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Immune reconstitution: an important component of a successful allogeneic transplantation.

The recipients of allogeneic haematopoietic stem cell transplants are characterised by an immunodeficiency of varying severity and duration. Their immunocompromised state is due in part to: (1) an impaired recapitulation of lymphoid ontogeny, (2) a lack of sustained transfer of donor immunity, (3) the effects of graft versus host disease and its therapy, and (4) a reduction in thymic function. Recipients can have delays in the production of naive T lymphocytes following transplantation which result in defects in the production of new antigen specific T lymphocytes and an inability to produce antibodies, especially to carbohydrate antigens. T-cell proliferation as well as immunoglobulin production remains impaired usually until the second half of the first year post-transplant. Other factors that can influence immunological reconstitution include the donor-recipient relationship (histocompatible or matched unrelated donor), intervening infections and recipient age, among others.

Adult↗

Cells mediating graft rejection in the mouse. IV. The Ly-5, 6, and 8 effector cell phenotype.

Skin graft rejection was previously shown to be mediated by sensitized lymphocytes bearing the Thy-1+, Ly-1+2-3- cell surface phenotype and these cells were further characterized using antisera to the Ly-5, 6, and 7 specificities. By using an adoptive transfer system in which ATXBM mice (CBA/H) received sensitized cells treated with antiserum and complement, it was shown that the cells mediating skin graft rejection were of the Ly-5+6-7+ phenotype. Other studies have demonstrated that cytotoxic T cells are Ly-5+6+7-, whereas helper T cells are Ly-5+6-7+, so that the T cells-mediating graft rejection is again clearly distinguished from the cytotoxic T. cell. At this time, however, it is not possible to separate the T cells mediating helper T cell functions, delayed-type hypersensitivity (DTH), and allograft rejections.

Animals↗

alpha1,3-Galactosyltransferase gene-knockout pig heart transplantation in baboons with survival approaching 6 months.

BACKGROUND: The recent generation of alpha1,3-galactosyltransferase gene-knockout (GalT-KO) pigs has allowed investigation of the survival of GalT-KO pig organs in nonhuman primates. METHODS: Heterotopic heart transplantation from GalT-KO pigs was carried out in baboons (n=8) using a human antihuman CD154 monoclonal antibody-based immunosuppressive regimen. RESULTS: In six of the eight cases, graft survival extended to between approximately 2 and 6 months. All grafts developed thrombotic microangiopathy (TM). In particular, the clinical course of one baboon in which the graft functioned for 179 days is summarized. This baboon received aspirin (40 mg on alternate days) from day 4 in addition to heparin, which may have been a factor in the delay of onset and progression of TM and in prolonged graft survival. Maintenance therapy with anti-CD154 mAb, mycophenolate mofetil, and methylprednisolone was associated with persistently low numbers of CD3CD4 and CD3CD8 cells. Despite persisting depletion of these cells, no infectious complications occurred. CONCLUSIONS: It remains to be established whether TM is related to a very low level of natural preformed or T-cell-induced antibody deposition on the graft, inducing endothelial activation and injury, or to molecular incompatibilities in the coagulation mechanisms between pig and baboon, or to both. However, function of a pig organ in a baboon for a period approaching six months, which has not been reported previously, lends encouragement that the barriers to xenotransplantation will eventually be overcome.

Animals↗

Transplantation tolerance in primates following total lymphoid irradiation and allogeneic bone marrow injection. II. Renal allografts.

A modified regimen of fractionated total lymphoid irradiation and allogeneic bone marrow (BM) injection in chacma baboons produced transplantation tolerance for allografted kidneys from the BM donors, and substantial chimerism without evidence of graft-versus-host disease. Increasing the dose of nucleated BM cells injected 4-fold over that used in liver transplantation resulted consistently in normal graft function in the early weeks after transplantation. Bone marrow injection and challenge with renal allografts could be delayed for at least 3 weeks after completion of irradiation. If it can be shown that this period can be extended even further, the protocols will be relevant to the circumstances of clinical cadaveric renal transplantation.

Animals↗

Is there an optimal time for the first cyclosporin dose in renal transplantation?

