Continuous infusional 5-fluorouracil chemotherapy.
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Antimetabolites, Antineoplastic↗
Biomedical subjects
A Shaked
Publications and source records attributed to A Shaked.
Adenoviral-p53 gene transfer to orthotopic and peritoneal murine bladder cancer.
PURPOSE: This study was designed to examine the potential for adenoviral-mediated gene therapy in primary and metastatic bladder cancer. MATERIALS AND METHODS: Orthotopic and intraperitoneal bladder tumors were established after delivery of 1 x 10(6) MBT-2 cells into syngeneic mice. Gene transfer was accomplished via intravesical or intraperitoneal instillation by using an E-1 deleted adenovirus encoding LacZ or human p53. Successful tumor transduction was confirmed in tumor DNA and mRNA by polymerase chain reaction. Detection of recombinant gene product was detected by histochemical staining (X-gal) and Western blot. RESULTS: Palpable tumors developed 18 days following implantation. LacZ and p53 mRNA were present in tumor and adjacent normal tissue after bladder and intraperitoneal vector administration. Recombinant gene products were identified by histochemistry and Western blot. CONCLUSION: Bladder tumor-directed gene transfer using adenoviral vectors is an efficient and powerful tool for evaluating the adjuvant role of therapeutic gene products.
Adenoviridae↗
Etiology and management of symptomatic adult hepatic artery thrombosis after orthotopic liver transplantation (OLT).
Hepatic artery thrombosis (HAT) after adult orthotopic liver transplantation (OLT) is associated with fulminant sepsis and irretrievable loss of the graft. The purpose of this study was 1) to identify recipients at risk for the development of HAT; 2) to define early signs and methods for diagnosis; 3) to determine surgical treatment strategies following diagnosis of HAT. The charts of 680 adults who underwent primary OLT were reviewed. Eleven patients were symptomatic from HAT. Operative data revealed problematic arterial reconstruction in 9/11, and were related to inadequate recipient inflow, necessitating an interposition allogeneic iliac graft in seven patients, or anastomosis to aberrant right hepatic artery in two recipients. Early HAT in 4/11 occurred within 4 weeks after transplantation, whereas late thrombosis in 7/11 was identified 30 days to 1 year after OLT. The postthrombosis course was manifested by elevated liver transaminases (7/11), sepsis and recurrent cholangitis (9/11), or gas gangrene of the liver (4/11). The treatment modalities included thrombectomy and revision of the arterial anastomosis (1/11), emergency hepatectomy with temporary portocaval shunt (2/11), and urgent retransplantation (5/11). Antibiotic therapy and elective retransplantation was the treatment in 4/11. Overall 1-year patient survival and satisfactory graft function was 45 percent.
Adult↗
Small intestine transplantation at the University of California, Los Angeles.
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ABO Blood-Group System↗
Long-term ganciclovir prophylaxis eliminates serious cytomegalovirus disease in liver transplant recipients receiving OKT3 therapy for rejection.
We conducted a trial of long-term ganciclovir prophylaxis for prevention of cytomegalovirus (CMV) disease in liver transplant recipients receiving OKT3 therapy for rejection. Intravenous ganciclovir (6 mg/kg once a day, Monday through Friday) was initiated on the same day OKT3 therapy was started and continued for 4 or more weeks. Fifty-one consecutive adult patients (80% CMV seropositive, 20% CMV seronegative) were evaluated. Due to the patient's noncompliance or the primary physician's decision, 6 patients received less than 2 weeks of ganciclovir. Three of these 6 (50%) developed CMV disease (hepatitis 1, CMV syndrome 2). In contrast, of 45 patients receiving 4 or more weeks of prophylactic ganciclovir, only 1 (2.2%) developed CMV disease (hepatitis). There were no cases of CMV disease among 29 patients who received 6 or more weeks of ganciclovir. Reversible neutropenia in 2 patients (4.4%) was the only side effect associated with long-term ganciclovir. Complications from central intravenous catheters did not occur. These results suggest that CMV can be eliminated as a significant pathogen in liver transplant recipients receiving OKT3 for rejection by the long-term administration of prophylactic gnaciclovir, which is safe.
