Atsushi Sugitani

A novel fully human anti-CD40 monoclonal antibody, 4D11, for kidney transplantation in cynomolgus monkeys.

Background. CD40-CD154 pathway blockade by anti-CD154 monoclonal antibodies (mAbs) significantly prolongs allograft survival in nonhuman primates. However, thromboembolic complications have prevented clinical application. Thus, blockade of the counter molecule by a novel fully human anti-CD40 mAb, 4D11, is an attractive alternative. Methods. Kidney transplantations were performed between outbred cynomolgus monkeys (stimulation index >3 in a mixed lymphocyte reaction). The animals were divided into five groups: nontreatment control (Group 1, n=3), 10-week treatment with either 10 mg/kg (Group 2, n=3), 20 mg/kg (Group 3, n=3), or 40 mg/kg (Group 4, n=1), and 4-week treatment (Group 5, n=1 each) with 10 mg/kg, 20 mg/kg, or 40 mg/kg followed by monthly administration. Graft survival, biochemistry, complete blood counts, lymphocyte phenotypes, blood drug levels, antidonor and antidrug antibodies, and renal histology were examined. Results. Survival (days) was as follows: Group 1 (5, 6, 7), Group 2 (150, 108, 108), Group 3 (84, 108, 379), Group 4 (147), and Group 5 (147, 102, 112). Two animals in Group 3 with normal graft function were killed upon development of hydronephrosis and cerebral infarction. B lymphocytes fell to one-third of the preoperative value at 4 weeks after transplantation in all animals. Antidonor antibodies developed in most of the animals after stopping drug treatment or at the time of death. No animals except for one formed anti-4D11 antibody. Conclusion. 4D11 appears to be a promising agent for antirejection treatment in clinical organ transplantation.

Introducing hand-assisted retroperitoneoscopic live donor nephrectomy: learning curves and development based on 413 consecutive cases in four centers.

Background. Hand-assisted and retroperitoneoscopic techniques reduce the risk of bleeding and intraabdominal complications in living donor nephrectomy (LDN). This study reports on our four-center experience, development, and learning curves from the first 413 LDNs using a hand-assisted retroperitoneoscopic (HARS) technique. Methods. The first 413 consecutive donors operated on using HARS were included in the study. Donor demographics, perioperative and postoperative data, complications, and recipient outcomes have been compiled. The data were analyzed as a whole and separately for each center, looking at center differences and learning curves over time. Results. Significant differences were found in donor demographics between centers for the variables: age, body mass index, number of arteries, and side of operation. Mean operating time was 170.2 min, with significant differences between centers. Operating time was also significantly influenced by learning curves, sex/body mass index, and side of operation. Warm ischemia time differed significantly between centers and was influenced by center-wise learning and number of arteries. Overall conversion rate was 2.4% and differed significantly between centers. There was no mortality and no intraabdominal complications. Apart from the conversions and one pulmonary embolism, there were no major intraoperative or postoperative complications. Overall 3-month graft survival was 99%, with 96% immediate onset of function and 1% ureteral complications. Conclusions. The HARS technique reduces the risk of intraabdominal complications. It can be implemented with excellent donor and recipient outcomes despite different population demographics and center/surgeon-related tradition and experience. On the basis of our experience, we recommend the technique to increase the safety margin of LDN.

Extrinsic intestinal reinnervation after canine small bowel autotransplantation

BACKGROUNDnThe process of extrinsic reinnervation after small bowel transplantation is poorly understood.nnnMETHODSnJejunal and ileal specimens, obtained from the dogs that underwent intestinal autotransplantation by an end-to end (E-E) or end-to-side arterial reconstruction, were analyzed at 1 (n = 7), 3 (n = 6), 6 (n = 6), 12 (n = 6), or 24 (n = 2) months and compared with control specimens (n = 7). Tissue catecholamine levels and indirect immunohistochemistry results for extrinsic neuropeptides, calcitonin gene-related peptide, neuropeptide Y, substance P, and tyrosine hydroxylase (TH) were examined.nnnRESULTSnCatecholamine levels in the grafts were undetectable until 6 months but increased significantly after 12 months, particularly in the E-E group. Immunohistochemistry results showed no significant indication of extrinsic reinnervation until 12 months, when TH fibers were observed in five of six dogs. The E-E group revealed some TH fibers extending across the arterial anastomosis toward the graft mesentery. Examination of the intestinal anastomosis at 12 months showed abundant peptidergic and TH extrinsic fibers in the host side, whereas there were few or none on the graft side.nnnCONCLUSIONSnThese results suggest that extrinsic reinnervation of the graft intestinal wall does occur but requires a prolonged period, and the major route of extrinsic reinnervation is along the arterial axis of the intestinal graft, not beyond the enteric anastomosis.

