Concerns on Clinical Application of Composite Tissue Allotransplantation

Composite tissue allograft has become a clinical reality: hands, vascularized femoral diaphyses, abdominal walls, a larynx have all been transplanted throughout the world. Conventional immunosuppressive protocol has shown to be sufficient and effective. Rejection has been prevented in most cases and when it did occur it was successfully reversed. Skin has been confirmed as the principal target of acute and chronic rejection. There has been no mortality or early graft losses and, particularly in hand transplantation, the survival graft rate is 91% with a follow-up period ranging from 6 months to 61 months. The side effects of immunosuppression are limited and include primarily transient hyperglycemia, an increase in creatinine values and some opportunistic infections (i.e. cytomegalovirus infection). Nerve regeneration and cortical reorganization have been demonstrated in hand transplantation. Functional results have been encouraging particularly for hand and larynx transplantation. Appropriate indications and patient selection, based particularly on patient motivation and compliance, are essential requirements for composite tissue allograft success.

Long-term follow-up in composite tissue allotransplantation: in-depth study of five (hand and face) recipients

Composite tissue allotransplantations (CTAs) have clinically shown little, if any, evidence of chronic rejection. Consequently, the effect of chronic rejection on bones, joints, nerves, muscles, tendons and vessels may still have undescribed implications. We thoroughly assessed all allograft structures by histology, magnetic resonance imaging, ultrasonography and high resolution peripheral quantitative computed tomography scan in four bilateral hand-grafted patients (10, 7, 3 and 2 years of follow-up, respectively) and in one facial allotransplantation (5 years of follow-up). All the recipients presented normal skin structure without dermal fibrosis. Vessels were patent, without thrombosis, stenosis or intimal hyperplasia. Tendons and nerves were also normal; muscles showed some changes, such as a variable degree of muscular hypotrophy, particularly of intrinsic muscles, accompanied by fatty degeneration that might be related to denervation. In the majority of hand-grafted patients graft radius and recipient tibia showed a decrease in trabecular density, although in the graft radius the alterations also involved the cortices. No deterioration of graft function was noted. In these cases of CTA no signs of chronic graft rejection have been detected. However, the possibility that chronic rejection may develop in CTA exists, highlighting the necessity of close continuous follow-up of the patients.

Médiatisation et «greffe de visage» ou «à qui appartient la greffe de visage»?

Mediatisation of a scientific event could be neither controlled, nor verifiable. The experience which has been lived through the first worldwide allotransplantation of composite tissues of the face confirms that the actors of a surgical innovation are not the owners. Because there is neither confidentiality nor possible patent. Curiously the scientific world, providing with a sharing ethic, which rightly privileges the free spreading of knowledge in the way that most people could benefit of it. Obviously it is made without denied controversy, for truth as purpose. This scientific word that way joins the media one, with a specific ethic of the duty of information, but also interested in mercantile preoccupations quick to cultivate controversy not to enlighten this truth but to better sell pictures or papers. Than the author should only sustain this instrumentation which could certainly flatter him, and from which he could used, but in reality that paralysed him a little to go on in serenity with his shadow worker way.

Bilateral hand transplantation: six years after the first case

In this study we present our experience concerning bilateral hand transplantation. Two cases were performed: the first in January 2000 and the second in April 2003. Both recipients received the same immunosuppressive treatment, which was similar to those used in solid organ transplantation, including tacrolimus, prednisone and mycophenolate mofetil while antithymocyte globulins were added for induction. Both recipients presented two episodes of acute rejection (maculopapular lesions) in the first 3 months after transplantation; however, these were easily reversed after a few days increasing oral steroid doses and using topical immunosuppressants. The first recipient presented hyperglycemia and serum sickness while the second recipient suffered a thrombosis of the right ulnar artery and an osteomyelitis of left ulna. All the complications were successfully treated. Functional Magnetic Resonance Imaging (fMRI) showed that cortical hand representation progressively shifted from the lateral to the medial region in the motor cortex. After 6 and 2 years respectively, they showed a relevant sensorimotor recovery particularly of sensibility and activity of intrinsic muscles. They were able to perform the majority of daily activities and to lead a normal social life. The first recipient has been working since 2003. They are both satisfied with their grafted hands.