Adult↗
Correlation between donor age and the pattern of liver graft recovery after transplantation.
We have observed an increased rate of delayed nonfunction (DNF) of liver grafts procured from older donors. The aim of this study was to correlate donor age and the patterns of graft failure after transplantation. Pattern of liver injury, synthetic function, and graft survival in recipients receiving liver grafts from donor older than age 50 (group I, n = 95) were compared with matched cohort of recipients transplanted with grafts from donors age 20-30 (group III, n = 50). Primary nonfunction (PNF) of the graft was defined as non-recoverable hepatocellular function necessitating emergency retransplantation within 72 hr. DNF was defined as marginal graft function necessitating retransplantation within one month. Recipient characteristics, including age and preoperative UNOS status, were similar between groups. Ischemic/reperfusion injury, reflected by SGOT and SGPT was more severe in older donors. PNF occurred at similar frequencies for all groups (7%). Normal liver function was regained in 76% of recipients in group I, and in 92% in group II. However, cholestatic pattern was observed in recipient of grafts from group I donors. Rapid rise in bilirubin, despite normalization of prothrombin time and liver transaminases, was the hallmark of DNF. DNF resulted in higher retransplantation rate in group I (24% vs. 8% in group II). Donor age did not affect patient survival. Liberalizing criteria for donor selection, and acceptance of older donors is a calculated risk. Over 75% of the recipients will regain normal liver function. However, a higher number of these grafts will exhibit slow recovery after transplantation, and a significant rate of DNF. Recognition of such pattern and early retransplantation should decrease mortality.
Adult↗
Biliary tract complications after orthotopic liver transplantation. Endoscopic approach to diagnosis and therapy.
This study was undertaken to further define the role of endoscopic methods in the evaluation and treatment of biliary tract complications after liver transplantation and to determine the efficacy and safety of this approach. Fifty liver transplant patients were referred for endoscopic evaluation of a suspected biliary tract complication. Two patient groups were identified based on the indication for the endoscopic retrograde cholangiopancreatography (ERCP): Group 1 was suspected of having biliary fistula and group 2 was suspected of having bile duct obstruction. Group 1 consisted of 35 patients who developed bile peritonitis after inadvertent migration of the T-tube or intentional T-tube removal. Group 2 consisted of 15 patients who developed cholestatic hepatic chemistries in the absence of allograft rejection on liver biopsy. ERCP identified a biliary fistula at the T-tube insertion site into the bile duct in 32 (91%) group 1 patients. Twenty-six of 26 treated with a nasobiliary tube had fistula closure at a mean 5.2 days. Five of 6 treated with a stent, with or without sphincterotomy, had no leak at the time of stent removal (mean, 45 days). ERCP identified a cause for the cholestatic hepatic chemistries in 11 (73.5%) group 2 patients, including bile duct stones (n = 4), anastomotic (n = 3) or intrahepatic (n = 2) strictures, bile duct necrosis (n = 1), and hemobilia (n = 1). Five of the 5 patients undergoing endoscopic therapy were treated successfully. The endoscopic complication rate was 4% and the 30-day mortality rate was 2%. During a mean follow-up of 15 months, 94% of the patients who were treated successfully had no recurrent biliary tract disease. The results of this study suggest that ERCP is an effective modality in the evaluation of patients with suspected biliary tract complications after liver transplantation. In selected patients, endoscopic therapy obviates the need for additional surgical or percutaneous intervention.
Adult↗
Randomised comparison of ganciclovir and high-dose acyclovir for long-term cytomegalovirus prophylaxis in liver-transplant recipients.