Immunohistochemical Study of Enteric Nervous System After Small Bowel Transplantation in Humans

The neurohormonal structures of two human intestines removed due to rejection 22 months and eight months after intestinal transplantation were studied by an indirect immunohistochemical method and compared with normal ileum. The distribution and density of neurons immunoreactive for tyrosine hydroxylase, substance P, calcitonin gene-related peptide, neuropeptide Y, vasoactive intestinal peptide, galanin, gastrin-releasing peptide,l-enkephalin, and somatostatin were examined. Mucosal endocrine cells immunoreactive for somatostatin, peptide YY, and glucagon were also examined. Extrinsic adrenergic fibers and perivascular fibers were absent in all intestinal layers of the failed grafts. The distribution of intrinsic neurons was unchanged; however, the density was decreased by one rank. Distribution of endocrine cells of the first graft was similar to the normal. Extrinsic fibers were not detected by immunohistochemistry in human small intestinal grafts following long-term survival and eventual rejection, while the immunohistochemical expression of intrinsic neural and endocrine transmitters were well preserved.

Tacrolimus without antilymphocyte induction therapy prevents pancreas loss from rejection in 123 consecutive patients

In this series, antilymphoid induction therapy did not appear to be necessary to prevent early graft loss from rejection. In addition, we have followed cytomegalovirus (CMV) antigenemia (pp65) for CMV infection. Although some patients developed a positive antigenemia in the seropositive to negative donor-recipient combinations, only one patient had a prolonged febrile course for 1 week.

The effect of small bowel transplantation on the morphology and physiology of intestinal muscle: a comparison of autografts versus allografts in dogs.

The effects of acute (AR) and chronic rejection (CR) on intestinal smooth muscle that are responsible for the dysmotility following small bowel transplantation (SBTX) are incompletely understood. Jejunal and ileal specimens from normal control dogs (n=7), and autotransplanted dogs were examined at 7 days (n=6) and 1 (n=7), 3 (n=6), 6 (n=6), and 12 months (n=6). Allotransplanted dogs that developed AR (n=8) and CR (n=5) were examined for gross and microscopic morphology (muscle thickness, the number and size of myocytes, and inflammatory infiltrate), and for contractile and intracellular electrical function in vitro. Auto-SBTX did not alter morphology at any period, but contractile function was impaired at 7 days (73.6%) compared with normal intestine. Acute rejection did not influence myocyte number or size, but was associated with a prominent infiltrate of neutrophils and lymphocytes, and severely impaired contractile function (20.6%) compared with auto-SBTX controls. Acute rejection also significantly inhibited the amplitude of slow waves and of inhibitory junction potentials. Chronic rejection caused thickening of muscularis propria by both hyperplasia (175.5%) and hypertrophy (202.6%) accompanied by moderate inflammatory cell infiltrate compared with auto-SBTX controls. We conclude that the marked inflammatory infiltrate into the muscularis propria indicates that the graft muscle is injured by both acute and chronic rejection; impaired function of intestinal smooth muscle following SBTX results from both rejection and the injury associated with transplantation, and chronic rejection following SBTX is associated with both hyperplasia and hypertrophy of the muscularis propria.

Enteric-Drained Pancreas Transplants Monitored by Fine-Needle Aspiration Biopsy

As we previously reported1•2 documentation of pancreas rejection remains problematic because of the lack of specific and sensitive markers. Since most pancreas transplants are performed simultaneous with a kidney, clinical dysfunction from rejection, documented by an increase in serum creatinine and renal-core biopsy, automatically leads to the treatment of both grafts. Rejections of pancreatic grafts are in some way preemptively treated by the initiation of kidney-transplant treatment. Nevertheless, in combined kidney-pancreas transplantation, an incidence of isolated pancreas rejection has been documented.3 .4 We report herein our experience in documenting rejection episodes with fine-needle aspiration biopsy (FNAB) in pancreas transplant patients. The FNAB rationale resides in the fact that the immunoactivation phenomenon begins in the graft. where infiltrating mononuclear cells endure a transformation process into blasts. Acute cellular rejection is defined by an accumulation of immature cells (lymphoblasts. plasmablasts. monoblasts) that can be quantified according to established cytologic criteria. Vascular rejection is generally assigned to humoral immunity with the proliferation of mononuclcar phagocytcs and tissue macrophages. However, on several occasions the cellular and humoral component of rejcction can be simultaneously detected.

Serum lipase as a marker for pancreatic allograft rejection.

In patients with enteric drainage of pancreas transplants, urinary amylase cannot be used as a marker of rejection. Since most of the patients in our center have enteric drainage, the aim of this study was to evaluate serum lipase as a potential marker for rejection. From July 1994 to March 1997, 100 patients underwent pancreas transplantation with enteric (78) or bladder (22) drainage. Forty-two of the 100 patients had both daily serum lipase (sLip) values and either kidney core or fine needle aspiration biopsies of the pancreas and/or kidney. Thirty-one of the 42 had biopsy proven rejection and were treated on day 0 (D0). From day - 7 (D - 7) to day + 7 (D + 7), sLip, serum amylase (sAmy), fasting blood sugar (FBS) and serum creatinine (sCr) were measured daily. Serum lipase values rose from 322 ± 107 IU/L on D 2 to 634 ± 247 IU/L on D - 1 (p = 0.0203) in 22 of the 31 patients with biopsy proven rejection (sensitivity 71%). The rise in sCr in combined kidney pancreas transplants with biopsy proven rejection was a better marker than sLip (sensitivity 86%). The sensitivity of sAmy and FBS was 50 and 33%, respectively. Other than sCr, sLip appeared to be the best marker for acute rejection in enterically drained pancreas transplants which should be useful as a non-invasive indicator of rejection in solitary pancreas transplants where sCr cannot be used.