It is customary for patients undergoing kidney transplantation to receive their first dose of cyclosporin either just before or during the transplant operation. This ensures the early establishment of good levels of immunosuppression but might depress early graft function and contribute towards the development of acute tubular necrosis. In a controlled clinical trial, we have studied the effects of withholding cyclosporin for 12 h in patients undergoing cadaveric renal transplantation. Consecutive adult recipients of a cadaveric renal transplant were randomised to receive their first dose of cyclosporin (10 mg/kg p.o.) 6 h prior to transplant surgery or 12 h afterwards. All patients received azathioprine (1.5 mg/kg i.v.) and methylprednisolone (0.5 g i.v.) in addition during surgery. From the 2nd day onwards both groups were treated with an identical triple immunosuppressive regimen. The 27 patients who received their first dose of cyclosporin post-operatively had significantly better immediate and subsequent function than did the 26 patients who received their cyclosporin at the time of surgery. The delayed dosing was associated with improved graft survival and no increase in the frequency of rejection episodes. This regimen is recommended for all patients receiving triple therapy.

Adult↗

Prolonged myocardial hibernation exacerbates cardiomyocyte degeneration and impairs recovery of function after revascularization.

OBJECTIVES: We sought to define the effects of time on contractile function, morphology and functional recovery after coronary revascularization in patients with dysfunctional but viable (hibernating) myocardium. BACKGROUND: Functional recovery after coronary artery bypass graft surgery in patients with chronic myocardial hibernation is incomplete or delayed. The proposed cause is a progressive temporal degeneration of cardiomyocytes. METHODS: In 32 patients with multivessel coronary disease, regional wall motion analysis was performed in hypoperfused but metabolically active areas before and 6 months after bypass surgery. During bypass surgery, transmural biopsy samples were obtained from the center of the hypokinetic zone for light and electron microscopic analyses. The proposed duration of myocardial hibernation was retrospectively assessed. RESULTS: Patients with a subacute hibernating condition (<50 days) demonstrated a higher preoperative ejection fraction (EF, 50+/-8%), and a better preserved wall motion (WM) in the supraapical wall (-1.4+/-0.4) than did patients with intermediate-term (>50 days, EF 37+/-9%, p < 0.05; WM -2.4+/-1.5, p = 0.08) or chronic (>6 months, EF 40+/-14%, WM -2.7+/-0.9, p < 0.005) ischemia. Structural degeneration correlated with the duration of ischemia (r = 0.56, p < 0.05). Postoperative recovery of function was enhanced in patients with a short history of hibernation compared with patients with an intermediate-term or chronic condition (EF 60+/-10% vs. 40+/-10%, p < 0.001, and vs. 47+/-14%, p < 0.05). CONCLUSIONS: Hibernating myocardium exhibits time-dependent deterioration due to progressive structural degeneration with enhanced fibrosis. Early revascularization should be attempted to salvage the jeopardized tissue and improve postoperative outcome.

Aged↗

In vivo biocompatibility evaluation of cellulose macrocapsules for islet immunoisolation: Implications of low molecular weight cut-off.

Earlier we showed the in vitro suitability of cellulose molecular dialysis membrane of low cut-off for islet immunoisolation. Using a syngenic islet transplantation model, here we report the in vivo biocompatibility status and discuss implications of the low molecular weight cut-off of this membrane. Streptozotocin diabetic mice were transplanted ip with islet grafts in cellulose macrocapsules and monitored for 6 weeks for their blood glucose profiles. Membrane biocompatibility was evaluated by assessing islet graft morphometry, viability, functionality, and tissue reaction against the capsules. Animals (n = 10) attained normoglycemia after 1 week of transplantation and remained nondiabetic throughout a follow-up of 6 weeks. Animals subjected to a glucose tolerance test at the end of the study showed delayed glycemic control, indicating a delayed insulin response. Grafts retrieved after the 15(th) day and after 6 weeks showed viable islets, between 70-80% and approximately 40%, respectively, with morphometric parameters similar to freshly isolated islets. Graft retrievals resulted in a recurrence of hyperglycemia, indicating a functional tissue mass. A mild tissue reaction with a few immunocytes and a very thin fibrous capsular reaction were seen against the macrocapsule membrane. This study points out the in vivo suitability of cellulose membrane for islet immunoisolation. However, applicability of this membrane is limited due to its low cut-off value. Membranes with a higher molecular weight cut-off may render better glycemic control and higher graft viability.