Despite current approaches to prophylaxis, cytomegalovirus (CMV) continues to be a common cause of infection and disease in solid-organ-transplant patients. Thus, we conducted a controlled trial comparing long-term administration of ganciclovir with high-dose acyclovir for prevention of CMV infection and disease in liver transplant recipients. At the time of transplant, patients were randomised to receive either ganciclovir (6 mg/kg body weight per day intravenously from postoperative day 1 to day 30, then 6 mg/kg per day Monday through Friday until day 100) or acyclovir (10 mg/kg intravenously every 8 h from postoperative day 1 to day of discharge, then 800 mg orally four times a day until day 100). Patients were followed for development of CMV infection, CMV disease, and drug-related toxicity by frequent cultures, serological tests, laboratory measurements, and tissue biopsies. During the first 120 days after transplant, CMV infection occurred in 48 of 126 (38%) acyclovir patients but in only 6 of 124 (5%) ganciclovir patients (p < 0.0001). Similarly, symptomatic CMV disease developed in 12 of 126 (10%) acyclovir patients but in only 1 of 124 (0.8%) ganciclovir patients (p = 0.002). Ganciclovir reduced the incidence of CMV infection in both CMV antibody positive (37 vs 4%, p = 0.001) and negative patients (42 vs 11%, p = 0.06). In a multivariate analysis of donor-recipient CMV antibody status and other risk factors, prophylactic ganciclovir was the most significant factor protecting against CMV infection (p < 0.0001) and disease (p = 0.001). Ganciclovir and acyclovir were generally well-tolerated. Incidences of leukopenia, thrombocytopenia, renal failure, and other adverse events were similar in the two groups. CMV can be eliminated almost completely as a significant pathogen in liver transplant recipients by the long-term administration of prophylactic ganciclovir. In addition, the treatment is safe.
Acyclovir↗
Multiple vectors effectively achieve gene transfer in a murine cardiac transplantation model. Immunosuppression with TGF-beta 1 or vIL-10.
The application of gene transfer techniques to organ transplantation offers the potential for modulation of immunity directly within an allograft without systemic side effects. Expression vectors and promoter elements are important determinants of gene transfer and expression. In this study, various vectors (naked plasmid DNA, retroviral vector, herpes simplex viral vector, and adenoviral vector) with various promoters (RSV-LTR, SV40, MuLV-LTR, HCMVie1) were directly compared to demonstrate the successful gene transfer and expression of beta-galactosidase in murine myoblasts in vitro and within murine heterotopic, nonvascularized cardiac isografts or allografts in vivo. Expression of transferred genes was not toxic to cells and strength of expression varied according to the type of vector. Plasmid DNA was expressed in myocytes, retroviral vector was expressed in the graft infiltrating cells, and herpes simplex and adenoviral vectors were expressed in both myocytes and graft-infiltrating cells. Preliminary studies evaluated the ability of these vectors to deliver immunologically important signals. Allografts injected with pSVTGF-beta 1, a plasmid-encoding transforming growth factor beta 1 (TGF-beta 1) under the control of the SV40 promoter, showed significant prolongation of graft survival of 26.3 +/- 2.5 days compared with 12.6 +/- 1.1 days for untreated allografts, and 12.5 +/- 1.5 days for the allografts injected with control plasmid (P < 0.05). Allografts injected with MFG-vIL-10, a retroviral vector encoding viral interleukin-10 under the control of the MuLV-LTR, showed prolongation of graft survival of 36.7 +/- 1.3 days versus 12.6 +/- 1.1 days for the untreated allograft, and 13.5 +/- 2.0 days for the allografts injected with control retroviral vector (P < 0.001). Both vectors were transcriptionally active in vivo and did not appear to have toxic effects. Gene therapy for transplantation can induce transient expression of immunologically relevant molecules within allografts that impede immune activation while avoiding the systemic toxicity of conventional immunosuppression.
Animals↗
Adenovirus-mediated gene transfer in the transplant setting. Part III. Variables affecting gene transfer in liver grafts.
