Long-term follow-up of a randomized trial of biliary drainage in perihilar cholangiocarcinoma

BACKGROUND AND AIMS

The DRAINAGE trial was a randomized controlled trial comparing preoperative endoscopic (EBD) and percutaneous biliary drainage (PTBD) in patients with potentially resectable, perihilar cholangiocarcinoma (pCCA). The aim of this study was to compare the long-term outcomes.

METHODS

Patients were randomized in four tertiary referral centers. Follow-up data were available for all included patients. Primary outcome was overall survival (OS). Secondary outcomes were readmissions, and re-interventions not including in-trial interventions.

RESULTS

A total of 54 patients were randomized; 27 in both groups. Median follow-up for both groups was 62 months (95% CI 54-70). The median OS was 13 months (95% CI 7.9-18.1) in the EBD and 7 months (95% CI 0.0-17.2) in the PTBD group (P = 0.28). Twenty (37%, n = 8 EBD vs n = 12 PTBD, P = 0.43) of 54 patients were readmitted at least once, mostly due to drainage-related complications (n = 13, 24%). Of note, 14 out of the 54 patients died within the trial. A total of 76 drainage procedures (32 EBD and 44 PTBD) were performed in 28 patients. The median number of stent or drain placements was 2 (2-4) for the EBD group and 2 (1-3) for the PTBD group (P = 0.77).

DISCUSSION

Although this follow-up study represented a small cohort, no long-term differences in survival, readmissions, and drainage procedures for EBD and PTBD were found, even when comparing the resected and unresected group. However, this study demonstrates the complexity of biliary drainage for patients with potentially resectable pCCA, even in tertiary referral centers.

An Engineered IL15 Cytokine Mutein Fused to an Anti-PD-1 Improves Intratumoral T-Cell Function and Antitumor Immunity

The use of cytokines for immunotherapy shows clinical efficacy but is frequently accompanied by severe adverse events caused by excessive and systemic immune activation. Here, we set out to address these challenges by engineering a fusion protein of a single, potency-reduced, IL15 mutein and a PD-1-specific antibody (anti-PD1-IL15m). This immunocytokine was designed to deliver PD-1-mediated, avidity-driven IL2/15 receptor stimulation to PD-1+ tumor-infiltrating lymphocytes (TILs) while minimally affecting circulating peripheral natural killer (NK) cells and T cells. Treatment of tumor-bearing mice with a mouse cross-reactive fusion, anti-mPD1-IL15m demonstrated potent antitumor efficacy without exacerbating body weight loss in B16 and MC38 syngeneic tumor models. Moreover, anti-mPD1-IL15m was more efficacious than an IL15 superagonist, an anti-mPD-1, or the combination thereof in the B16 melanoma model. Mechanistically, anti-PD1-IL15m preferentially targeted CD8+ TILs and scRNA-seq analyses revealed that anti-mPD1-IL15m treatment induced the expansion of an exhausted CD8+ TILs cluster with high proliferative capacity and effector-like signatures. Antitumor efficacy of anti-mPD1-IL15m was dependent on CD8+ T cells, as depletion of CD8+ cells resulted in the loss of antitumor activity, whereas depletion of NK cells had little impact on efficacy. The impact of anti-hPD1-IL15m on primary human TILs from cancer patients was also evaluated. Anti-hPD1-IL15m robustly enhanced the proliferation, activation, and cytotoxicity of CD8+ and CD4+ TILs from human primary cancers in vitro, whereas tumor-derived regulatory T cells were largely unaffected. Taken together, we showed that anti-PD1-IL15m exhibits a high translational promise with improved efficacy and safety of IL15 for cancer immunotherapy via targeting PD-1+ TILs.

Response to Letter: Intrapatient Comparison of the Hepatobiliary Phase of Gd-BOPTA and Gd-EOB-DTPA in the Differentiation of HCA From FNH

LEVEL OF EVIDENCE

5 TECHNICAL EFFICACY STAGE: 3 J. Magn. Reson. Imaging 2020;52:1281-1282.

Grafts from selected deceased donors over 80 years old can safely expand the number of liver transplants: A systematic review and meta-analysis

AIM

The aim of this systematic review and meta-analysis was to present the outcome of deceased adult liver transplantation from octogenarian (≥80 years old) donors compared to younger grafts.

METHODS

A systematic search was performed on six databases to identify all available original papers that report the outcome of adult recipients who underwent liver transplantation from a deceased octogenarian donor.

RESULTS

Overall, 39,034 liver transplantations from 12 studies were reported with 789 (2.02%) cases receiving grafts from octogenarian donors. Eight studies were included in the meta-analysis. There was no difference regarding the one, three, and five-year graft and patient survival between the recipients of livers <80 years old and octogenarian grafts. There were significantly more episodes of biliary complications in the recipients of octogenarian grafts (34/459; 7.4%) in comparison to the recipients of livers <80 years old (372/37074; 1.0%) (OR 0.53; 95% CI = 0.35-0.81; P 0.004; I² = 0%). The incidence of primary non-function, vascular complications and re-transplantation did not differ between groups.

CONCLUSIONS

The short- and medium-term graft and patient survival of octogenarian liver transplantation is not inferior compared to the liver transplantation with younger grafts, however with a higher rate of biliary complications.