Human hand transplantation: what have we learned?

Hand transplantation may become an important procedure for upper limb functional restoration. To date, 18 patients have been undergone 24 hand operations in the world. Initial results are extremely promising; the functional results are apparently superior to those obtained with prostheses. We report on the combined French and Italian experience of six patients (eight hands), which is based on a jointly devised protocol and represents the largest available clinical series. Six male patients aged 43, 33, 35, 32, 33, and 22 years received either a single right hand-dominant transplantation (four cases) or a simultaneous double hand transplantation (two cases). The time since the amputation ranged from 3 to 22 years. The level of transplantation was at the wrist in five cases (six hands) and at the distal forearm in two cases (two hands). Cold ischemia averaged 11.5 hours. Three patients simultaneously received additional full-thickness skin taken from the donor and transplanted onto their left hip area. This skin served as a source for biopsies and as an additional area to monitor rejection (distant sentinel skin graft). The immunosuppressive protocol included polyclonal antibodies (three patients) or monoclonal anti-CD 25 antibody (three patients), tacrolimus, mycophenolate mofetil, and prednisolone. No surgical complications occurred. Skin rejection occurred at least once in all patients at a mean of 40 days postoperatively. Three patients recovered protective and some discriminative sensation in their palm and fingers. Two patients are recovering sensation, but are still in the early phases of the regenerative process, due to the short time since the transplantation. One patient was not compliant with the immunosuppressive therapy, and underwent uncontrolled rejection and reamputation.

[Cystic lymphangioma in the adrenal gland: a case report]

Cystic lymphangioma of the adrenal gland are rarely encountered tumoural formations with no clinical expression. Pre-operative diagnosis is difficult. Echography and CT scan are essential exploratory techniques, diagnosis is histological. Usually surgical exploration is indicated due to uncertain diagnosis. We report a new case of cystic lymphangioma of the adrenal gland and a review of recent literature.

Detection of bladder dysplasia using 5-aminolaevulinic acid-induced porphyrin fluorescence

OBJECTIVE

To report results of a clinical investigation on the detection of bladder dysplasia and in situ carcinoma by using fluorescence induced by 5-aminolaevulinic acid (ALA).

PATIENTS AND METHODS

The study included 50 patients with a primary bladder lesion, who had a bladder instillation of 50 mL of 3% ALA solution >or= 1 h before transurethral resection of the tumour. Random biopsies were taken using white-light cystoscopy, then using blue light to induce fluorescence; positive zones were noted and biopsied. The primary lesion was then resected. The frequency of dysplasia detected by ALA-induced fluorescence was evaluated, as was the risk of recurrence with a follow-up of >or= 2 years.

RESULTS

In all patients the tumours were positive; in 21 fluorescence distant from the tumour was detected. The pathological report of the biopsies showed 11 cases of dysplasia, six of carcinoma in situ and four of inflammatory lesions. In 29 patients there was no fluorescence and quadrant biopsies were normal in all but three with moderate dysplasia. Within the minimum follow-up patients with bladder dysplasia detected by ALA-induced fluorescence had a higher risk of recurrence.

CONCLUSION

ALA-induced fluorescence of the bladder significantly enhanced the detection of dysplasia and in situ carcinoma. However, this technique requires further investigation using well-characterized instrumentation and study protocols to determine any effect on treatment choice.

[First transplantation of two hands: results after 18 months]

AIM OF THE STUDY

The previous results achieved in single hand transplantations confirmed the feasibility of this procedure and encouraged us to perform the first human double hand transplantation, which was performed in January 2000. In the present study we reported the results obtained eighteen months after transplantation.

PATIENT AND METHODS

The recipient was a 33-year old man suffering from a traumatic amputation of both hands in 1996. Surgery included procurement of the upper extremities from a 18-year old multiorgan cadaveric donor, preparation of the graft and recipient's stumps, transplantation of the hands, which included bone fixation, arterial and venous anastomoses, nerve suture, joining of tendons and muscles, and skin closure. Immunosuppressive protocol included tacrolimus, prednisone and mycophenolate mofetil. An intensive rehabilitation program was performed. Follow-up included immunological tests, skin biopsies, arteriography, bone scintigraphy, electromyography and brain functional magnetic resonance imaging.

