Recurrent Hepatitis C After Liver Transplantation Experience of the First 21 Patients Treated in Lausanne

BACKGROUND AND AIM: Recurrent hepatitis C is a major cause of morbidity and mortality after liver transplantation (LT), and optimal treatment algorithms have yet to be defined. Here, we present our experience of the first 21 patients with recurrent hepatitis C treated in Lausanne. PATIENTS AND METHODS: Twenty-one patients with histologyproven recurrent hepatitis C after LT were treated since 2003. Treatment was initiated with pegylated interferon-α2a 135 μg per week and ribavirin 400 mg per day in the majority of patients, and subsequent doses were adapted individually based on on-treatment virological responses and clinical and/or biochemical side effects. RESULTS: On an intention-to-treat basis, sustained virological response (SVR) was achieved in 12/21 (57%) patients (5/11 [45%], 2/3 [67%], 4/5 [80%] and 1/2 [50%] of patients infected with genotypes 1, 2, 3 and 4, respectively). Two patients experienced relapse and 6 did not respond to treatment (NR). Treatment duration ranged from 24 to 90 weeks. It was stopped prematurely due to adverse events in 5/21 (24%) patients (with SVR achieved in 2 patients, NR in 2 patients, and death of one patient awaiting re-transplantation). Of note, SVR was achieved in a patient with combined liver and kidney transplantation. Importantly, SVR was achieved in some patients despite the lack of an early virological response or HCV RNA negativity at week 24. Darbepoetin α and filgrastim were used in 33% and 14%, respectively. CONCLUSION: Individually adapted treatment of recurrent hepatitis C can achieve SVR in a substantial proportion of LT patients. Conventional stopping rules do not apply in this setting so that prolonged therapy may be useful in selected patients.

Prevalence of infection in kidney transplantation from living versus deceased donor: systematic review and meta-analysis

OBJECTIVE To verify if the type of donor is a risk factor for infection in kidney transplant recipients. METHODS Systematic Review of Literature with Meta-analysis with searches conducted in the databases MEDLINE, LILACS, Embase, Cochrane, Web of Science, SciELO and CINAHL. RESULTS We selected 198 studies and included four observational studies describing infections among patients distinguishing the type of donor. Through meta-analysis, it was shown that in patients undergoing deceased donor transplant, the outcome infection was 2.65 higher, than those who received an organ from a living donor. CONCLUSION The study showed that deceased kidney donor recipients are at an increased risk for developing infections and so the need for establishing and enforcing protocols from proper management of ischemic time to the prevention and control of infection in this population emerges.

High Specificity of C4d/CD68 Staining for the Diagnosis of Late Antibody-Mediated Rejection in Heart Transplantation.

In heart transplantation (HTx), acute antibody-mediated rejection (AMR) is infrequent but carries high mortality and increased risk of graft vasculopathy. The diagnosis requires evidence of acute graft dysfunction, capillary lesions on endomyocardial biopsy (EMB), and immunopathological criteria of antibodymediated injury. Multiple markers of antibody-mediated injuries have been proposed, but there is ample debate on their usefulness. In kidney transplantation, C4d deposition in peritubular capillaries is a reliable marker of alloantibody-dependant graft injury. In this study, we prospectively screened all EMBs for C4d and CD68 in new HTx recipients, and correlated pathological fi ndings with immunological evidence of donor-specifi c antibodies (DSA) and graft dysfunction. Methods Between Nov 05 and Aug 08, we had 22 HTx, and 17 cases were analysed. All recipients received polyclonal rabbit anti-thymocytes globulin, calcineurin inhibitors, mycophenolate mofetil, and corticosteroids (weaning in 6 -12 months). They had EMB every 1-2 weeks in the fi rst 3 months, and then monthly for 9 months. C4d and CD 68 were assessed by immunochemistry. Echocardiography and DSA assessment or crossmatch (early phase) were realised if C4d or CD68 staining was positive. Results There was 1 early and 1 late AMR. Table 1 C4d and CD68 positive, at least 1 EMB 6 / 17; 35% 1 treated C4d and CD68 positive, at least 2 consecutive EMBs 3 / 17; 17.5% 1 treated C4d and CD68 positive, and graft dysfunction 1 / 17; 6% 1 treated C4d and CD68 positive, with DSA and crossmatch + 1 / 17; 6% 1 treated Table 2 C4d and CD68 positive, at least 1 EMB 1 / 17; 6% 1 treated C4d and CD68 positive, at least 2 consecutive EMBs 1 /17; 6% 1 treated C4d and CD68 positive and graft dysfunction 1 / 17; 6% 1 treated C4d and CD68 positive, and + DSA 1 / 17; 6% 1 treated Conclusion In this single-center experience, C4d / CD68 positive staining was frequent in the early phase and raised the question of false positive cases of AMR. However, these markers showed high specifi city for the diagnosis of AMR in the late phase. Of course these data need to be confi rmed in larger multi-center studies.

