Masataka Banshodani

Successful hepatitis B vaccination in liver transplant recipients with donor-specific hyporesponsiveness.

Currently, patients are prescribed lifelong treatment with hepatitis B immunoglobulin (HBIg) after liver transplantation (LT) for hepatitis B virus (HBV)‐related diseases in order to prevent reinfection with HBV. Active immunization with an HBV vaccine would be a preferable alternative; however, the immunosuppressive environment in LT recipients is believed to elicit a poor response to vaccination. Minimizing the exposure of the HBV‐infected LT recipients to immunosuppressants would be beneficial in inducing adaptive immunity against HBV by vaccination. In this study, in addition to efforts to minimize immunosuppression, prophylaxis with HBV vaccination combined with continuous HBIg administration was performed in 17 LT recipients who had undergone transplantation attributable to HBV‐related diseases. During the observation period, the overall response rate to HBV vaccination was 64.7%. The immune status of the recipients was evaluated by a mixed lymphocyte reaction assay in response to allostimulation. Patients showing a donor‐specific hyporesponse with a well‐maintained response to the third‐party stimulus always achieved a sustained immune response to the vaccine, whereas patients showing a hyporesponse to both the donor and the third‐party stimulus were unable to do so. Thus, inducing an anti‐donor‐specific immunosuppressive status by minimizing immunosuppression should enable post‐transplant HBV vaccination to be a promising prophylactic strategy.

Modified MILLER banding procedure for managing high-flow access and dialysis-associated steal syndrome

Purpose Both high-flow vascular access (VA) and dialysis-associated steal syndrome are serious complications requiring a flow reduction technique. We adopted the minimally invasive limited ligation endoluminal-assisted revision (MILLER) banding procedure with some modifications to control the high blood flow and steal syndrome during VA procedures and retrospectively assessed the outcome. Methods Seven patients with high-flow access (access flow >1400 ml/min) and five patients with steal syndrome (with pain, coldness, or cyanosis) were treated using the MILLER banding method. Flow volume of the brachial artery was monitored using Doppler ultrasonography during the banding procedure. In patients with steal syndrome, the finger probe of a pulse oximeter was attached to a finger on the ipsilateral side, and the peripheral oxygen saturation (SpO2) was monitored. Results In the high-flow group, the mean access blood flow (Qa) decreased from 2043 ± 463 ml/min (mean ± SD) to 1248 ± 388 ml/min (p<0.001). In the steal syndrome group, the SpO2 value improved in all steal syndrome patients after banding. Symptoms were almost relieved in two steal syndrome patients. The Qa in the steal group decreased from 997 ± 867 to 548 ± 376 ml/min (p = 0.12). The secondary patency rates of the high-flow and steal groups at 6 months were 83.3% and 50%, respectively. Conclusions The MILLER banding procedure with intraoperative access flow monitoring is effective to treat high-flow VA and steal syndrome.

Adoptive transfer of allogeneic liver sinusoidal endothelial cells specifically inhibits T-cell responses to cognate stimuli.

Although it is well known that liver allografts are often accepted by recipients, leading to donor-specific tolerance of further organ transplants, the underlying mechanisms remain unclear. We had previously used an in vitro model and showed that mouse liver sinusoidal endothelial cells (LSECs) selectively suppress allospecific T-cells across major histocompatibility complex (MHC) barriers. In the present study, we established an in vivo model for evaluating the immunomodulatory effects of allogeneic LSECs on corresponding T-cells. Allogeneic BALB/cA LSECs were injected intraportally into recombination activating gene 2 γ-chain double-knockout (RAG2/gc-KO, H-2b) mice lacking T, B, and natural killer (NK) cells. In order to facilitate LSEC engraftment, the RAG2/gc-KO mice were injected intraperitoneally with monocrotaline 2 days before the adoptive transfer of LSECs; this impaired the host LSECs, conferring a proliferative advantage to the transplanted LSECs. After orthotopic allogeneic LSEC engraftment, the RAG2/gc-KO mice were immune reconstituted intravenously with C57BL/6 splenocytes. After immune reconstitution, mixed lymphocyte reaction (MLR) assay using splenocytes from the recipients revealed that specific inhibition of host CD4+ and CD8+ T-cell proliferation was greater in response to allostimulation with irradiated BALB/cA splenocytes rather than to stimulation with irradiated third party SJL/jorllco splenocytes. This inhibitory effect was attenuated by administering anti-programmed death ligand 1 (PD-L1) monoclonal antibody during immune reconstitution in the above-mentioned mice, but not in RAG2/gc-KO mice engrafted with Fas ligand (FasL)-deficient BALB/cA LSECs. Furthermore, engraftment of allogeneic BALB/cA LSECs significantly prolonged the survival of subsequently grafted cognate allogeneic BALB/cA hearts in RAG2/gc-KO mice immune reconstituted with bone marrow transplantation from C57BL/6 mice. In conclusion, murine LSECs have been proven capable of suppressing T-cells with cognate specificity for LSECs in an in vivo model. The programmed death 1/PD-L1 pathway is likely involved in these suppressive effects.