RESULTS

No surgical complications, infectious complications and graft-versus-host-disease occurred. Two episodes of acute skin rejection were demonstrated and they were completely reversed increasing steroid dose. Nerve regeneration and cortical reorganization were shown. Sensorimotor recovery was encouraging and life quality improved.

CONCLUSION

This double hand transplantation showed that conventional immunosuppressive protocol is effective and safe as well as that functional results are at least as good as those achieved in replanted upper extremities.

[Treatment of uretero-intestinal and uretero-vesical stenoses with the Acucise balloon catheter]

OBJECTIVE

Acucise balloon catheter has been proposed as an alternative to open surgery for the treatment of strictures of the ureteropelvic junction because of its low morbidity and the short hospital stay following the endoscopic procedure. The objective of this study was to evaluate the results of this technique applied to patients developing strictures after surgical reimplantation of the ureterovesical (UV) or uretero-intestinal (UI) junction.

MATERIAL AND METHODS

Between March 1997 and January 2000, 12 strictures (11 patients) were treated by Acucise balloon catheter via an antegrade and/or retrograde approach with double J stenting for an average of 6 weeks (range: 4 to 12 weeks): 6 uretero-ileal strictures (3 Bricker, 1 uretero-ileoplasty, 1 enterocystoplasty and 1 Kock pouch) and 6 ureterovesical strictures (Lich-Grégoir or Faquin UV reimplantations after gynaecological, vascular or endoscopic surgery). The median postoperative follow-up was 16 months (range: 10 months-36 months). A good result was defined by the absence of recurrence of the stricture evaluated both clinically and radiologically (regression of stasis measured by IVU and/or ultrasonography).

RESULTS

The mean operating time was 70 min and the mean hospital stay was 4.8 days (range: 3 and 14 days). Only one intraoperative complication was observed (migration of the double J stent to the kidney). The operation was successful in 8 patients (75%). The success rate was 83% for ureterovesical strictures and 50% for uretero-ileal strictures. A history of previous irradiation appeared to be a factor of failure.

CONCLUSION

The Acucise procedure is a minimally invasive and effective (75% success rate) treatment option for the treatment of postoperative stricture after ureteric reimplantations. In our department, this option is considered to be first-line treatment, as surgical reimplantation is reserved for failures of the endoscopic technique.

[Recanalization of pelvic ureter in prostatic neoplastic obstruction: endoscopic and radiologic approach]

Obstruction of the lower ureter by pelvic cancer requires a palliative treatment. Percutaneous derivation is often performed as an emergency. If obstruction is limited to the peri-meatic area (a few mm or a cm) resection of the ureteral orifice can be enough to catheterize the obstructed ureter. Stenting of the ureter can be done even if the obstruction is longer, using the extra vesical repermeabilization.

METHODS

A guide wire is passed via the nephrostomy, and ureteral stent is passed over the guide wire. Dye additionned with methylene blue is injected tovisualize the lower extremity of the ureter. A regular resectoscope is placed transuretraly, and resection is conducted using X ray localisation with a C arm and several incidences. The tissue resected first is usually extravesical, in the adipous perivesical tissue. Dissection of this area can be performed bluntly with the tip of the resectoscope until the ureter is reached. At this time, the resectoscope is used to open the lower extremity of the ureter, localized with the C arm. It is important to open widely the ureter, so as to be sure to catheterize easily this opening with a ureteral catheter. A double J can then be passed easily. Tunnel of several cm can be performed using this technique.

RESULTS

Seven patients with pelvic cancer with obstruction of the last cm of the pelvic ureter were included in this series. They were recurrent prostate cancer already treated with hormone therapy, stage T3, T4. All procedures were performed under rachianesthesia or general anesthesia according to general status. After this procedure normal miction were obtain in all patients and nephrostomies were removed. This technique is possible for extended pelvic obstruction. Blunt dissection with the endoscope is usualy blood less. This palliative procedure can be done in patients with poor general condition and allows for a better quality of life than nephrostomy or urinary diversions.