Mothers' perceptions of care practices for children who underwent heart transplantation

Abstract OBJECTIVE To learn mothers' perceptions of the main care practices that are to be administered after their children's heart transplantation, as well as the main difficulties they experience. METHOD A descriptive qualitative study conducted in March and April 2014, using the focus group technique for data gathering. Participants were 12 mothers who were monitoring their children in a hospital that is a reference for treating cardiopulmonary diseases. Speeches were recorded, transcribed, and organized around the care practices that the mothers performed after the children's heart transplantations, the mothers' main difficulties, their perceptions of their children's quality of life, and the use of educational materials to disseminate post-transplantation care practices. For data analysis, we used the content analysis technique. RESULTS The following were clarified: the schedule of immunosuppressive medication; food, environmental, and bodily and oral hygiene; the use of surgical masks; and keeping the children away from crowds. CONCLUSION The study contributed to the situational diagnosis of the care administered by the mothers of transplanted children.

Reduction of connexin36 content by ICER-1 contributes to insulin-secreting cells apoptosis induced by oxidized LDL particles.

Connexin36 (Cx36), a trans-membrane protein that forms gap junctions between insulin-secreting beta-cells in the Langerhans islets, contributes to the proper control of insulin secretion and beta-cell survival. Hypercholesterolemia and pro-atherogenic low density lipoproteins (LDL) contribute to beta-cell dysfunction and apoptosis in the context of Type 2 diabetes. We investigated the impact of LDL-cholesterol on Cx36 levels in beta-cells. As compared to WT mice, the Cx36 content was reduced in islets from hypercholesterolemic ApoE-/- mice. Prolonged exposure to human native (nLDL) or oxidized LDL (oxLDL) particles decreased the expression of Cx36 in insulin secreting cell-lines and isolated rodent islets. Cx36 down-regulation was associated with overexpression of the inducible cAMP early repressor (ICER-1) and the selective disruption of ICER-1 prevented the effects of oxLDL on Cx36 expression. Oil red O staining and Plin1 expression levels suggested that oxLDL were less stored as neutral lipid droplets than nLDL in INS-1E cells. The lipid beta-oxidation inhibitor etomoxir enhanced oxLDL-induced apoptosis whereas the ceramide synthesis inhibitor myriocin partially protected INS-1E cells, suggesting that oxLDL toxicity was due to impaired metabolism of the lipids. ICER-1 and Cx36 expressions were closely correlated with oxLDL toxicity. Cx36 knock-down in INS-1E cells or knock-out in primary islets sensitized beta-cells to oxLDL-induced apoptosis. In contrast, overexpression of Cx36 partially protected INS-1E cells against apoptosis. These data demonstrate that the reduction of Cx36 content in beta-cells by oxLDL particles is mediated by ICER-1 and contributes to oxLDL-induced beta-cell apoptosis.

Should possible recurrence of disease contraindicate liver transplantation in patients with end-stage alveolar echinococcosis? A 20-year follow-up study.

Liver transplantation (LT) is currently contraindicated in patients with residual or metastatic alveolar echinococcosis (AE) lesions. We evaluated the long-term course of such patients who underwent LT and were subsequently treated with benzimidazoles. Clinical, imaging, serological, and therapeutic data were collected from 5 patients with residual/recurrent AE lesions who survived for more than 15 years. Since 2004, [(18) F]-2-fluoro-2-deoxyglucose (FDG)-positron emission tomography (PET) images were available, and the levels of serum antibodies (Abs) against Echinococcus multilocularis-recombinant antigens were evaluated. Median survival time after LT was 21 years. These patients were from a prospective cohort of 23 patients with AE who underwent LT: 5 of 8 patients with residual/recurrent AE and 4 of 9 patients without residual/recurrent AE were alive in September 2009. High doses of immunosuppressive drugs, the late introduction of therapy with benzimidazoles, its withdrawal due to side effects, and nonadherence to this therapy adversely affected the prognosis. Anti-Em2(plus) and anti-rEm18 Ab levels and standard FDG-PET enabled the efficacy of therapy on the growth of EA lesions to be assessed. However, meaningful variations in Ab levels were observed below diagnostic cutoff values; and in monitoring AE lesions, images of FDG uptake taken 3 hours after its injection were more sensitive than images obtained 1 hour after its injection. In conclusion, benzimidazoles can control residual/recurrent AE lesions after LT. Using anti-rEm18 or anti-Em2(plus) Ab levels and the delayed acquisition of FDG-PET images can improve the functional assessment of disease activity. The potential recurrence of disease, especially in patients with residual or metastatic AE lesions, should not be regarded as a contraindication to LT when AE is considered to be lethal in the short term.