Surgical Safety and Efficacy of Third Kidney Transplantation in the Ipsilateral Iliac Fossa

BACKGROUND Kidney re-transplantation is a relevant option for patients who are returning to dialysis after graft failure. However, evidence is lacking to what extend a third kidney transplantation in the ipsilateral iliac fossa is safe and effective. The aim of this study was to investigate the outcomes of third kidney transplantations in the ipsilateral iliac fossa compared to first and second ipsilateral fossa kidney transplantations. MATERIAL AND METHODS There were 2074 kidneys transplanted at the Erasmus MC Rotterdam and at the University Medical Centre Groningen. Donor, recipient, and surgical data were collected. The cohort was divided into 3 groups: recipients of a first graft (I KTx; n=1744), recipients of a second graft (II KTx; n=44), and recipients of a third graft (III KTx; n=7). RESULTS Recipients from the II KTx group had a significantly higher rate of primary non-function (PNF) compared to recipients in the I KTx group and recipients in the III KTx group (4.5% versus 0.7% and 0% respectively; P=0.006). The 1-year graft survival did not differ between groups: 96% for I KTx, 91% for II KTx, and 85% for III KTx (P=0.214). The 5-year graft survival did differ significantly between groups: 89% for I KTx, 82% for II KTx, and 68% for III KTx (P=0.029). There were no differences regards hospital stay and rate of complications between groups. CONCLUSIONS Third kidney transplantation in the ipsilateral iliac fossa is feasible and viable. Short-term results are comparable to the first and the second kidney transplantation, however, long-term results are inferior but acceptable compared to dialysis.

Prednisolone does not affect direct-acting antivirals against hepatitis C, but inhibits interferon-alpha production by plasmacytoid dendritic cells

BACKGROUND

Chronic hepatitis C virus (HCV) infection compromises long-term outcomes of liver transplantation. Although glucocorticosteroid-based immunosuppression is commonly used, discussion is ongoing on the effect of prednisolone (Pred) on HCV recurrence and response to antiviral therapy post transplantation. Recently, new drugs (direct-acting antivirals) have been approved for the treatment of HCV, however, it remains unknown whether their antiviral activity is affected by Pred. The aim of this study was to investigate the effects of Pred on the antiviral activity of asunaprevir (Asu), daclatasvir (Dac), ribavirin (RBV), and interferon-alpha (IFN-α), and on plasmacytoid dendritic cells (PDCs), the main IFN-α-producing immune cells.

METHODS

The effects of Pred and antiviral compounds were tested in both a subgenomic and infectious HCV replication model. Furthermore, effects were tested on human PDCs stimulated with a Toll-like receptor-7 ligand.

RESULT

Pred did not directly affect HCV replication and did not inhibit the antiviral action of Asu, Dac, RBV, or IFN-α. Stimulated PDCs potently suppressed HCV replication. This suppression was reversed by treating PDCs with Pred. Pred significantly decreased IFN-α production by PDCs without affecting cell viability. When Asu and Dac were combined with PDCs, a significant cooperative antiviral effect was observed.

CONCLUSION

This study shows that Pred acts on the antiviral function of PDCs. Pred does not affect the antiviral action of Asu, Dac, RBV, or IFN-α. This implies that there is no contraindication to combine antiviral therapies with Pred in the post-transplantation management of HCV recurrence.

Genotype-phenotype correlations in hepatocellular adenoma: an update of MRI findings

Hepatocellular adenoma (HCA) is a generally benign liver tumor with the potential for malignancy and bleeding. HCAs are categorized into four subtypes on the basis of genetic and pathological features: hepatocyte nuclear factor 1α-mutated HCA, β-catenin-mutated HCA, inflammatory HCA, and unclassified HCA. Magnetic resonance imaging (MRI) plays an important role in the diagnosis, subtype characterization, and detection of HCA complications; it is also used to differentiate HCA from focal nodular hyperplasia. In this review, we present an overview of the genetic abnormalities, oncogenesis, and typical and atypical MRI findings of specific subtypes of HCA using contrast-enhanced MRI with or without hepatobiliary contrast agents (gadobenate dimeglumine and gadoxetate disodium). We also discuss their different management implications after diagnosis.

Organ donation as transition work: Policy discourse and clinical practice in The Netherlands

An increasing number of patients become eligible for organ transplants. In the Netherlands, at the level of policy discourse, growing waiting lists are often referred to as a persistent “shortage” of organs, producing a “public health crisis.” In this way, organ donation is presented as an ethical, social, and medical necessity. Likewise, policy discourse offers a range of seemingly unambiguous solutions: improving logistical infrastructure at the level of hospitals, developing organizational and legal protocols, as well as public information campaigns. Instead of taking these problem and solution definitions as given, we critically examine the relationship between policy discourse and clinical practice. Based on a historical review, first, we trace the key moments of transformation where organ donation became naturalized in Dutch policy discourse, particularly in its altruistic connotation. Second, based on in-depth interviews with medical professionals, we show how those involved in organ donation continue to struggle with the controversial nature of their clinical practice. More specifically, we highlight their use of different forms of knowledge that underlie clinicians’ “transition work”: from losing a patient to “gaining” a donor.

For love or money? Attitudes toward financial incentives among actual living kidney donors

Due to lengthening waiting lists for kidney transplantation, a debate has emerged as to whether financial incentives should be used to stimulate living kidney donation. In recent surveys among the general public approximately 25% was in favor of financial incentives while the majority was opposed or undecided. In the present study, we investigated the opinion of living kidney donors regarding financial incentives for living kidney donation. We asked 250 living kidney donors whether they, in retrospect, would have wanted a financial reward for their donation. We also investigated whether they were in favor of using financial incentives in a government-controlled system to stimulate living anonymous donation. Additionally, the type of incentive deemed most appropriate was also investigated. In general almost half (46%) of the study population were positive toward introducing financial incentives for living donors. The majority (78%) was not in favor of any kind of reward for themselves as they had donated out of love for the recipient or out of altruistic principles. Remarkably, 60% of the donors were in favor of a financial incentive for individuals donating anonymously. A reduced premium or free health insurance was the preferred incentive.

