive necrosis with hyalinized obstructive vessels. The tumor was under control at the 9-month follow-up examination.
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Affiliation(s)
- C S Matsumoto
- Department of Ophthalmology, Oita Medical University, Japan
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