[Bilateral adrenal pheochromocytomas in von Hippel-Lindau disease]

The pheochromocytoma is a medullo-adrenal tumor which develops at the cost of the chromaffin cells. It appears in 11-19% of cases of von Hippel-Lindau's disease (VHL), is often bilateral, and the symptomatology is often crude: arterial hypertension is frequently isolated and unstable, and the classic triad of headache, palpitations and sweating is quite rarely observed. We report four observations of bilateral pheochromocytomas in patients with von Hippel-Lindau's disease (three with phenotype IIA and one with phenotype IIB). The tumor was bilateral during the diagnosis in three cases; in the fourth patient, the attack on the contralateral adrenal gland came two years after the first adrenalectomy. All the patients had undergone an adrenalectomy by open surgery after a short preparation of 48 hours; replacement therapy was begun in each patient. Morbidity was low, and the patients submitted to a prolonged follow-up in order to screen for the onset of future lesions of VHL.

MRI appearance of prostate following transrectal HIFU ablation of localized cancer

OBJECTIVES

To evaluate the accuracy of gadolinium-enhanced MRI in gauging the extent of the tissue damage induced by transrectal high intensity focused ultrasound (HIFU) therapy and to assess how well the results obtained with this modality correlate with histological findings (control biopsies).

METHODS

Twenty-one patients with biopsy-proven prostate cancer (T1-T2-T3a, Nx, M0) who gave informed consent were included in the protocol. They underwent pre- and postoperative (2-5 days after HIFU treatment) MR examinations. Fifteen patients also underwent a follow-up MR examination 1-5 months postoperatively. MR findings were compared with the results of postoperative transrectal biopsy examinations.

RESULTS

The prostate volume increased after the HIFU session from 43.9+/-18.6 to 52.1+/-21 cm(3) by day 2 (p<0.001). On fat-saturated gadolinium-enhanced T1-weighted images, the treated area appeared as a hypointense zone surrounded by a peripheral rim of enhancement in all patients. A positive correlation (r = 0.75) was found between the volume of the hypointense zone measured at days 2-5 (30+/-11 cm(3), 67% of the posttreatment prostate volume) and the theoretical target volume (22+/-5 cm(3), 61% of the initial prostate volume). MRI showed that the anterior part of the base was not reached by the ultrasound beam. The mean volume of the untreated zone (prostate without any MRI modifications) was 8 cm(3) (range, 0.4-36). No correlation was found between the MRI appearance of the treated area and the intensity of the necrosis or the presence of foci of residual, viable cancer.

CONCLUSION

Gadolinium-enhanced MRI is an accurate way of determining the extent of tissue damage induced in HIFU ablative therapy, but cannot predict histological results.

Transrectal high intensity focused ultrasound for the treatment of localized prostate cancer: factors influencing the outcome

OBJECTIVES

Efficacy evaluation of high intensity focused ultrasound (HIFU) treatment for localized prostate cancer and identification of the factors affecting the outcome.

PATIENTS AND METHODS

102 patients with prostate cancer stage T1-T2 and noncandidates for radical prostatectomy have been treated with HIFU (Ablatherm, EDAP-Technomed). The disease progression (failure) was strictly defined by any positive sample at control biopsies, whatever the prostate-specific antigen (PSA) level, or by 3 consecutive increases in PSA levels in case of negative biopsies.

RESULTS

At inclusion, patients' baseline characteristics were (mean +/- standard deviation): age 70.8 (+/-6.13) years, PSA 8.38 (+/-4.8) ng/ml, prostate volume 33.3 (+/-16.71) cm3. The population mean follow-up was 19 months (3-76 months). The overall success rate was 66%. Statistically significant variations of the overall success with a more favorable outcome were observed when (1) the initial PSA level was < or =10 ng/ml (73 vs. 50%, p = 0.02), (2) the Gleason score was < or =6 (81 vs. 46%, p<0.001) and (3) the pretreatment sextant biopsy evidenced 1-4 positive samples (68 vs. 40%, p = 0.01).

CONCLUSION

Results observed after HIFU treatment in localized prostate cancer are now challenging those obtained after radiation therapy. The success rate is influenced by disease-related prognostic factors.