Kidneys from donors after cardiac death provide survival benefit

The continuing shortage of kidneys for transplantation requires major efforts to expand the donor pool. Donation after cardiac death (DCD) increases the number of available kidneys, but it is unknown whether patients who receive a DCD kidney live longer than patients who remain on dialysis and wait for a conventional kidney from a brain-dead donor (DBD). This observational cohort study included all 2575 patients who were registered on the Dutch waiting list for a first kidney transplant between January 1, 1999, and December 31, 2004. From listing until the earliest of death, living-donor kidney transplantation, or December 31, 2005, 459 patients received a DCD transplant and 680 patients received a DBD transplant. Graft failure during the first 3 months after transplantation was twice as likely for DCD kidneys than DBD kidneys (12 versus 6.3%; P=0.001). Standard-criteria DCD transplantation associated with a 56% reduced risk for mortality (hazard ratio 0.44; 95% confidence interval 0.24 to 0.80) compared with continuing on dialysis and awaiting a standard-criteria DBD kidney. This reduction in mortality translates into 2.4-month additional expected lifetime during the first 4 years after transplantation for recipients of DCD kidneys compared with patients who await a DBD kidney. In summary, standard-criteria DCD kidney transplantation associates with increased survival of patients who have ESRD and are on the transplant waiting list.

Optimizing the outcome of surgery in patients with rectal cancer and synchronous liver metastases

BACKGROUND

This study evaluated the outcome of patients treated for rectal cancer and synchronous hepatic metastases in the era of effective induction radiotherapy and chemotherapy.

METHODS

All patients undergoing surgical treatment of rectal cancer and synchronous liver metastases between 2000 and 2007 were identified retrospectively from a prospectively collected database. Three approaches were followed: the classical staged, the simultaneous and the liver-first approach.

RESULTS

Of 57 patients identified, the primary tumour was resected first in 29 patients (group 1), simultaneous resection was performed in eight patients (group 2), and 20 patients underwent a liver-first approach (group 3). The overall morbidity rate was 24.6 per cent; there was no in-hospital mortality. Median in-hospital stay was significantly shorter for the simultaneous approach (9 days versus 18 and 15 days for groups 1 and 3 respectively; P < 0.001). The overall 5-year survival rate was 38 per cent, with an estimated median survival of 47 months.

CONCLUSION

Long-term survival can be achieved using an individualized approach, with curative intent, in patients with rectal cancer and synchronous liver metastases. Simultaneous resections as well as the liver-first approach are attractive alternatives to traditional staged resections.

Within-Patient Variability of Mycophenolic Acid Exposure

Exposure to mycophenolic acid (MPA) is highly variable among patients on standard dose mycophenolate mofetil (MMF) therapy. In addition, MPA exposure increases with time posttransplant and exposure is predictive for the development of acute rejection. Consequently, therapeutic drug monitoring (TDM) of MPA may improve clinical outcome, although a large within-patient variability could be a limitation. This study was designed to analyze the extent of within-patient variability of MPA exposure for area-under-the-curve (AUC0-12) and pre-dose concentrations (C0). For 9 occasions during the first 5 months after transplantation, AUC0-12 and C0 values from 45 renal transplant recipients, all using cyclosporine and corticosteroids, were divided into quartiles. When AUC0-12 or C0 changed 1, 2, or 3 quartiles within a patient from one occasion to the next, a score of respectively 1, 2, or 3 points was assigned. Doing this for all 8 between occasion intervals, the maximal score for within-patient variability could be 8 x 3 = 24 per patient. For AUC0-12, the median overall score was 3.4 of maximal 24. For C0 measurements, this score was significantly higher: 6.0 (P < 0.001). The higher overall score for C0 was explained by more quartile changes during the first weeks after transplantation. It is concluded that within-patient variability for MPA exposure is low in kidney transplant recipients during the first 5 months after transplantation. In the first weeks after transplantation, within-patient variability is larger for C0 than for AUC0-12.

[Cross-over transplantation; a new national program for living kidney donations]

In the Netherlands, cross-over kidney transplantation has been introduced as an extra option in the living kidney donation programme. In cross-over transplantation, patients who cannot be given their own partner's kidney for immunological reasons are given a kidney from the partner of another patient in exchange for a kidney from their own partner. There is no difference in the medical indications and contraindications between direct and indirect living donation. There are no ethical obstacles since the net gain for the two couples is no different from that of direct living kidney donation and because the exchange takes place on the basis of equality. One should be aware that the extra possibilities may result in more psychological pressure on potential donors. It is important that the donation procedures start at the same moment and that the wishes of patients and donors for anonymity be preserved. A successful cross-over kidney transplantation programme requires a large pool of donors and patients. Therefore, this has been organised in a national programme. The Dutch Transplantation Foundation is responsible for the allocation of cross-over kidneys. Organ trade will thus be impossible. The seven Dutch centres for kidney transplantation have developed a protocol.

Reassuring effect of pravastatin on natural killer cell activity in stable renal transplant patients

BACKGROUND

Administration of pravastatin soon after transplantation successfully lowers cholesterol levels, whereas a reduced number of acute rejection episodes is accompanied by a decrease in natural killer (NK) cell activity. As a consistent low NK cell activity caused by pravastatin might impair tumor surveillance leading to cancer, we studied the effect of pravastatin on NK cell activity in stable renal transplant patients.

METHODS

From 14 cyclosporine (CsA)-treated and 11 azathioprine (AZA)-treated patients with hypercholesterolemia, more than 1 year after kidney transplantation, we determined NK cell number and cytotoxic activity before, and at 6 and 12 weeks after, initiating pravastatin treatment. Additionally, cholesterol levels and liver and kidney function parameters were assessed.

RESULTS

During pravastatin treatment, total cholesterol and low-density lipoprotein-cholesterol levels decreased significantly in both patient groups. In the CsA group, the number and cytotoxic activity of the NK cells at 12 weeks after institution of pravastatin was in the same range as before pravastatin. Additionally, in the AZA group, pravastatin did not influence the number of NK cells. However, in the AZA group, both the number of NK cells and their cytotoxic activity were significantly (<0.002) lower compared to the values in the CsA group.