Animals↗

Adenovirus-mediated CTLA4Ig or CD40Ig gene transfer delays pancreatic islet rejection in a rat-to-mouse xenotransplantation model after systemic but not local expression.

Transient costimulation signal blockade of either CD28/CD80-86 interactions and/or CD40/CD154 interactions can prevent islet rejection in some models of both allo- and xenotransplantation. We have used adenoviruses coding for CTLA4Ig or CD40Ig and compared the efficacy of genetic modification of islets to systemic production through either intramuscular (i.m.) or intravenous (i.v.) injection of these vectors in a rat-to-mouse islet transplantation model. When gene transfer was performed into islets, a high level of primary nonfunction was induced. Furthermore, transduced functional grafts were rejected with the same kinetics as nontransduced islets. In contrast, i.m. AdCTLA4Ig and i.v. AdCD40Ig significantly delayed rejection (mean survival time of 54 +/- 26.9 and 67.6 +/- 44.9 days, respectively, vs. 24.3 +/- 9.7 days for unmodified islets, p < 0.05). Combination of ex vivo AdCTLA4Ig islet transduction and i.v. AdCD40Ig did not improve graft survival further. In conclusion, islet graft transduction with adenoviruses coding for costimulation inhibitors resulted in local expression with low serum concentrations of CTLA4Ig or CD40Ig and was unable to protect islet xenografts from rejection. In contrast, i.m. or i.v. gene transfer resulted in high serum concentrations of these molecules and was highly efficient in prolonging xenograft survival. These results contrast with the efficacy of AdCTLA4Ig we observed in a rat islet allotransplantation model and suggest that islet xenograft rejection might be more difficult to control.

Abatacept↗

Glial cell line-derived neurotrophic factor released by synthetic guidance channels promotes facial nerve regeneration in the rat.

Regeneration of the human facial nerve after lesion is often limited, leading to severe functional impairments, in particular when repair is delayed for several months, when cross-facial nerve grafts have to be performed, or in elderly patients. To improve the outcome, the potential accelerating and maturating effects of the neurotrophic factors glial cell line-derived neurotrophic factor (GDNF) and neurotrophin-3 (NT-3) on nerve regeneration were assessed using an axotomy model of the rat facial nerve. One-centimeter-long synthetic guidance channels releasing the neurotrophic factors over several weeks were used to bridge an 8 mm nerve gap, a distance that does not allow regeneration in the absence of growth factors. Nerve cables regenerated in the presence of GDNF showed a large number of myelinated axons 6 weeks after grafting (871 +/- 373, n = 5), whereas only 106 +/- 86 (n = 5) myelinated axons were counted in the presence of NT-3. Retrograde labeling with fluorogold revealed 981 +/- 450 (n = 5) and 53 +/- 38 (n = 5) retrogradely labeled motoneurons in the facial nucleus in the presence of GDNF and NT-3, respectively. No regenerated axons or retrogradely labeled cells were observed in the absence of growth factors (n = 6). These results demonstrate that GDNF, as previously described for the sciatic nerve, a mixed sensory and motor nerve, is also very efficient in promoting regeneration of the facial nerve, an essentially pure motor nerve. GDNF may therefore be useful in improving facial nerve regeneration in the clinic.

Animals↗

Treatment of osteochondral fracture of the trochlea of the PIP joint.

INTRODUCTION: Osteochondral (OC) fractures of the trochlea of the PIP joint are rare but the treatment of these fractures can be challenging [2, 5, 6, 10]. And the therapeutic guideline is not determined. MATERIALS AND METHODS: All of the three cases were male. Two were delayed union with minimal displacement and the other was a fresh displaced fracture. All cases were treated with ORIF using small K-wires. In delayed union cases, bone grafting was added. RESULTS: Although bone union was obtained in all cases, rotation of the fragment due to the absorption of the grafted bone resulted in deformity of the trochlea in one of the delayed union cases. The functional recovery at the 2-year follow-up was satisfactory in all cases. CONCLUSION: Although OC fracture of the trochlea of PIP joint carry significant fixation implications, successful treatment could be done with ORIF using small K-wire fixation technique.

Adolescent↗

The results of secondary microsurgical repair of radial nerve in 33 patients.