Hand transplantation: comparisons and observations of the first four clinical cases

Twenty, 15, and 8 months after the first four successful human hand transplant procedures were performed in Lyon (France), Louisville (U. S.), and Guangzhou (China), the transplant teams convened in Louisville, Kentucky, to share their experiences at the Second International Symposium on Composite Tissue Allotransplantation. This article presents reconstructive and immunological data from these landmark procedures in tabular format, in an attempt to answer some key questions about early outcomes of clinical hand transplantation. On the basis of these data, the initial outcomes of the first four hand transplants are encouraging and warrant proceeding with additional hand transplantations.

Regeneration of cutaneous innervation in a human hand allograft

On Sept 23, 1998, a human hand allograft was done in our hospital. We followed up the patients for 24 months to assess the skin structure by immunohistology. Most cutaneous structures (including dermal nerves with their Schwann cells and perineurial fibroblasts) were present immediately after surgery and remained detectable throughout the study; from day 464 onwards, axons became detectable within dermal nerves, and their density increased progressively with time. Merkel cells reappeared in the epidermis 12 months after the operation. The regeneration of cutaneous innervation paralleled the recovery of cutaneous sensitivity.

Antibody-induced modulation of the leukocyte CD11b integrin prevents mild but not major renal ischaemic injury

BACKGROUND

CD11/CD18 beta(2) integrins are involved in leukocyte adhesion to the activated endothelium, and therefore represent a possible therapeutic target in the prevention of ischaemic acute renal failure (ARF).

METHODS

To assess the effect of an anti-CD11b monoclonal antibody (mAb) in ischaemic ARF, uninephrectomized Fischer rats were subjected to 45 or 60 min of warm renal ischaemia, then received 1 mg of anti-CD11b mAb 5 min before reperfusion.

RESULTS

After 45 min of ischaemia, renal function tests at 24 and 48 h were less altered in mAb-treated than in control rats, but after 60 min of ischaemia the same level of renal insufficiency was observed in the two groups. In parallel, milder tubular necrosis and less leukocyte infiltration were observed in the treated group after 45 min of ischaemia, but no difference was seen after 60 min compared to the control group. The mAb was detected on blood neutrophils up to 48 h after infusion and a marked down-regulation of CD11b expression on neutrophil surfaces was documented by flow cytometry.

CONCLUSION

These results indicate that anti-CD11b mAb administered prior to reperfusion decreases moderate ischaemic ARF but fails to prevent renal injury secondary to prolonged ischaemia in this model.

Transrectal high-intensity focused ultrasound: minimally invasive therapy of localized prostate cancer

BACKGROUND AND PURPOSE

Criteria for determining the durability of the response to transrectal high-intensity focused ultrasound (HIFU) ablation of prostate cancer have been established by calculating progression-free probability.

PATIENTS AND METHODS

A series of 82 patients (mean age 71 +/- 5.7 years) with biopsy-proven localized (stage T1-T2) cancer who were not suitable candidates for radical surgery underwent transfectal HIFU ablation with the Ablatherm machine. The mean follow-up was 17.6 months (range 3-68 months). The mean serum prostate specific antigen (PSA) value and mean prostate volume were 8.11 +/- 4.64 ng/mL and 34.9 +/- 17.4 cm3, respectively. Progression was rigidly defined as any positive biopsy result, regardless of PSA concentration, or three successive PSA increases for patients with a negative biopsy (PSA velocity > or = 0.75). Times to specific events (positive biopsy and PSA elevation) were analyzed with the Kaplan-Meier survival method.

RESULTS

Overall, 62% of the patients exhibited no evidence of disease progression 60 months after transrectal HIFU ablation. In particular, the disease-free rate was 68% for the moderate-risk group of 50 patients (PSA < 15.0 ng/mL, Gleason sum < 8, prostate volume < 40 cm3, and number of positive biopsies < 5). For the low-risk group of 32 patients (PSA < 10 ng/mL and Gleason sum < 7), the disease-free survival rate was 83%.

CONCLUSION

Transrectal HIFU prostate ablation is an effective therapeutic alternative for patients with localized prostatic adenocarcinoma.

