Tércio Genzini

Beneficial effects of prolactin and laminin on human pancreatic islet-cell cultures.

The problem of pancreas donor shortage could be addressed through in vitro islet-cell proliferation prior to transplantation into diabetic patients. Therefore, we set out to evaluate the effects of prolactin (rhPRL) and laminin on primary cultures of human pancreatic islets. Our results showed that rhPRL induced an increase in islet-cell number and in cumulative insulin secretion (p<0.01). However, glucose-induced insulin secretion was enhanced only in the presence of both laminin and rhPRL. In addition, we describe, for the first time in human islets, the PRL-induced activation of JAK2, and signal transducer and activator of transcription (STAT) 1, 3 and 5. Our results demonstrate a significant beneficial effect of rhPRL and laminin on human islets and support widely held notion that the closer physiological stimuli and environment of beta cells are mimicked, the better are the results in cell proliferation and secretory function, both essential for successful islet transplantation.

Expanding postmortem donor pool using steatotic liver grafts: A new look

Background. Clinical demand for liver transplant steadily grows while organs offer has reached a plateau years ago. To expand the donor liver pool, various options have been considered including acceptance of suboptimal donors and steatotic grafts, with a risk of poorer outcomes. The latter risk and its relation to the grade of liver graft steatosis have been studied in this prospective clinical study. Methods. One hundred eighteen consecutive liver transplantation (115 patients) performed between May 2002 and March 2008 were prospectively analyzed. According to the grade of steatosis on a 2 hr postreperfusion biopsy, four groups were considered: absence (<5%) (n=34), mild (<30%) (n=40), moderate (30%–60%) (n=23), or severe steatosis (≥60%) (n=21). Donors and recipients demographic data, and patients and grafts survival rates were compared among the four groups. Results. Eighty-four (71%) grafts presented some degree of steatosis (macrosteatosis: 19.5%, microsteatosis: 47%, mix type: 33.5%). Patient and graft survival were significant lower in the “severe steatosis” group, as a whole. Grafts with less than 30% predominant macro-, or microsteatosis also had poorer outcomes with lower patient and graft survival rates. Conclusion. Steatotic liver grafts were used on a large scale (71%) in this clinical series. The analysis confirms that using grafts with moderate (>30%) and severe steatosis (>60%) have a negative impact on outcomes. The authors conclude that using these grafts allow a significant increase in organ offer that counterbalances the negative outcome for patients who are not offered a transplant, and this supports the need for further clinical research.

Microencapsulation and tissue engineering as an alternative treatment of diabetes

In the 70s, pancreatic islet transplantation arose as an attractive alternative to restore normoglycemia; however, the scarcity of donors and difficulties with allotransplants, even under immunosuppressive treatment, greatly hampered the use of this alternative. Several materials and devices have been developed to circumvent the problem of islet rejection by the recipient, but, so far, none has proved to be totally effective. A major barrier to transpose is the highly organized islet architecture and its physical and chemical setting in the pancreatic parenchyma. In order to tackle this problem, we assembled a multidisciplinary team that has been working towards setting up the Human Pancreatic Islets Unit at the Chemistry Institute of the University of São Paulo, to collect and process pancreas from human donors, upon consent, in order to produce purified, viable and functional islets to be used in transplants. Collaboration with the private enterprise has allowed access to the latest developed biomaterials for islet encapsulation and immunoisolation. Reasoning that the natural islet microenvironment should be mimicked for optimum viability and function, we set out to isolate extracellular matrix components from human pancreas, not only for analytical purposes, but also to be used as supplementary components of encapsulating materials. A protocol was designed to routinely culture different pancreatic tissues (islets, parenchyma and ducts) in the presence of several pancreatic extracellular matrix components and peptide growth factors to enrich the beta cell population in vitro before transplantation into patients. In addition to representing a therapeutic promise, this initiative is an example of productive partnership between the medical and scientific sectors of the university and private enterprises.

Antibody-mediated rejection (AMR) after pancreas and pancreas-kidney transplantation.

Antibody‐mediated rejection (AMR) requires specific diagnostic tools and treatment and is associated with lower graft survival. We prospectively screened C4d in pancreas (n = 35, in 27 patients) and kidney (n = 33, in 21 patients) for cause biopsies. Serum amylase and lipase, amylasuria, fasting blood glucose (FBG) and 2‐h capillary glucose (CG) were also analysed. We found that 27.3% of kidney biopsies and 43% of pancreatic biopsies showed C4d staining (66.7% and 53.3% diffuse in peritubular and interacinar capillaries respectively). Isolated exocrine dysfunction was the main indication for pancreas biopsy (54.3%) and was followed by both exocrine and endocrine dysfunctions (37.1%) and isolated endocrine dysfunction (8.6%). Laboratorial parameters were comparable between T‐cell mediated rejection and AMR: amylase 151.5 vs. 149 U/l (P = 0.075), lipase 1120 vs. 1288.5 U/l (P = 0.83), amylasuria variation 46.5 vs. 61% (P = 0.97), FBG 69 vs. 97 mg/dl (P = 0.20) and 2‐h CG maximum 149.5 vs. 197.5 mg/dl (P = 0.49) respectively. Amylasuria values after treatment correlated with pancreas allograft loss (P = 0.015). These data suggest that C4d staining should be routinely investigated when pancreas allograft dysfunction is present because of its high detection rate in cases of rejection.

Apoptosis in kidney and pancreas allograft biopsies.