CONCLUSIONS

In contrast to previous reports on decreased NK cell cytotoxicity caused by pravastatin treatment early after transplantation, we cannot confirm these results in stable kidney recipients. In our hands, NK cell cytotoxicity during pravastatin treatment was within the same range as in the absence of pravastatin. Thus, in view of the potential role of NK cells in tumor surveillance, these data are reassuring.

The influence of cholesterol on mortality after transplantation is age dependent

There is still no consensus on the treatment of elevated serum cholesterol in patients with a renal transplant. In the general population treatment is age dependent. We studied the influence of serum cholesterol 1 year after transplantation in all 676 recipients of a kidney graft transplanted in Rotterdam that survived and functioned for at least 1 year. The other variables included in this analysis are: donor and recipient age and gender, original disease, race, number of HLA A and B mismatches, number of previous transplantations, postmortal or living related transplantation and transplantation year. At 1 year after transplantation the following variables were included: serum cholesterol, serum creatinine, proteinuria and hypertension. In the Cox proportional hazards analysis, serum cholesterol at 1 year after transplantation turned out to be an important, independent variable influencing patient failure. The influence was linear but there was interaction with recipient age. The negative influence of serum cholesterol on the RR for patient failure decreased with increasing recipient age. For example, the proportional increase in RR of a 20-year-old with a serum cholesterol of 12 mmol/l compared with that of a cholesterol of a patient with serum cholesterol of 6 mmol/l was 6. In a 60-year-old with a cholesterol of 12 mmol/l the proportional increase in RR was only 1.2 compared with a contemporary with a cholesterol of 6 mmol/l. Serum cholesterol levels have an independent influence on patient failure. The RR is influenced by recipient age, so that the negative effect of increasing cholesterol levels in the elderly is overruled by the RR of age and disappears.

LONG-TERM GRAFT SURVIVAL AFTER UROLOGICAL COMPLICATIONS OF 695 KIDNEY TRANSPLANTATIONS

PURPOSE

We ascertain the incidence, management and long-term outcome of early urological complications requiring surgical exploration in kidney transplantation.

MATERIALS AND METHODS

Data of 695 consecutive kidney transplantations performed between January 1985 and January 1997 were assessed in regard to urological complications that occurred within 1 year after transplant. A computerized database was used to analyze graft recipient characteristics, the implantation procedure, complications and outcome in select patients and all those who underwent transplant during the same period. In the noncomplication group sufficient data for evaluation was available for 556 patients. We performed the Cox proportional hazards analysis with overall graft failure, graft failure or death as end points of observation.

RESULTS

Overall, 42 (6.0%) patients required revision of vesicoureteral anastomosis. Complications were identified after a median of 6 days (range 0 to 135). The primary reconstruction technique was extravesical in 64% and transvesical in 33% of patients, including 1 that involved ureteral Bricker anastomosis. Obstruction and/or leakage at vesicoureteral anastomosis accounted for 69% of urological complications. Revision was performed with a number of different reconstruction techniques. A second revision was required in 16.7%. Mean followup after primary transplant was 9.1 years (range 3.2 to 15). Multivariate analysis showed that surgical treatment of urological complication during year 1 after kidney transplantation did not increase the risk of overall graft failure, graft failure or death.

CONCLUSIONS

Our results indicate that long-term graft survival is not affected by a surgically treated urological complication.

Ureteroneocystostomy contributes to late functional and morphological changes in rat kidney transplants

PURPOSE

We investigated whether the surgical technique used to reconstruct the ureter has an impact on the late function of kidney transplants by comparing ureteroneocystostomy and ureteroureterostomy. To rule out alloantigeneic mediated effects on late graft dysfunction kidney transplants were performed in a syngeneic model.

MATERIALS AND METHODS

Rat kidney isografts were transplanted with simultaneous ureteroneocystostomy or ureteroureterostomy. Unilaterally nephrectomized rats served as controls. Eight weeks after transplantation intrapelvic pressure was measured during baseline diuresis, and after intravesical and intrapelvic infusion. Albuminuria was determined monthly until sacrifice at week 52. Histomorphological analysis included the degree of glomerulopathy, tubular atrophy, interstitial fibrosis and intimal hyperplasia. CD4+- and CD8+ T cells, and macrophages were identified using immunohistochemical testing.

RESULTS

Eight weeks after transplantation intrapelvic pressure during baseline diuresis and after intrapelvic infusion was significantly increased in rats with ureteroneocystostomy versus those with ureterostomy and unilateral nephrectomy, whereas intravesical infusion did not change the pressure in any group. During followup albuminuria after ureteroureterostomy did not differ from that after unilateral nephrectomy. In contrast, albuminuria significantly increased after ureteroneocystostomy from week 36 onward. At week 52 the ureter and kidney after ureteroureterostomy and unilateral nephrectomy had a normal appearance, whereas all ureters were dilated after ureteroneocystostomy. Nevertheless, 6 of the 8 kidneys in the ureteroneocystostomy group had a normal appearance. However, histomorphological findings in rats with transplants and ureterovesical anastomosis demonstrated significantly more interstitial fibrosis, CD8+ T cells and macrophages than isografts ureteroureterostomy.

CONCLUSIONS

As a surgical technique for restoring the urinary tract after kidney transplantation, ureteroneocystostomy contributes to the development of long-term functional and histological renal changes. Partial obstruction may be the cause of this renal impairment.