Simultaneous pancreas-kidney transplantation: portal versus systemic venous drainage of the pancreas allografts

Simultaneous pancreas-kidney (SPK) transplantation is considered a valid therapeutic option for patient with type I diabetes mellitus and end-stage diabetic nephropathy. This study was performed to determine whether the technique of pancreas venous drainage affects patient survival as well as graft survival and function. From October 1996 to April 1999 34 uremic patients with type I diabetes mellitus were randomly assigned to two groups: the first group (SV group = 17) received SPK transplantation with systemic venous drainage, and the second group (PV group = 17) received pancreas allograft with portal drainage. A Roux-en-Y loop was performed in all the patients. Patient follow-up included clinical course and metabolic studies. At 1 yr, patient survival rates were 88.2% in the SV group and 94.1% in the PV group while graft survival rate was 76.4% in both groups. Several surgical complications were attributed to the enteric drainage without any graft failure in both groups. One venous thrombosis occurred in each group. No significant differences have been evidenced in kidney and pancreas function. The preliminary results of this randomized trial did not evidence any significant differences between portal and systemic venous drainage of pancreas allograft.

Rat multiple organ blocks: microsurgical technique of removal for ex vivo aerobic organ preservation using a fluorocarbon emulsion

A multiple organ block (MOB) is composed of en bloc removed organs (heart, lungs, liver, pancreas, kidneys, and bowel), connected by the vascular system, of which blood circulation is maintained by the heart and oxygenation by the lungs under artificial ventilation. The aim of this study is the description of a surgical technique of MOB removal in the rat. Ninety-five MOBs were removed from Wistar rats. The rats were anesthetized, a tracheotomy was performed, and the cannula was connected to a pressure-regulated respirator. A colectomy was performed. Ureters, vena cava inferior, aorta, and bile duct were cannulated using an operative microscope. The vessels that joined the MOB to the carcass were tied or coagulated to make removal of the MOBs possible. Once removed, the MOBs were placed in a vaseline oil bath at 37 degrees C and the aorta and vena cava were connected to an accessory vascular circuit to stabilize arterious pressure. Success rate (ex vivo survival of more than 10 min) after the 30th attempt was 90% and after the 60th attempt was 95% (global success rate 82%). Ex vivo survival of MOBs at 37 degrees C ranged from 1 to 450 min. Rat MOBs allows us to study the normothermic preservation of all the organs susceptible of being transplanted in one single series of experiments. We showed that removal of rat MOBs is feasible. This microsurgical technique is codified. Rat MOBs are suitable if perfusion liquids are difficult to obtain or if a great number of experiments are required. As MOBs are composed of synergically functioning organs in the absence of striated muscle, bone, and nervous system, they also could be useful for physiologic and pharmacologic studies.

Towards a specific immunosuppression for pancreas and islet grafts

This brief article is a summary of the presentations at a meeting organized in Lyon, France, to discuss strategies of reducing post-transplant diabetes mellitus and to suggest an ideal immunosuppressive therapy for pancreatic and islet allografts.

Effects of portal versus systemic venous drainage in kidney-pancreas recipients

A randomized study of combined kidney-pancreas transplantation was performed on 30 insulin-dependent diabetic patients with end-stage renal disease to compare the consequences of pancreas transplantation with portal venous (PV) and systemic venous (SV) drainage. Fourteen patients (SV) group) received systemically drained and sixteen (PV group) portally drained pancreas allografts. Enteric drainage was performed in both groups. The routine follow-up included documentation of the clinical course and detailed endocrine studies. At 1 year after transplantation, the patient survival rate was 92% for the SV group and 96% for the PV group; the graft survival rate was 78% and 82%, respectively. Endocrine studies indicated no difference in fasting and stimulated glucose or in glycosylated hemoglobin between the two groups. In addition, no hyperinsulinemia and lipidic abnormalities were evidenced in either group Long-term studies are required to conclude whether PV and SV drainage in pancreas transplantation are equivalent in terms of patient and graft survival as well as metabolic consequences.