33 patients with injuries to the radial nerve were reviewed, on average, 12.1 (5-20) years after secondary repair. 24 were male and nine female, with a mean age of 29.8 (7-54) years. Most of the nerve lesions were blunt (17) or sharp (14) injuries. Division was total in 24 cases and they were mostly injured at the upper arm level (21 cases). The average interval between injury and repair was 6.0 (1-19) months. The procedures used were fascicular grafting in 21 and direct suture in 12 cases. Motor and sensory recovery were evaluated quantitatively. Useful results were obtained in 65.0% and useless in 25.0%. Fascicular grafting restored a useful level of motor function in only 8/21 cases (38.1%). Pre-operative delay had a significant influence. Associated lesions proved to be the critical factor for restoration of radial nerve function.

Adolescent↗

Determinants of cardiac failure after coronary bypass surgery within 30 days of acute myocardial infarction.

Timing of coronary artery bypass grafting after acute myocardial infarction (MI) is controversial, especially if myocardial function is depressed. Early coronary artery bypass grafting may result in reperfusion injury causing cardiac failure. Delay, however, may risk a second ischemic event. This study was performed to determine if four preoperative factors--time after MI, ejection fraction, ischemia (need for intravenous administration of nitroglycerin), and failure (need for inotropic support)--independently predict postoperative cardiac failure. Postoperative failure was defined as the need for inotropic support or intraaortic balloon pumping. The study group consisted of 145 patients who underwent isolated coronary artery bypass grafting between January, 1980, and July, 1985, within 4 weeks of an acute MI. Postoperatively 38 patients (26%) had cardiac failure. Five patients, all of whom had postoperative cardiac failure, died. Univariate and stepwise logistic regression analyses showed preoperative failure (p = .0001), ejection fraction less than 45% (p = .002), and preoperative ischemia (p = .02) were predictors of postoperative cardiac failure. Time after MI was not found to be an independent predictor (p = .96). We conclude that if ischemia or threatening coronary anatomy is present early after MI and clinical improvement is not occurring, operative intervention should be strongly considered at that time, as it does not appear that delay itself reduces the risk of cardiac failure and may risk a second ischemic event.

Coronary Artery Bypass↗

Salvage of open tibial fracture with segmental loss of tibial nerve: case report and review of the literature.

We report a case history, treatment, and follow-up of an open comminuted distal tibial fracture with significant soft tissue loss and segmental loss of the tibial nerve and posterior tibial artery. This constellation of injuries with an insensate plantar foot has often been an indication for amputation. In this instance, a functional distal extremity was salvaged with the use of Ilizarov fixation, delayed primary tibial nerve cable grafting, and staged soft tissue coverage. Clinical follow-up and review of the literature on the techniques used are offered for consideration.

Accidents, Traffic↗

Higher expression of transcription targets and components of the nuclear factor-kappaB pathway is a distinctive feature of umbilical cord blood CD34+ precursors.

Delayed engraftment, better reconstitution of progenitors, higher thymic function, and a lower incidence of the graft-versus-host disease are characteristics associated with umbilical cord blood (UCB) transplants, compared with bone marrow (BM). To understand the molecular mechanisms causing these intrinsic differences, we analyzed the differentially expressed genes between BM and UCB hematopoietic stem and progenitor cells (HSPCs). The expressions of approximately 10,000 genes were compared by serial analysis of gene expression of magnetically sorted CD34(+) cells from BM and UCB. Differential expression of selected genes was evaluated by real-time polymerase chain reaction on additional CD34(+) samples from BM (n = 22), UCB (n = 9), and granulocyte colony stimulating factor-mobilized peripheral blood (n = 6). The overrepresentation of nuclear factor-kappaB (NF-kappaB) pathway components and targets was found to be a major characteristic of UCB HSPCs. Additional promoter analysis of 41 UCB-overrepresented genes revealed a significantly higher number of NF-kappaB cis-regulatory elements (present in 22 genes) than would be expected by chance. Our results point to an important role of the NF-kappaB pathway on the molecular and functional differences observed between BM and UCB HSPCs. Our study forms the basis for future studies and potentially for new strategies to stem cell graft manipulation, by specific NF-kappaB pathway modulation on stem cells, prior to transplant.