We have established a system of efficient gene transfer to liver grafts using adenovirus vectors. The purpose of this study was to examine variables affecting gene transfer to rat liver grafts during cold preservation. Our results demonstrate that gene transfer efficiency was directly correlated with the ratio of vector to hepatic cells (multiplicity of infection [MOI] and the length of exposure to the vector. At MOIs of 10:1 and 50:1, the hepatic cell transduction rate was 25-30% and 100%, respectively. However, higher MOI was associated with significant mortality. Prolonging the cold preservation/exposure time resulted in an increased transduction rate (50% at MOI of 10:1). Similar gene transfer efficiencies were observed when the vector was diluted in lactated Ringer's or University of Wisconsin solution. Recombinant protein production was evident within 12 hr after reperfusion, and increased to a peak level within 48 hr. These results suggest a predictable pattern of gene transfer and expression after ex vivo transduction of liver grafts with adenovirus vectors. These data are essential in directing desirable levels of recombinant protein within the transplanted organ.
Adenoviridae↗
Perforin and granzyme B. Cytolytic proteins up-regulated during rejection of rat small intestine allografts.
Perforin and granzyme B are 2 cytolytic proteins specific to activated killer cells, particularly CTL. We have studied the mRNA expression of these 2 proteins by a reverse transcriptase polymerase chain reaction method in a unidirectional model of rat small intestine transplant rejection. The allograft group consisted of Lewis x Brown Norway F1 donors into Lewis recipients. The isograft controls were Lewis donors into Lewis recipients. Grafts were placed heterotopically and no immunosuppression was given. Five animals in each group were killed at postoperative days (POD) 3, 5, 7, 8, 9, 10, 12, and 14. mRNA was extracted and a semiquantitative reverse transcriptase polymerase chain reaction was performed. For the semiquantitative analysis, we compared scintillation counts from excised bands. Results were expressed as a percent activity compared with beta-actin. From the same tissue samples, a histologic evaluation was made and rejection was graded according to severity. The isograft controls showed no evidence of histologic rejection and a very low expression of mRNA for perforin and granzyme B from POD 3-14. In contrast, the allograft group began to show histologic evidence of mild rejection on POD 5. By day 7, rejection was moderately severe and associated with a significant up-regulation of perforin and granzyme B in the allografts compared with the controls (P < 0.01), which persisted through POD 14. Peak expression for perforin and granzyme B was on POD 10 and 8, respectively. We conclude that the up-regulation of perforin and granzyme B in rat small intestine transplant allografts is a useful marker of clinically important rejection.
Animals↗
Efficient gene transfer to pancreatic islets mediated by adenoviral vectors.
Genetic manipulation of pancreatic islets before transplantation has the potential to alter cellular immunity as well as islet function. The purpose of this study was to examine the feasibility of gene transfer to islets, using replication-defective adenoviral vectors. Newborn mouse islets were infected with AdHCMVsp1LacZ vector encoding Escherichia coli beta-galactosidase (beta-gal). Islets were cocultured with vector, at virus-to-target cell ratios of 10:1, for 1 hr. Gene transfer was assessed by specific histochemical stain for beta-gal (X-gal). Islet DNA and RNA were analyzed by Southern and PCR for beta-gal and adeno sequences, and recombinant protein production by western and ONPG assays. Islet integrity after gene transfer was assessed by static incubations and transplantation to nondiabetic and to diabetic mice. Southern analysis and PCR confirmed the presence of E coli beta-galactosidase and the E4 adeno DNA in infected islets, but not in controls. Reverse-transcription PCR and western analysis demonstrated expression and protein production of inserted E coli beta-galactosidase, but not E4 message. Insulin release in response to static incubations was unimpaired in infected islets. Syngeneic islet grafts stained positively for insulin for up to 7 days. Transplanted, genetically manipulated islets functioned similarly to control islets in reversing murine drug-induced diabetes. Thus, gene transfer into islets can be accomplished using adenovirus-based vectors. The capacity of this virus to infect non-dividing cells allows insertion of cDNA into pancreatic islets, with potential application to the transplant setting.