Effects of portal versus systemic venous drainage in kidney-pancreas recipients

A randomized study of combined kidney-pancreas transplantation was performed on 30 insulin-dependent diabetic patients with end-stage renal disease to compare the consequences of pancreas transplantation with portal venous (PV) and systemic venous (SV) drainage. Fourteen patients (SV) group) received systemically drained and sixteen (PV group) portally drained pancreas allografts. Enteric drainage was performed in both groups. The routine follow-up included documentation of the clinical course and detailed endocrine studies. At 1 year after transplantation, the patient survival rate was 92% for the SV group and 96% for the PV group; the graft survival rate was 78% and 82%, respectively. Endocrine studies indicated no difference in fasting and stimulated glucose or in glycosylated hemoglobin between the two groups. In addition, no hyperinsulinemia and lipidic abnormalities were evidenced in either group Long-term studies are required to conclude whether PV and SV drainage in pancreas transplantation are equivalent in terms of patient and graft survival as well as metabolic consequences.

Evidence of recurrent type I diabetes following HLA-mismatched pancreas transplantation

Type 1 diabetes mellitus is considered as an autoimmune disease against beta cells. Diabetes recurrence after pancreas transplantation is well known in HLA-identical twins while it is rarely reported in recipients of cadaveric pancreatic grafts. In the present case report, diabetes recurrence occurred in a recipient who underwent cadaveric combined pancreas kidney transplantation. Seven years after transplantation the patient exhibited progressive hyperglycemia needing insulin therapy while the renal graft was well functioning. The diagnosis of recurrent disease was obtained on the histological features such as selective loss of beta cells without clear signs of insulitis and on the presence of markers (GAD 65 and IA-2) for humoral autoimmunity. It is intriguing that, at the time of recurrence of type 1 diabetes, the patient had stopped steroids and azathioprine, while only cyclosporine was maintained as immunosuppressive treatment. Our case report underlines the relevance of studying the humoral autoimmune response directed to islet autoantigens in cadaveric pancreas allograft recipients. Furthermore, it suggests that an efficient immunosuppressive treatment after transplantation may be able to reduce the autoimmune response against the pancreatic allograft.

Sequential histological and immunohistochemical study of the skin of the first human hand allograft

BACKGROUND

On September 1998, the first human hand allograft was successfully performed in Lyon.

METHODS

A 48-year-old white man who had suffered accidental amputation of the arm in 1984, received a forearm and hand allograft from a 42-year-old white male cadaveric heart-beating donor. Immunosuppressive therapy included prednisone, mycophenolate mofetil, FK506, and antithymocyte globulins. Sequential skin biopsies were taken from the grafted limb and examined (immuno)histologically to detect a possible graft rejection and to evaluate the structural integrity of the skin of the allograft.

RESULTS

The skin showed histologically a normal appearance, except on days 57 and 63, when a mononuclear perivascular cell infiltrate was observed in the dermis; this appeared concomitantly with erythematous lesions of the skin that developed after a slight decrease of the immunosuppressive treatment. These changes were considered as signs of graft rejection, and were reversed by an increase of the immunosuppressive treatment. No skin necrosis was seen at any time. Immunohistochemically, the main cell types of the skin were present throughout the study. From day 77 onward the epidermis of the grafted hand harbored some epidermal Langerhans cells of recipient's origin.

CONCLUSION

This study shows that the skin of the hand allograft maintains overall a normal histological structure and contains most essential cell types, including cells of recipient origin, such as Langerhans cells. Furthermore, it shows that in this system of composite tissue transplantation, skin biopsies may reveal a starting graft rejection, before the appearance of clinically obvious lesions.

Serological markers of recurrent beta cell destruction in diabetic patients undergoing pancreatic transplantation

BACKGROUND

Besides alloimmunity to transplanted pancreatic tissue, recurrent autoimmune beta cell destruction is an additional limitation to successful clinical pancreatic allografts in type 1 diabetic patients.

METHODS

We studied the prevalence of autoantibodies to glutamate decarboxylase (GAD) 65 and tyrosine phosphatase (IA-2) in 68 C-peptide-negative diabetic patients receiving pancreatic allografts. Sera from patients were obtained immediately before grafting. A second blood sample was analyzed at the time of graft failure in patients who returned to hyperglycemia and during the same follow-up period in those who experienced a functional pancreatic allograft. Patients were classified according to clinical outcome into chronic graft failure (group A, n=20), acute graft failure and/or arterial thrombosis (n=7), or functional pancreatic graft (group C, n=41). Sera from patients were screened for the presence of specific autoantibodies using an islet cell autoantibody assay, a combi-GAD and IA-2 test, and individual GAD and IA-2 assays.