Background. Apoptosis is a particular form of cell death involved in the elimination of somatic cells. In this study, the occurrence of apoptotic cells in kidney and pancreas allograft biopsies was analyzed and correlated with the number of infiltrating macrophages and lymphocytes and granzyme B expression. Methods. Kidney and pancreas biopsies from patients submitted to simultaneous pancreas-kidney transplantation were classified into three groups: acute rejection, chronic rejection, and transplant cases without evidence of rejection. Formalin-fixed paraffin biopsies were used to identify apoptosis by the terminal deoxynucleotidyl transferase [TdT]-mediated dUTP nick end labeling (TUNEL) method. Results. In normal kidney, only few apoptotic cells were observed. In contrast, in kidney-allograft biopsies, the TUNEL signal was detected in the nuclei of tubular epithelial cells and also in mononuclear cells scattered in the interstitium. In pancreas biopsies, numerous apoptotic cells were detected in acinar cells, in ducts, and occasionally in islets. The number of apoptotic cells in acute pancreas rejection was significantly higher compared with acute rejection of kidney grafts (50±14 vs. 21±4 cells/mm2; P<0.05). In kidney biopsies, there was a positive correlation between apoptosis and macrophages (r=0.51; P<0.005), and apoptosis versus T lymphocytes (r=0.45; P<0.05). In pancreas biopsies, the number of apoptotic cells correlated only with the number of macrophages (r=0.41; P<0.05). Conclusions. Apoptosis occurs in kidney and pancreas allograft biopsies, markedly in acute rejection in pancreas biopsies. Although apoptosis may reflect a mechanism of down-regulation of the allograft immune response by eliminating infiltrating cells, the elimination of graft cells may result in graft damage, particularly in pancreas transplantation.

Transplante de pâncreas e ilhotas em portadores de diabetes melito

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.

Hepatorenal syndrome: an update

Hepatorenal syndrome (HRS) is the development of renal failure in patients with chronic previous liver disease, without clinical or laboratory evidence of previous kidney disease. It affects up to 18% of cirrhotic patients with ascites during the first year of follow-up, reaching 39% in five years and presenting a survival of about two weeks after its establishment. HRS diagnosis is based on clinical and laboratory data. The occurrence of this syndrome is related to the mechanism for ascites development, involving vasoconstriction, low renal perfusion, water and sodium retention, increased plasma volume, and consequent overflow at the splanchnic level. Renal vasoactive mediators like endothelin 1, thromboxane A2, and leukotrienes are also involved in the genesis of this syndrome, which culminates in functional renal insufficiency. The treatment of choice can be pharmacological or surgical, although liver transplantation is the only permanent and effective treatment, with a four-year survival rate of up to 60%. Liver function recovery is usually followed by renal failure reversion. Early diagnosis and timely therapeutics can increase life expectancy for these patients while they are waiting for liver transplantation as a definitive treatment.

Cystadenoma of the seminal vesicle

Primary tumors of the seminal vesicle are extremely rare. Among them, there is a spectrum of tumors derived from both epithelium and stroma and so classified as epithelial-stromal tumors. Herein, we report a case of a cystadenoma in a 49-year-old asymptomatic man, detected in a routine ultrasonography for liver disease follow-up. The digital rectal examination detected a large mass anterior to rectum and posterior to bladder. Computed tomography scan and magnetic resonance imaging showed a normal prostate and a 9.0 cm cystic tumor, replacing the left seminal vesicle. The gross appearance and microscopic aspect was compatible with cystadenoma of seminal vesicle. Patients postoperative recovery was uneventful. He is currently alive, 3 years after the diagnosis, with no signs of recurrence.

Prolactin-induced changes in protein expression in human pancreatic islets.

Ex vivo islet cell culture prior to transplantation appears as an attractive alternative for treatment of type 1 diabetes. Previous results from our laboratory have demonstrated beneficial effects of human prolactin (rhPRL) treatment on human islet primary cultures. In order to probe into the molecular events involved in the intracellular action of rhPRL in these cells, we set out to identify proteins with altered expression levels upon rhPRL cell treatment, using two-dimensional (2D) gel electrophoresis and mass spectrometry (MS). An average of 300 different protein spots were detected, 14 of which were modified upon rhPRL treatment (p<0.01), of which 12 were successfully identified using MS and grouped according to their biological functions. In conclusion, our study provides, for the first time, information about proteins that could be critically involved in PRLs action on human pancreatic islets, and facilitate identification of new and specific targets involved in islet cell function and proliferation.

PERFORATION OF SIGMOID COLON AFTER EXTRACORPOREAL LITHOTRIPSY

A 32-year-old white man presented with an 8 mm. renoureteral calculus on the left side. He was placed in the ventral decubitus position and underwent ESWL with 3,000, 7 kV. shock waves. The patient had symptoms of nephritic colic on the left side and on day 5 after ESWL he complained of indistinct pain in the left iliac fossa along with 6 episodes of diarrhea in 24 hours. Symptoms improved after receiving analgesics but on day 7 significant clinical worsening was characterized by signs of septicemia and an acute abdomen. An x-ray of the abdomen revealed pneumoperitoneum with the right diaphragmatic cupula and bilateral disappearance of the psoas muscle line (fig. 1). With the diagnostic hypothesis of perforative acute abdomen due to the use of antiinflammatory drugs the patient underwent laparotomy. The surgical finding was diffise pustular peritonitis and a blocked 1 cm. perforation in the distal sigmoid colon in the mesocolic margin. No diverticulum or foreign body was identified in the colon or in the cavity. In the distal urethral projection an intense organized inflammatory process was identified. The patient elected resection of the perforated intestinal segment following terminal colostomy of the sigmoid, rectal stump closure, washing of the abdominal cavity and broad-spectrum antibiotic therapy (fig. 2). On pathological examination a perforative process was observed in a segment of the sigmoid with infiltrating polymor