Adult↗

Some endocrine aspects of the thymus gland.

In studies of the mouse thymus, lymphocyte mitoses are seen to be most frequent in the thymus cortex. There is evidence from thymic grafts that a hypothetical factor, thymopoietin, may stimulate mitosis of thymic lymphocytes. It is a factor which is postulated to act in conjunction with the PAS-positive mesenchymal reticular cells and epithelial reticular cells of the cortex. The thymus medulla is necessary for the integrity of thymic grafts, and may also elaborate a secretion for maintaining the cellular functions of the gland. Thymectomy has been used as a gauge for judging normal thymic function and results, in the mouse, in lymphopenia, degeneration of spleen and lymph nodes, delayed rejection of skin allografts, reduced ability of spleen cells to mount the graft versus host reaction, and reduced primary immune response to certain antigens. Correction of these deficiencies offers a means of evaluating various thymic extracts and grafts. Lymphocytosis-stimulating hormone (LSH) is known to maintain the peripheral lymphoid organs and cause lymphocytosis in the thymectomized animal. Diffusion chamber studies of thymic grafts also show restored lymphoid tissue by a cell-free factor (CIF). These two factors may be the same and probably represent the basis of the highly purified lymphocyte-stimulating proteins, LSHr and LSHh, which restore the L/P ratio in thymectomized animals and may stimulate lymphopoiesis in spleen and lymph nodes. LSHr, unlike LSHh, increases the total lymphocyte count. LSHr has been found to increase the humoral antibody response in neonatal mice both by the PFC technique and by direct hemolysis of sheep erythrocytes. Homeostatic thymic hormone (HTH) is a thymic extract of small molecular weight and contains nucleic acid. In the thymectomized guinea pig it has been found to maintain normal levels of lymphocytes in the blood, spleen and lymph nodes, to restore antibody titers to typhoid H antigen and to restore the toxic allergic reaction. Thymic humoral factor (THF) is of smaller molecular weight (less than 1,000) and probably is not a protein. It also enhances lymphoid proliferation in neonatally thymectomized mice. There is evidence that THF participates in humoral antibody formation because it stimulates PFC formation from neonatally thymectomized mice after inoculation with sheep erythrocytes. Its effects on cell-mediated immunity are seen from findings that injection of THF restores the ability of thymectomized mice to reject skin allografts. THF enables spleen cells from thymectomized or neonatal animals to mount the graft versus host reaction, and causes maturation of bone marrow cells and spleen or lymph node cells so that they can participate in the graft versus host reaction. It has been reported to stimulate lymphocytes to kill isogeneic tumor cells in vitro. Thymosin is protein extracted from the thymus. It has been found to alleviate leukopenia slightly and provide some improvement in lymphoid histology in thymectomized mice...

Aging↗

Treatment of distal femoral nonunion and delayed union by using a retrograde intramedullary interlocking nail.

OBJECTIVE: To analyze the causes of distal femoral nonunion and delayed union and assess the outcome of the corresponding treatment, retrograde intramedullary interlocking nail (RIIN). METHODS: From June 1995 to December 1998, 15 patients (9 males and 6 females) with distal femoral nonunion and delayed union were treated with RIIN. The average age of the patients was 34.5 years (23-46 years). Bone grafting was performed in 10 patients, closed reaming was done in the other 5 patients. Correction osteotomy was performed in 2 patients, and intra-articular release of knee adhesion in 11 patients. X-ray examination and knee society clinical rating system (KSS) were used to evaluate the results. RESULTS: All fractures were followed up for at least 9 months with average follow-up duration of 14.5 months (9-33 months). Solid union was documented in all patients at 6.4 months on average. There were no infections or malunions in this series. Based on the final follow-up data, acceptable functional range of motion (ROM) of over 90 degrees was achieved in most patients. The average ROM was 93.5 degrees with significant improvement of 28 degrees (42.7%, P<0.05) compared with the preoperative ROM. The average knee score was 96. Excellent ROM emerged in 13 patients. The knee function score was 90.5 on average. CONCLUSIONS: The main causes of distal femoral nonunion and delayed union are improper indications and improper use of the implants. RIIN is an effective alternative for treatment of distal femoral nonunion and delayed union because it can provide a stable and reliable fixation which is beneficial for early functional exercise of knee. Bone grafting, closed reaming and intra-articular release of knee adhesion should be considered in order to enhance the bone healing and improve ROM and the knee function.