Prophylactic isradipine treatment after kidney transplantation: a prospective double-blind placebo-controlled randomized trial

There is evidence that calcium antagonists may have a beneficial effect on cyclosporine-induced nephropathy after transplantation. We treated 50 consecutive non-diabetic patients receiving their first cadaveric transplant with isradipine, a dihydropyridine calcium antagonist, or placebo in a double-blind, randomized, placebo-controlled trial. There were no significant differences between the two groups as regards age, weight, sex, HLA matching and ischaemic periods. To achieve optimal vasodilation, treatment was started intravenously 2 h before the transplantation procedure, and continued orally afterwards for 3 months. The immunosuppressive treatment included rabbit antithymocyte globulin on day 0, and oral cyclosporine from day 5. In both groups 7 patients had primary non-functioning grafts, but the incidence of never functioning kidneys due to vascular and thrombotic complications was significantly higher in the placebo group (0 vs 4 patients, P < 0.05). Hypertension was treated with oral labetolol in combination with guanfacine if necessary. In the placebo group antihypertensive medication had to be prescribed significantly more often (67% vs 33% of patients, P < 0.05), but resulted in similar blood pressure recordings in the two study groups. Cyclosporin A (CsA) plasma concentrations were also comparable but in the isradipine group a significantly higher dose of CsA was needed to achieve adequate levels (8.0 +/- 0.5 vs 6.2 +/- 0.5 mg/kg per day, P < 0.01). However, in the isradipine-treated patients creatinine clearance was significantly higher (66.1 +/- 4.5 vs 55.6 +/- 6.2 ml/min, P < 0.05) after 3 months. We conclude that isradipine is an effective antihypertensive agent after kidney transplantation. Isradipine ameliorates CsA-induced nephropathy and seems to protect against early postoperative vascular complications.

Cold ischemia augments allogeneic-mediated injury in rat kidney allografts

BACKGROUND

Some clinical studies demonstrate that kidney grafts with prolonged cold ischemia experience early acute rejection more often than those with minimal ischemia. The mechanism, however, is putative. Therefore, the aim of this study was to unravel the impact of ischemia on the immune response in rat kidney allografts compared with that in isografts.

METHODS

To induce ischemic injury, donor kidneys were preserved for 24 hours in 4 degrees C University of Wisconsin solution before transplantation. No immunosuppression was administered. The histomorphology according to the BANFF criteria for acute rejection and infiltrating cells were assessed at days 1, 2, 3, 4, 6, and 8 post-transplantation.

RESULTS

In allografts, exposure of the kidney to ischemia led to a significantly earlier onset of interstitial cell infiltration and tubulitis compared with nonischemic allografts. The BANFF score of interstitial cell infiltration was 1 +/- 0 vs. 0.25 +/- 0.29 at day 3 and 2 +/- 0 vs. 1.25 +/- 0.25 at day 4. In contrast, in isografts, the effect of ischemia on the histology was not significant. From day 6, the histologic differences between ischemic and nonischemic grafts disappeared. Ischemia led to a more intense expression of P-selectin (day 1), intercellular adhesion molecule-1 (ICAM-1; day 2), and major histocompatibility complex (MHC) class II on endothelium and proximal tubular cells (day 2) in both allografts and isografts. Concurrently with the up-regulated ICAM-1 and MHC expression, significantly more CD4(+) cells and macrophages infiltrated the ischemic allografts at days 2 and 3 and the ischemic isografts at day 4. Importantly, the influx of these cells after ischemia was significantly greater in allografts than in isografts.

CONCLUSIONS

Cold ischemia augments allogeneic-mediated cell infiltration in rat kidney allografts. The earlier onset of acute rejection in 24-hour cold preserved allografts may be prevented by better preservation or treatment using tailored immunosuppression.

[Treatment of non-resectable liver tumors with percutaneous interstitial laser coagulation while interrupting blood circulation to the liver]

OBJECTIVE

To evaluate, in patients with hepatocellular carcinoma or colorectal carcinoma disseminated to the liver, treatment with interstitial laser coagulation (ILC) during temporary occlusion of vascular inflow in the liver: feasibility, complications and initial tumour response.

DESIGN

Prospective, descriptive.

METHODS

Patients were included if their tumours were surgically irresectable and smaller than 4 cm in diameter and did not exceed a number of 3. ILC was performed under general anaesthesia, basically via a percutaneous approach. Vascular inflow was occluded during laser treatment. Twenty-four hours after ILC a triphasic spiral CT was performed to assess the result of the treatment.

RESULTS

In 10 patients 14 hepatic tumours were lasered in 12 treatment sessions (10 percutaneous and 2 at laparotomy). After 5 treatment sessions, complications were observed of which pain at the insertion site of the catheters was the most frequent. For 6 out of the 10 patients with percutaneous procedures, discharge was within 24 hours after ILC. Nine out of the 14 tumours (65%) were completely coagulated.

CONCLUSION

ILC with vascular inflow occlusion is a safe and feasible technique that can be performed during a short hospital stay. Initial tumour response is 65% and these results justify determination of duration of response in a larger group of patients.

Late graft dysfunction after prolonged cold ischemia of the donor kidney: inhibition by cyclosporine

BACKGROUND

The present study was devised to elucidate the influence of prolonged cold ischemia on the development of chronic transplant dysfunction (CTD) in kidney isografts (Brown Norway-->Brown Norway; BN-->BN) and in kidney allografts (BN-->Wistar Agouti/ Rij [WAG]) under temporary cyclosporine (CsA) therapy.

METHODS

To induce ischemic injury, BN donor kidneys were preserved for 24 hr in 4 degrees C University of Wisconsin solution before transplantation. Renal function (proteinuria), histomorphology according to the BANFF criteria for CTD, and infiltrating cells were assessed. Grafts were examined both early at days 2, 3, 6, and 10, and late at week 26 (allografts) or at week 52 (isografts).