Hepatic Angiomyolipoma with Minimal Intratumoral Fat Content

We report a rare case of hepatic angiomyolipoma with minimal fat content. The low fat content led to an incorrect preoperative diagnosis. A 38-year-old man who was a carrier of hepatitis B virus infection incidentally presented with a hepatic tumor. His serum alpha-fetoprotein level was normal. Ultrasonography revealed a well-circumscribed, heterogeneous hypoechoic nonencapsulated liver tumor measuring 34 × 24 mm. Precontrast computed tomography (CT) did not reveal fatty attenuation in the lesion. Contrast-enhanced CT revealed a hypervascular nonencapsulated tumor in the arterial phase and moderate washing out of the contrast medium in the portal phase. A hypervascular tumor was observed on CT hepatic arteriography, and complete washing out of the contrast medium on CT during arterial portography. These findings are compatible with hepatocellular carcinoma. The tumor exhibited low signal intensity on T1-weighted images and high signal intensity on T2-weighted images; no hypointensity was observed on fat suppression images. The patient underwent left hemihepatectomy because of a preoperative diagnosis of hepatocellular carcinoma. The histopathological diagnosis was a hepatic angiomyolipoma with 5% fat content. Low fat content makes the diagnosis of this condition difficult. The absence of serum tumor markers and the presence of a nonencapsulated hypervascular tumor may facilitate the accurate preoperative diagnosis of hepatic angiomyolipomas that have a low fat content and mimic hepatocellular carcinoma.

Hypomagnesemia as a predictor of mortality in hemodialysis patients and the role of proton pump inhibitors: A cross-sectional, 1-year, retrospective cohort study.

Introduction This study aimed to evaluate the association between proton pump inhibitor (PPI) use and serum magnesium levels, and the role of hypomagnesemia and PPI use as a risk factor for mortality in hemodialysis patients.

Long-Term Outcome of Hepatic Artery Reconstruction during Living-Donor Liver Transplantation

BACKGROUND Hepatic artery thrombosis (HAT) after living-donor liver transplantation (LDLT) is a potentially life-threatening complication. Although the introduction of microsurgical techniques has significantly decreased the incidence of HAT after LDLT, it remains a challenge for microsurgeons. We previously reported the use of the microsurgical hepatic arterial reconstruction technique during LDLT using the head-mounted surgical binocular system. METHODS In this study, we describe the long-term outcome of microsurgical hepatic artery reconstruction using the head-mounted surgical binocular system and our hepatic arterial reconstruction techniques on LDLT patients, including intimal dissection cases and clinical courses. Between August 2001 and February 2010, 146 patients underwent LDLT at our institution. Using a surgical loupe, the Varioscope AF3, which is a head-mounted surgical binocular system with automatic focusing and continuous zoom magnification from 3.6× to 7.2×, 150 arteries of 146 liver grafts were reconstructed. When the tunica intima was separated from the tunica media, suturing was performed from the inside of the vessels to the outside using an 8-0 monofilament Prolene with double needles, which facilitates secure sutures with good intima adaptation. RESULTS The 1- and 3-year survival rates of the 146 patients were 80.3% and 74.9%, respectively, with a mean follow-up of 40.2 months. The mean diameter of the graft hepatic artery was 2.79 mm. HAT was not encountered in this series of patients. CONCLUSION The use of the Varioscope and the application of our suturing techniques have provided entirely satisfactory long-term results of hepatic artery reconstruction during LDLT, even in intimal dissection cases.