Adenoviruses, Human↗
Transjugular intrahepatic portosystemic shunts: impact on liver transplantation.
This study was designed to evaluate the impact of transjugular intrahepatic portosystemic shunts (TIPS) on liver transplantation. Historically, the complications of portal hypertension have been temporized with sclerotherapy or surgical portosystemic shunts. In patients whose liver disease progressed, liver transplantation has been used as definitive treatment. More recently, TIPS is being used increasingly for the management of the complications of portal hypertension. The impact of this new modality on liver transplantation is evaluated. The records of 135 adult patients undergoing liver transplantation at University of California at Los Angeles between October 1992 and June 1993 were reviewed. Twenty-three patients had received at least one shunt before transplantation. The TIPS procedure complicated the operative course of 5 patients (22%). In 2 patients the TIPS had been placed cephalad, making placement of the suprahepatic vena caval clamp difficult. In 2 other patients, the shunt had been placed caudad, extending in the extrahepatic portal vein. In all 4 of these patients, the intima had been damaged at the area of the subsequent anastomosis. In the fifth patient, the bile duct had been perforated during the placement of the shunt, causing diffuse bile peritonitis, which was sterile, and the transplantation was performed. The average intraoperative blood loss for these 5 patients was 13 U. There was no significant decrease in intraoperative blood loss for all patients with a TIPS when compared with 112 adults who underwent liver transplantation during the same period (11 U v 10.5 U). The TIPS stent did not improve objective intraoperative parameters as compared with liver transplant recipients without TIPS. The indications for TIPS must be carefully weighed against the potential risks of increasing the technical difficulty of the transplantation and jeopardizing the candidacy of some liver transplantation candidates. Liver transplantation is not facilitated by TIPS insertion and therefore should not be used to justify TIPS placement.
Adult↗
The inhibitor cytokine interleukin-1 receptor antagonist synergistically augments cyclosporine immunosuppression in a rat cardiac allograft model.
Interleukin-1 receptor antagonist (IL-1ra) competes with IL-1 for binding of the IL-1 receptor, but does not elicit a cellular immune response. This study was designed to evaluate the effectiveness of IL-1ra in the immune and inflammatory responses to rat heart allografts. Experimental design was as follows: Group I HTx was syngeneic, BN to BN. The remaining groups were DA (RT 1a) to BN (RT 1n) allogeneic HTx. Group II was transplanted without immunosuppression. Group III received a low-dose IL-1ra regimen via osmotic pump into the peritoneum. Group IV recipients were similarly treated with a higher dose IL-1ra regimen. Group V rats received subtherapeutic cyclosporine (CsA) therapy while Group VI was treated with both CsA and low-dose IL-1ra. Group I rats survived indefinitely. Group II rats rejected their grafts at 5.33 +/- 1.37 days. Group III grafts survived for 7.16 +/- 0.48 days, and Group IV grafts for 8.16 +/- 0.75 days, both significantly longer than in Group II (P < 0.01). Group V animals treated with low-dose CsA had graft survival of 7.7 +/- 1.6 days, but combined therapy with CsA and IL-1ra in Group VI yielded significantly prolonged graft survival of 17.2 +/- 1.3 days (P < 0.0001). Histologic examination in treated recipients revealed delayed appearance of mononuclear cell infiltration. IL-1ra-treated recipients all demonstrated significantly reduced numbers of graft-infiltrating leukocytes; all phenotype subsets were equally affected. This study demonstrates the effectiveness of IL-1ra, in combination with low-dose CsA, in reducing the inflammatory response and rejection in the transplant setting.
Animals↗
Transduction of hepatic allografts achieves local levels of viral IL-10 which suppress alloreactivity in vitro.