RESULTS

Nonischemic isografts preserved a normal function and morphology. Ischemic isografts developed a progressive proteinuria over time and demonstrated significantly more glomerulopathy with macrophage (Me) infiltration and intimal hyperplasia than nonischemic controls at week 52. During the initial 10 days, there was an increased infiltration of MHC class II+ cells, predominantly CD4+ cells and Mphi, coinciding with up-regulated intercellular adhesion molecule-1 expression. CsA treatment in ischemic isografts inhibited infiltration of MHC II+ cells in the early stage, which was accompanied by significantly less renal damage at week 52 compared with untreated controls (proteinuria: 59+/-8 vs. 134+/-19 mg/24 hr; BANFF score: 2.8+/-0.4 vs. 4.3+/-1.0). Under CsA therapy, 24-hr cold ischemia of the allograft affected neither the onset or progress of proteinuria, nor the histomorphology (BANFF score: 7.8+/-2.4 vs. 7.3+/-1.9). In both ischemic and nonischemic allografts, intercellular adhesion molecule-1 expression and mononuclear cell infiltration (CD4, CD8, Mphi was abundantly present during the first 10 days and function deteriorated rapidly.

CONCLUSIONS

Prolonged cold ischemia plays a role in the induction of CTD, but its deleterious effect can be successfully inhibited by CsA. Therefore, the alloantigeneic stimulus is the overriding component in the multifactorial pathogenesis of CTD.

[Immunology in clinical practice. XXIII. Xenotransplantation]

Currently xenotransplantation is being discussed on national and international levels as a possible solution to tranplantation waiting lists, in view of the lack of alternative therapies. In recent years, enormous progress has been made in the area of immunology, especially concerning hyperacute rejection. However, long-term survival is still fiction due to relatively unknown, sequential rejection processes. Moreover, it remains questionable if xenogeneic organs will function physiologically, especially if they are metabolically complex. A third problem is the possible infectious risk of xenotransplantation to the patient and the population. Regarding this hazard, various committees and policy reports demand clarity first before the initial clinical transplantations become fact. In the Netherlands, the government largely adopted an identical advice by the Health Council. Artificial organs and cloning developments indicate that xenotransplantation might merely be an intermediate station in the route to develop adequate treatment for patients with organ failure.

Renal graft survival in native and non-native European recipients

Most studies on the influence of recipient race on kidney transplant survival have been performed in the United States. Generally, they show a lower survival in African-Americans than in Caucasians. Since Rotterdam has gradually become a multi-ethnic society, we were able to study the effect of origin on kidney survival. We restricted our study to recipients of a primary cadaveric kidney graft between July 1983 and July 1997 who received cyclosporin as primary immunosuppression. Patients were divided into two main groups according to origin: European (n = 399) and non-European (n = 110). No statistical differences were found for mean donor age, sex distribution, or the total number of HLA-A and DR mismatches. Non-Europeans had significantly more mismatches on their HLA-B locus (P = 0.01) and recipient age was lower (P = 0.003). The reason non-Europeans had lost their native kidneys was more often hypertension and less often congenital or hereditary diseases compared to Europeans. The causes of death and of transplant failure did not differ. A multivariate Cox proportional hazards analysis did not show European or non-European origin to be an independent predictor of graft survival (two categories, P = 0.25). The variable origin in five categories did show an independent influence on graft survival, with Arab en African recipients running higher risks than European and Asian recipients. We conclude that, in our center, the prognosis after kidney transplantation is comparable for Europeans and non-Europeans; however, in the subcategories, Arab and African recipients have a worse prognosis.

[Laparoscopic donor nephrectomy for kidney transplants from living family members: good preliminary results]

OBJECTIVE

Evaluation of safety and technical feasibility of laparoscopic live donor nephrectomy.

DESIGN

Descriptive.

METHOD

The per- and postoperative results were analysed of 15 patients subjected to laparoscopic live donor nephrectomy in the Erasmus Medical Centre Rotterdam, Dept. of General Surgery, the Netherlands. Both left and right nephrectomy were performed via the transperitoneal route. The kidney was removed via a subumbilical incision.

RESULTS

Laparoscopic donor nephrectomy was attempted in 15 patients and completed successfully in 14. Conversion to flank incision was resorted to one patient because of a venous bleeding. Median operating time was 290 min (SD: 57). Mean warm ischaemia time was 7 min (range: 4-17), including laparoscopic harvest. All kidneys were functioning well after transplantation. The mean duration of postoperative hospitalization of the donors was 4 days.

CONCLUSION

Laparoscopic live donor nephrectomy is a safe and technically feasible procedure in a kidney transplant programme involving a living relative.

Interstitial laser coagulation for hepatic tumours

BACKGROUND

The potential role of interstitial laser coagulation (ILC) for patients with irresectable hepatic tumours is currently being investigated. Since its introduction in 1983 it has evolved into an innovative minimally invasive technique.

METHODS

On the basis of a Medline literature search and the authors' experience, the principles, current state and prospects of ILC for hepatic tumours are reviewed.

RESULTS

Animal studies and early clinical studies have shown the safety and feasibility of ILC. The site of interest can be approached at laparoscopy or percutaneously and treatment is easily repeatable. Recent advances include the use of fibres with a cylindrical diffusing light-emitting tip, the length of which is adaptable to tumour diameter, water-cooled fibre systems, simultaneous multiple fibre application, and hepatic inflow occlusion during laser treatment. ILC allows complete destruction of tumours up to 5 cm in diameter. Currently a limitation is the lack of reliable real-time monitoring of laser-induced effects but progress in magnetic resonance imaging techniques should allow accurate temperature measurements to be obtained rapidly during treatment. However, the actual benefit of ILC in terms of patient survival remains to be investigated.

CONCLUSION

In terms of tools and experience, ILC has now been developed sufficiently to study its effect on survival of patients with irresectable hepatic tumours.

Hepatocellular carcinoma and liver transplantation: an animal model

The objective of this study was to develop an animal model to evaluate the biology of hepatocellular carcinoma (HCC) recurrence after liver transplantation. HCC was induced in Brown Norway (BN) rats (n = 45) by diet-hylnitrosamine (DEN) administered continuously through the drinking water. Starting from day 14, rats were sequentially autopsied or syngeneically transplanted according to Kamada's cuff technique. After 74 days of DEN administration, neoplastic liver lesions appeared and after a mean of 102 days (SD +/- 6) the animals died of abdominal haemorrhage from liver tumours. At this time lung metastases were present in three-fifths animals. Transplantation success was dependent on the DEN consumption and thereby the tumour stadium. After 74 days of DEN administration BN rats could no longer be transplanted because of anaesthetic problems or technical problems due to tumour adhesion to surrounding tissues. No recurrence was found in the transplants. In conclusion, we believe that timing of the operation in this HCC model is essential because the physical condition of the animals prohibits orthotopic liver transplantation in an advanced tumour stage. With a different DEN dosage scheme this problem may be solved.