Kinetics of Cellular and Humoral Immunity in a Successful Case of Positive Crossmatch Kidney Transplantation: A Case Report

A positive crossmatch remains one of the major barriers to successful kidney transplantation. Highly sensitized patients are at greater risk of hyperacute rejection and subsequent graft loss after transplantation. Although recent advances in desensitization therapy allow kidney transplantation in these patients, the success rate is quite low. Herein, we have reported a successful case of positive crossmatch living donor kidney transplantation using a desensitization protocol with an immune monitoring assay. A 42-year-old woman with end-stage renal disease due to IgA nephropathy had been on hemodialysis for 36 months. She showed positive T-cell and B-cell cytotoxic crossmatches with her husband owing to pretransplantation blood transfusions. We performed a preconditioning regimen comprising a single dose of rituximab (375 mg/m(2)) combined with double-filtration plasmapheresis (DFPP) followed by low doses of intravenous immunoglobulin (DFPP/IVIG treatment). Tacrolimus (target trough level, 5-10 ng/mL) and mycophenolate mofetil (1500 mg/body) were started 2 weeks before the DFPP/IVIG treatment. After 6 DFPP/IVIG sessions, the crossmatch became negative. An induction quadruple immunosuppression protocol included tacrolimus, mycophenolate mofetil, basiliximab, and methylprednisolone. After the transplantation, the patients immune status was evaluated regularly by mixed lymphocyte reactions (MLR) using an intracellular carboxyfluorescein diacetate succinimidyl ester (CFSE)-labeling technique (CFSE-MLR assay) and immunosuppressant therapy was adjusted accordingly. During the observation period, neither antibody-mediated rejection nor acute cellular rejection was encountered in this patient.

De Garengeot hernia with perforated appendicitis and a groin subcutaneous abscess: A case report

Highlights • De Garengeot hernia with a groin subcutaneous abscess is rare.• Appendectomy and herniorrhaphy via the same incision may be more effective.• Clinicians should consider de Garengeot hernia in patients with a groin hernia.

Past and Present Perspectives on Encapsulating Peritoneal Sclerosis

Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis. The mortality rate for EPS has been high, primarily due to complications related to bowel obstruction. However, recent advances in clinical research have established the pathogenesis, the disease course, and a treatment strategy. Currently, there is consensus on therapy; however, treatment with corticosteroids and tamoxifen should be administered in a timely manner. The final therapeutic option for EPS is surgical enterolysis (adhesiolysis). Moreover, a biocompatible peritoneal dialysis solution has become available for patients worldwide, which may further reduce peritoneal deterioration and EPS risk. These activities have promoted a better understanding of and have prompted countermeasures against EPS. EPS is no longer considered a fatal complication.

Efficacy of Intra‐Arterial Treatment for Massive Gastrointestinal Bleeding in Hemodialysis Patients

The incidence of acute nonvariceal massive gastrointestinal bleeding (GIB) is higher in hemodialysis (HD) patients than in healthy individuals, and this is often a life‐threatening event. We evaluated the efficacy of intra‐arterial treatment for GIB in HD patients. Between January 2006 and June 2012, eight HD patients with GIB were treated with superselective transarterial embolization. Of the eight cases, one was duodenal bleeding, two were jejunal bleeding, one was ileocecum bleeding, two were ascending colonic bleeding, and two were sigmoid colonic bleeding. After examining the site of bleeding by endoscopy or contrast‐enhanced computed tomography (CT), embolizations with microcoils, gelatin sponges, or N‐butyl cyanoacrylate were performed through interventional radiology (IVR). In all cases, blood transfusions were frequently administered. Six of the eight patients with GIB were successfully salvaged by transarterial embolization. In one case, duodenal bleeding was refractory to endoscopic treatment. Embolization was performed twice in this case; however, the patient died of an aneurysm rupture at the embolization site 24 days after the embolizations. In another case, massive jejunal bleeding and disseminated intravascular coagulation were identified at the time of the first examination, and the patient died of multiorgan failure 26 days after the embolization. On the basis of our experience, we established an effective treatment strategy for HD patients with acute nonvariceal massive GIB, by immediately identifying the exact site and degree of bleeding using contrast‐enhanced computed tomography and performing early treatment with transarterial embolization.