RESULTS

Patients from group A had significantly higher combi-test values than patients from group C (13+/-16 vs. 4.5+/-12 units, P<0.02) and higher anti-GAD65 antibody (Ab) levels (0.19+/-0.3 vs. 0.04+/-0.13 units, P<0.01) immediately before grafting. After graft failure in group A, both anti-GAD65 and anti-IA-2 Ab levels increased from baseline, but only the increase in anti-IA-2 Ab levels reached statistical significance (0.28+/-0.12 vs. 15+/-34, P=0.03). When compared with group C, patients from group A had higher anti-GAD65 Abs (0.29+/-0.35 vs. 0.05+/-0.16, P<0.001) after graft failure. Interestingly, the number of double-Ab-positive patients rose from 5% to 35% in group A, whereas it remained at 5% in group C. In pancreatic transplants with bladder drainage, the presence of anti-GAD65 and/or anti-IA2 Abs was not associated with a reduction in urinary amylase levels. This suggests that a loss of endocrine function was not associated with exocrine failure in patients from group A.

CONCLUSIONS

We can conclude from the present study that peripheral autoimmune markers are useful in diabetic patients receiving pancreatic allografts.

In vivo effects of monoclonal antibodies against rat beta(2) integrins on kidney ischemia-reperfusion injury

BACKGROUND

Ischemia-reperfusion (IR) involves adhesion of leukocytes to the activated endothelium, leading to tissue damage. CD11/CD18 beta(2) integrins interact with their ligands on endothelial cells and may therefore represent a therapeutic target for the prevention of IR. We investigated the effects of three monoclonal antibodies (mAbs) that recognize epitopes of heavy or light chain of the beta(2) integrins on IR in kidneys.

METHODS

Uninephrectomized Fischer rats were subjected to 45 or 60 min of renal ischemia, treated with intravenously anti-beta(2) integrin monoclonal antibodies (anti-CD11a, anti-CD11b, and anti-CD18) 5 min prior to reperfusion, and compared to a nontreated group. Serum creatinine, blood urea nitrogen (BUN), and kidney histopathological damages were assessed at 1, 2, and 7 days after ischemia.

RESULTS

After 45 and 60 min of ischemia, serum creatinine and BUN were significantly higher in the control than in animals treated with anti-CD11a and anti-CD18 at 24 and 48 h. Administration of anti-CD11b had a beneficial effect on renal function after 45 min but not after 60 min of ischemia. Histologic and immunostaining studies demonstrated mild tubular necrosis and less leukocyte infiltration in the anti-CD11a- and anti-CD18-treated groups compared to the control group.

CONCLUSION

These results indicate that selected antibodies to CD11a/CD18 may decrease kidney IR injury when administered prior to reperfusion.

[The first transplantation of a hand in humans. Early results]

The first hand allograft was performed on September 23, 1998. The right distal forearm and hand of a brain dead donor was transplanted to a 48 year old recipient who had undergone a traumatic amputation of the distal third of his right forearm. The donor's arm was irrigated with organ preservation solution (UW) and transported to Lyon in a cool container. Two teams simultaneously dissected the donor's limb and the recipient's stump to identify anatomical structures. Transplantation involved bone fixation, arterial and venous anastomoses, nerve sutures, joining of the muscles and tendons, and skin closure. Immunosuppression consisted of anti-lymphocyte, polyclonal and monoclonal antibodies, tacrolimus, mycophenolic acid, and prednisone. Mild clinical and histological signs of rejection occurred at week 9 after surgery. They disappeared with adjustments of the immunosuppressant doses. Seven months after surgery the patient was in good general condition. Intensive physiotherapy led to satisfactory progress of motor function. Sensory progress is excellent, reaching the fingertips. A longer follow-up is necessary to appreciate the final result. In the absence of further rejection, the functional prognosis of the graft should be similar to that reported after successful autoreconstruction.