Laparoscopy and laparoscopic ultrasonography in staging of oesophageal and cardial carcinoma

BACKGROUND

The ideal method for staging tumours of the oesophagus and gastric cardia is not known. This paper was designed to assess the value of laparoscopy and laparoscopic ultrasonography in the staging of oesophageal and cardial carcinoma.

METHODS

From October 1993 to January 1996, 60 patients in whom no metastases were seen on gastroscopy, ultrasonography of the abdomen and supraclavicular region, helical computed tomography of the chest and abdomen or endosonography were scheduled for laparoscopy and laparoscopic ultrasonography.

RESULTS

Some 40 patients had carcinoma of the oesophagus, in one of whom liver metastases were found at laparoscopy and proven histologically. On laparoscopic ultrasonography metastases were found in four patients but were impossible to biopsy. These lymph node metastases were confirmed at exploratory laparotomy. Twenty patients had carcinoma of the gastric cardia; distant metastases were found in four at laparoscopy. On laparoscopic ultrasonography metastases were present in four further patients, all proven by biopsy.

CONCLUSION

In this study laparoscopy was not an effective staging technique for oesophageal carcinoma. The inclusion of laparoscopic ultrasonography was of little benefit. A problem that was encountered was biopsy under laparoscopic guidance. In carcinoma of the gastric cardia, laparoscopy was more effective; adding laparoscopic ultrasonography doubled the number of patients seen to have metastatic disease.

Chronic rejection of concordant aortic xenografts in the hamster-to-rat model

Several groups have demonstrated that it is possible to obtain long-term graft survival of concordant xenografts. One of the important questions that remains is whether xenografts are susceptible to chronic rejection. To answer this question we used the aorta transplantation model. One centimetre of hamster aorta was interposed in the abdominal aorta of Lewis rat recipients. The recipients were either untreated (group 1), or treated with 10 mg/kg cyclosporine (CsA), given intramuscularly three times a week (group 2). Rats were sacrificed at day 7, 14, 21, 28, 56 and 84 and the thickness of the intima, the media and the adventitia was measured. Furthermore, the cellularity of the media and the adventitia was assessed by counting the number of nuclei per 0.05 mm2 and immunohistochemistry of the aortic grafts was performed. Graft arteriosclerosis developed in aortic xenografts of both group 1 and group 2. In group 1, intimal lesions were already present from day 21 onwards in all rats, whereas in group 2 they were present only in 33% (2/6) of the rats. At day 84 all the grafts in group 1 were totally occluded, while those in group 2 were still open. The thickness of the media was slightly increased in both groups during the whole observation period, mainly due to edema. Although a few infiltrating macrophages could be seen, the number of nuclei per 0.05 mm2 of the media remained constant during the first 21 days, but declined sharply from day 21 onwards, as a consequence of disappearing myocytes. Thickness of the adventitia in both groups increased after transplantation due to infiltrating macrophages and T cells, reaching a peak at day 14. After day 14 the adventitial thickness in group 1 decreased rapidly to reach values comparable to group 2 from day 28 onwards. In conclusion, graft arteriosclerosis, as a sign of chronic rejection, occurs in concordant aortic xenografts. The lesions in the xenografts develop extremely rapidly, and compared to data from the literature, faster than in aortic allografts. The process of chronic rejection in aortic xenografts can be reduced by CsA.

A membrane cofactor protein transgenic mouse model for the study of discordant xenograft rejection

BACKGROUND

In recent years, interest has been revived in the possibility of transplanting organs into humans from a phylogenetically disparate species such as the pig (xenotransplantation). Such discordant xenografts, however, are subject to hyperacute rejection (HAR) and activation of host complement plays a major role in this rejection. This problem may be solved through the use of transgenic technology by providing the grafted tissue with molecules that down-regulate the action of host complement.

RESULTS

Transgenesis with a yeast artificial chromosome (YAC) was used to produce transgenic mice with the complete genomic gene of the human complement regulator membrane cofactor protein (MCP). Transgenic mice were obtained that exhibit full regulation of MCP as normally observed in humans. Hearts from these mice were shown to be significantly protected from HAR caused by human serum in an in vivo experimental procedure.

CONCLUSIONS

We conclude that MCP can protect discordant xenografts from HAR caused by human serum and that transgenic mice can be used effectively as in vivo models for the study of the role of human complement regulatory molecules in xenotransplantation.

[Focal nodular hyperplasia of the liver: assessment of diagnosis and treatment in 31 patients in 15 years]

OBJECTIVE

Analysis of the diagnostic approach, therapy and management of focal nodular hyperplasia (FNH) of the liver.

SETTING

University Hospital Rotterdam-Dijkzigt, Rotterdam.

DESIGN

Retrospective follow-up analysis.

METHOD

Medical records of patients with histologically proven FNH were analysed with respect to complaints, diagnostic approach and therapeutic management. Follow-up took place at the outpatient clinic where history-taking, physical examination, ultrasonography and hepatitis B and C serology tests were performed.

RESULTS

Thirty-one patients with histologically proven focal nodular hyperplasia were treated: 19 were treated conservatively, 12 underwent hepatic resection; one of these patients died postoperatively. Follow-up investigation was carried out in 16 and 9 patients, respectively. Laboratory results did not contribute to the diagnosis. Computed tomography was the most reliable imaging method; 71% of the lesions were correctly diagnosed. After a median follow-up of 52 months none of the patients treated conservatively showed tumour growth on ultrasonography.