The application of gene therapy in transplantation might be targeted at immunoregulation within the donor graft. Viral IL-10 (vIL-10) down-regulates antigen presenting cells (APC) and effector functions in in vitro and in vivo models of alloreactivity. In the current study, we have constructed a replication-defective adenovirus bearing the cDNA encoding viral IL-10 and examined the level and chronicity of its expression in rat liver allografts up to 7 days after orthotopic transplantation. The results demonstrate that liver allografts may be efficiently transfected with adenovirus expressing viral IL-10. Detection of the recombinant viral cytokine was limited to the allograft without measurable levels in peripheral blood. In parallel, the effect of vIL-10 on mixed leukocyte reaction is also assessed using peripheral blood lymphocytes obtained from naive donor and recipient animals. Equivalent levels of viral IL-10 (5-10 ng/ml) achieved after adenovirus-mediated gene transfer suppress the in vitro alloreactivity of peripheral blood lymphocytes up to 70%. Adenovirus-mediated gene transfer of viral IL-10 offers the promise of effectively and favorably altering the alloreactive immune response.
Adenoviridae↗
Hepatic function is preserved following liver-directed, adenovirus-mediated gene transfer.
Inherited and acquired disorders of the liver are attractive targets for gene therapy. Hepatic cells are susceptible targets for shuttle vectors because of a diversity of protein and viral receptors and accessibility of a selective afferent blood supply. Preservation of existing hepatic cell integrity and metabolic function is of paramount importance for successful whole animal gene therapy trials. In this report, we examine hepatic cell function and integrity following adenovirus-mediated reporter gene transfer to the liver in vivo. E1-deleted, replication-defective adenovectors encoding the LacZ gene driven by the human CMV promoter were delivered to the liver by isolated portal perfusion. The gene transfer rate, as determined by specific histochemical staining, approached 30% with recombinant protein detectable by Western blot throughout the course of study. Hepatic cell integrity as assessed by histology and hepatic enzyme profile (serum aspartate aminotransferase, gamma-glutamyl transpeptidase) demonstrated normal cellular architecture and no significant difference between transfected liver and controls. Hepatic synthetic and metabolic function, as determined by albumin levels, prothrombin time, and bilirubin, were similar between the two study groups. This study demonstrates that efficient adenovirus-mediated gene transfer and expression in the rat liver do not compromise hepatic cell metabolism and integrity.
Adenoviridae↗
Reduced-size grafts--the solution for hepatic artery thrombosis after pediatric liver transplantation?
Reduced-size liver grafts (RSG) were developed to alleviate the donor shortage for pediatric patients, particularly those requiring emergency transplantation. In theory, the large size of the hepatic artery available for anastomosis from RSG, as opposed to whole pediatric grafts, is less likely to lead to hepatic artery thrombosis (HAT). Therefore, the authors reviewed their experience with HAT, comparing RSG and whole-liver grafts in pediatric patients undergoing emergency liver transplantation. Despite the severity of illness of the recipients (UNOS status IV), and the intrinsic damage to the graft during reduction, HAT was not seen after RSG for emergency pediatric transplantation. In contrast, 29% of pediatric recipients who received whole grafts for emergency transplantation had HAT. RSG is a safe alternative to whole-liver grafts for pediatric liver transplantation, and may reduce the incidence of HAT.
Adolescent↗
Living-donor liver transplantation at UCLA.
BACKGROUND: Living-donor (LD) liver transplantation has been developed as an alternative to overcome the shortage of cadaver donor organs for pediatric recipients. PATIENTS AND METHODS: We reviewed our experience with 9 LD transplants performed between August 25, 1993 and August 3, 1994. The median recipient age and weight were 13 months and 10 kilograms. Left lateral segments from parental donors, with aortic inflow via saphenous vein grafts, were used in all cases. RESULTS: At a median follow-up of 160 days, all donors were alive and well. Recipient and graft survival were both 89%. Rates of hepatic artery thrombosis, portal vein thrombosis, biliary complications, and acute rejection were 22%, 11%, 11%, and 67%, respectively. CONCLUSIONS: Excellent outcome can be achieved with LD liver transplantation in small children with minimal donor risk. This procedure has the potential to emerge as the preferred treatment for pediatric liver transplant candidates for whom it is an option.
Adolescent↗