En bloc pancreas and kidney transplantation in a patient with limited vascular access.

We report a successful en bloc pancreas and kidney transplantation on a type I diabetic patient with advanced peripheral arterial calcific disease, who had frequent life-threatening episodes of hypoglycemia. The en bloc double organ, created by joining the graft renal artery to the arterial Y graft of the pancreas, was implanted to the proximal left common iliac artery, which was the only site available for an arterial anastomosis. Under appropriate circumstances, this procedure would be an option for potential combined pancreas-kidney transplant recipients with severe calcific arterial disease.

Venous-right atrial bypass for superior vena cava thrombosis during orthotopic liver transplantation

The introduction of veno-venous bypass during orthotopic liver transplantation (OLT*) in 1984 avoided venous stagnation and hemodynamic instability during the anhepatic phase (1). In patients with superior vena cava (SVC) thrombosis or stenosis, the use of veno-venous bypass with the standard technique should be avoided because it can precipitate the onset of severe SVC syndrome (2). We describe here the use of a veno-right atrial bypass in a patient with SVC thrombosis who underwent simultaneous OLT and kidney transplantation. n nA 51-year-old man with the diagnosis of cryptogenic cirrhosis and chronic renal failure underwent simultaneous OLT and renal transplantation at our institution on February 5, 1995. A LeVeen shunt had been implanted elsewhere in October 1994 for refractory ascites and was subsequently removed 4 weeks later due to infection and occlusion. At the time of transplantation, insertion of an oxymetric pulmonary artery catheter was attempted through both the right and left internal jugular veins, but it could not be advanced on either side. An intraoperative venogram showed thrombosis of the SVC with several small collaterals draining caudally (Fig. 1). An oximetric pulmonary artery catheter was subsequently inserted through the right femoral vein and positioned in the pulmonary artery. In order to infuse volume during the transplant, a Biomedicus venous cannula with a side port was inserted through the left femoral vein. This cannula also served as the outflow catheter for the inferior vena cava (IVC) during the subsequent bypass. After a median sternotomy, a single straight Bard cannula (no. 32), modified in order to have a side port for volume infusion, was placed in the right atrium and secured with two 2-O Ethibond pledgeted purse-string sutures (Fig. 2). After transaction of the bile duct and the hepatic artery, the portal vein was cannulated with a Gott shunt cannula (no. 9) and connected with the other cannulas to a centrifugal force pump. n n n nFIGURE 1 n nIntraoperative SVC venogram shows obstruction of the SVC at the junction with the left subclavian vein, right subclavian vein thrombosis with collaterals. n n n n n nFIGURE 2 n nAs shown in this scheme of the portal-atrial bypass, a femoral vein cannula and a right atrial cannula were used as infusion ports for volume replacement. n n n nDuring the bypass, the flow was maintained at 3 L/min. The central venous pressure during bypass was 12 mmHg, and the pulmonary capillary wedge pressure was 16 mmHg. n nThe hepatectomy was performed using the piggyback technique (3) to maintain blood flow through the Ive and preserve the pulmonary catheter. During the veno-atrial bypass, the patient was hemodynamically stable with a total blood loss of 7 U of packed red blood cells. After reperfusion of the liver allograft, the right atrial cannula was removed and the purse-string suture was ligated to close the right atrial defect. Two no. 28 thoracostomy tubes were left in the mediatinum, and the sternum was closed with interrupted wire. The left kidney from the same donor was transplanted into the left iliac fossa. n nThe patient had an uneventful postoperative course. He received an antiarrhytmic agent for prophylaxis against atrial fibrillation, and the immunosuppression was iniated using tacrolimus and steroids. n nThe LeVeen modification for the peritoneovenous shunt has been used extensively for the treatment of refractory ascites since its introduction in 1974 (4). The incidence of SVC thrombosis or stenosis after LeVeen shunt has been reported with a variable incidence between 18.6% and 43% (5–7). Performing a liver transplantation in the presence of an SVC obstruction carries potential hemodynamic consequences, especially during the anhepatic phase. Volume infusion and hemodynamic monitoring were assured in this patient with an IVC access; interruption of the IVC was avoided by using the piggyback technique, and venous return was optimized with a portal-atrial bypass by right atrial cannulation. Given the concerns that had arisen because of this case, we currently assess SVC patency with Doppler ultrasound and SVC cavogram as needed in all candidates with prior LeVeen shunt in order to detect the presence of SVC thrombosis or stenosis before liver transplantation. It would also be possible to use transesophageal echocardiography instead of a pulmonary artery catheter for hemodynamic monitoring if occlusion of the IVC is necessary (e.g., in the case of cancer patients).