Adult↗

Functional and histologic effects of a free nonvascularised muscle graft implanted into a reinnervated muscle after prolonged denervation.

Striated muscle atrophy and degeneration, which increase with the delay of denervation, represent two of the main causes for poor recovery following delayed nerve repair. The present study, using a rat model, tests the hypothesis that an adjunction of small, free, nonvascularised muscle grafts of contralateral healthy triceps into a chronically denervated triceps improves muscle regeneration and recovery following sciatic nerve repair delayed for 3 months. Our experiments seem to show a relative increase in mechanical properties in animals in which free muscle graft into the triceps was performed 3 weeks following nerve repair. The improvement of the regenerative process of muscles which have suffered a long period of denervation should be considered as an additional therapeutic procedure in the case of late nerve repair.

Animals↗

Neurobiology of the regenerating retina and its functional reconnection with the brain by means of peripheral nerve transplants in adult rats.

Axotomy-induced degradation of retinal ganglion cells (RGC) can be delayed if the destructive features of activated microglial cells are pharmacologically neutralized, and prevented if the axons are permitted to regrow into transplanted autologous peripheral nerve (PN) pieces. Axotomized central nervous system neurons, whose regenerating axons are guided to their natural target areas in the brain with the aid of PN grafts, are capable of establishing synaptic contacts with normal morphological and electrophysiological properties. This study was undertaken to 1) morphometrically characterize and classify the regenerating rat RGC, 2) examine target-dependent effects on survival of subsets of neurons, and 3) investigate whether reconnected neurons are capable of restoring visual functions. In analogy to the normal rat retina, as a first step, the retrogradely labeled, regenerating RGC were categorized into five classes which are morphologically distinct and reminiscent of normal RGC correlates (called types RI, RII, RIII, Rdelta-cells, and displaced RGC). It appeared that all types of ganglion cells contributed proportionally to regeneration of axons. Transplantation of a PN graft which was not reconnected with a central target (blind-ending group) and monitoring of the extant neurons showed a progressive disappearance of the regenerating RGC, such that 6 months after surgery predominantly few, large cells survived. When the retinas were treated with macrophage/microglia inhibiting factor (MIF), and the regenerating axons were guided into the pretectum, predominantly large RGC of type RI survived. Guidance of the axons into their major natural target, the superior colliculus (SC), resulted in selective survival of many small, RII-like RGC. Calculation of the dendritic coverage factors for the major types of RGC revealed that dendrites of the most abundant, small cells of type RII overlapped uniformly and covered the retinal surface completely, whereas cells of types RI and RIII did not suffice for surface coverage. The results of this first part of the work suggest that combined suppression of axotomy-induced microglial activation and guidance of regenerating axons with a PN graft into central targets is a suitable technique to produce sufficient numbers of regenerating axons which may retrieve some functional properties. Target-specific neuronal contacts are likely involved in morphological stabilization and better survival of regenerating neurons. The second goal of this study was to analyze the functional significance of the reestablished synaptic contacts made by regenerated retinocollicular neurons. Adult rats were trained in a T- or Y-maze to obtain a food reward with the aid of visual cues. One of their optic nerves was transected and the regenerating axons were guided into the optic tract with a PN graft, to enable them to reinnervate the SC and thalamus. Postoperative testing of the animals showed a drastic improvement of visual perception. The protocol of denervation of the SC (prior to, simultaneous with, or with a delay with respect to fiber arrival) determined the performance of the animals. Rats belonging to the first two groups performed almost as well as they had before the transplantation. The functional integrity of the retina was assessed by electroretinography, which revealed typical rod spectral sensitivity at 380 and 500 nm but reduced responsiveness to illumination. In accordance, neuroanatomical assessment of the functionally relevant RGC revealed intact morphologies and multiple synaptic contacts both within the retina and within the SC. Neuroanatomical tracing of small contingents of axons throughout the regenerative pathway revealed a rough retinotopic arrangement within the graft and the area of termination. Thus, animals could discriminate between simplified vertical versus horizontal stripes, and visual evoked potentials were positive after grafting. (ABSTRACT TRUNCATED)

Animals↗