CONCLUSIONS

The most efficient approach to confirm the diagnosis of focal nodular hyperplasia consists of an ultrasound-guided needle biopsy and histological examination of the specimen. Conservative management is the treatment of choice in focal nodular hyperplasia. Hepatic resection should only be performed in symptomatic patients, in case of tumour growth or of uncertain histological diagnosis, to exclude a malignant process.

Tumour growth stimulation after partial hepatectomy can be reduced by treatment with tumour necrosis factor alpha

This study investigated whether partial hepatectomy enhances the growth of experimental liver metastases of colonic carcinoma in rats and whether treatment with recombinant human tumour necrosis factor (TNF) alpha can reduce this increased growth. Resection of 35 or 70 per cent of the liver was performed in inbred WAG rats, with sham-operated controls (five to eight animals per group). Immediately after surgery 5 x 10(5) CC531 colonic tumour cells were injected into the portal vein. After 28 days the animals were killed and the number of liver metastases counted. A 35 per cent hepatectomy induced a significant increase in the median number of liver metastases (28 versus 3 in controls), whereas a 70 per cent resection provoked excessive growth, consistently leading to more than 100 liver metastases and a significantly increased wet liver weight in all animals. TNF-alpha was given intravenously to rats following 70 per cent hepatectomy or sham operation in a dose of 160 micrograms/kg three times per week. This had only a marginal effect on tumour development in sham-operated rats but was very effective following partial hepatectomy (median 45 liver metastases). These observations confirm previous findings that surgical metastasectomy may act as a 'double-edged sword' by provoking outgrowth of dormant tumour cells and suggest that adjuvant treatment with TNF-alpha may be of benefit in patients undergoing resection of metastases.

Suppression of acute rejection prevents graft arteriosclerosis after allogeneic aorta transplantation in the rat

Rat aortic allografts develop arteriosclerotic alterations in the vascular wall that are histologically similar to those observed in chronic rejecting vascular allografts. We used cyclosporine and rapamycin (RAPA) in two different rat strain aorta transplantation models to investigate the effect of immunosuppression on posttransplant graft arteriosclerosis. High dose CsA (25 mg/kg, 3 times/week) treatment significantly inhibited intimal proliferation in the "strong" WAG-BN model (P < 0.01) as well as in the "weak" BN-WAG combination (P < 0.001), compared with untreated allogeneic controls. In the latter combination, even fewer intimal lesions were present than in WAG autotransplants, suggesting that CsA may also inhibit the arteriosclerotic response to mechanical injury. RAPA (3 mg/kg, 3 times/week) was as effective as CsA in reducing intimal lesions (P < 0.01 and P < 0.001 in the BN-WAG and WAG-BN models, respectively). Low dose CsA (5 mg/kg, 3 times/week) was only partially effective in preventing intimal lesions. Histology of the nontreated allografts showed ongoing acute rejection in the adventitial layer. The degree of cellular infiltration correlated with the severity of arteriosclerotic lesions. High dose CsA and RAPA treatment prevented adventitial infiltration in both models, while low dose CsA was only moderately effective. In conclusion, in the present study, the degree of arteriosclerotic involvement after allogeneic aorta transplantation was related to the severity of cellular adventitial infiltration. The myointimal thickening was inhibited by effective immunosuppressive treatment. These observations may imply that chronic rejection develops after ineffective immunosuppression.

Glomerular barrier function following conversion from cyclosporine to azathioprine in renal transplant recipients

The renal side effects are the major limitation of the use of cyclosporine in clinical transplantation. We studied the reversibility of changes in renal hemodynamics and glomerular barrier function in 17 patients with moderately impaired renal function at least 1 year after kidney transplantation. All patients were studied both during cyclosporine treatment and 3 months after conversion to azathioprine. During azathioprine treatment both glomerular filtration rate and effective renal plasma flow increased significantly (from 44.3 +/- 4.2 mL/min to 63.5 +/- 5.4 mL/min and from 192 +/- 12.8 mL/min to 260 +/- 14.6 mL/min, respectively). Despite the marked changes in renal hemodynamics, no significant changes were observed in the fractional clearances of uncharged dextrans. When calculating the characteristics of the filtration barrier, we observed a trend toward an increase in the ultrafiltration coefficient (Kt). This trend was abolished when an increase in net filtration pressure (delta P) was assumed to result from reduced prerenal vasoconstriction. We conclude that despite marked improvement of renal perfusion and glomerular filtration, conversion from cyclosporine to azathioprine did not significantly alter the permeability characteristics of the glomerular filtration barrier in renal transplant recipients with moderately reduced renal function. Improvement in renal function following conversion could result from an increase in either Kf or delta P. Since renal plasma flow was increased significantly, the observed improvement in glomerular filtration rate is likely to be, at least in part, due to an increase in glomerular capillary plasma flow.

[Criteria for and results of liver transplantation in patients with acute liver insufficiency]

OBJECTIVE

Evaluation of the results of emergency liver transplantation in patients with acute liver failure.

DESIGN

Analysis of 25 patients with acute liver failure.

SETTING

University Hospital Rotterdam Dijkzigt.

METHOD

Twenty-five patients with acute liver failure were admitted to the Intensive Care Unit in January 1989-May 1993. Patients were selected for emergency liver transplantation according to the Clichy criteria (presence of confusion or coma and factor V activity less than 20-30%).

RESULTS

Liver transplantation was indicated in 17 patients and performed in 13. The 1-year survival rate in patients with a liver transplant was 85%. Four patients with an indication for liver transplantation, but who could not be transplanted died. All 8 patients without an indication for emergency liver transplantation survived.

CONCLUSION

Survival after liver transplantation for acute hepatic failure is now about 80%; the Clichy criteria appear to be helpful in selecting patients with acute hepatic failure for liver transplantation.