Expression of killer cell immunoglobulin-like receptors (KIRs) by natural killer cells during acute CMV infection after kidney transplantation.

Human cytomegalovirus (CMV) infection may be a serious complication related to immunosuppression after solid organ transplantation. Due to their cytotoxicity, T-cells and natural killer (NK) cells target and clear the virus from CMV-infected cells. Although immunosuppressive drugs suppress T-cell proliferation and activation, they do not affect NK cells that are crucial for controlling the infection. The regulation of NK cells depends on a wide range of activating and inhibitory receptors such as the family of killer-cell immunoglobulin-like receptors (KIRs). Several human genetic studies have demonstrated the association of KIR genes with the clearance of infections. Since the respective activities of the different KIR proteins expressed by NK cells during CMV infection have not been extensively studied, we analyzed the expression of KIRs in a cohort of 22 CMV-IgG(+) renal transplant patients at the time of CMV reactivation, after antiviral therapy and 6 months later. Our data revealed a marked expression of KIR3DL1 during the acute phase of the reactivation. We set up an in vitro model in which NK cells, derived either from healthy donors or from transplanted patients, target allogeneic fibroblasts, CMV-infected or uninfected. Our results demonstrate a significant correlation between the lysis of CMV-infected fibroblasts and the expression of KIR3DL1. Blocking experiments with antibodies to MHC-I, to NKG2D and to NKG2C confirmed the importance of KIR3DL1. Consequently, our results suggest that KIR proteins and especially KIR3DL1 could play an important role during CMV-infection or CMV reactivation in immunosuppressed patients.

Homeostasis and in vivo effector function of antigen-specific CD4+CD25+ regulatory T cells in experimental transplantation.

CD4+CD25+ regulatory T cells (Tregs) play a critical role in the prevention of autoimmune diseases as well as in the induction and maintenance of dominant tolerance in transplantation models. While their suppressive function has been extensively studied in vitro, their homeostasis and mechanisms of immunoregulation still remain to be clarifi ed in vivo. Using a murine adoptive transfer and skin allograft model, we analysed the expansion, effector function and traffi cking of effector T cells in the presence or absence of donor-specifi c Tregs. Although hyporesponsive to allogeneic and polyclonal stimulation in vitro, transferred Tregs survived and expanded, in response to an allograft in vivo. When co-transferred with naive CD4+CD25- effector T cells, they specifi cally prevented donor but not 3rd party allograft rejection by inhibiting the production of effector cytokines rather than the proliferation of effector T cells in response to alloantigens. The co-transfer of donor-specifi c Tregs did not affect the homing of effector T cells towards the graft draining lymph nodes, but it markedly reduced the infi ltration of the allograft by these pathogenic cells. Furthermore, in recipients where donor-specifi c transplantation tolerance was induced, Tregs preferentially accumulated in the allograft draining lymph nodes and within the grafted skin itself. Taken together, our results suggest that the suppression of graft rejection is an active process that involves the persistent presence of Tregs at the site of antigenic challenge.

Use of long-term suppressive acyclovir after hematopoietic stem-cell transplantation: impact on herpes simplex virus (HSV) disease and drug-resistant HSV disease.

The effect that long-term use of suppressive acyclovir (ACV) has on both overall herpes simplex virus (HSV) disease and ACV-resistant HSV disease was examined in 3 consecutive cohorts of hematopoietic stem-cell transplant (HCT) recipients (n=2049); cohort 1 received ACV for 30 days after HCT, cohort 2 received it for 1 year after HCT, and cohort 3 received it for an extended period (i.e., >1 year) if the patient's immunosuppression continued after 1 year. The 2-year probability of HSV disease was 31.6% (95% confidence interval [CI], 28.0%-35%) in cohort 1, 3.9% (95% CI, 2.7%-5.2%) in cohort 2, and 0% in cohort 3 (P<.001). ACV-resistant HSV disease developed in 10 patients in cohort 1 (2-year probability, 1.3% [95% CI, 0.8%-2.7%]), in 2 patients in cohort 2 (2-year probability, 0.2% [95% CI, 0%-0.8%]; P=.006), and in 0 patients in cohort 3 (cohort 2 vs. cohort 3, P=.3). Long-term use of suppressive prophylactic ACV appears to prevent the emergence of drug-resistant HSV disease in HCT.

Transplanted beta cell response to increased metabolic demand. Changes in beta cell replication and mass

We determined the capacity of transplanted beta cells to modify their replication and mass when stimulated by changes in metabolic demand. Five groups of Lewis rats were studied: group 1 (Tx-Px) had a 95% pancreatectomy 14 d after transplantation of 500 islets; group 2 (Px-Tx) had a 95% pancreatectomy 14 d before transplantation of 500 islets; group 3 (Tx) was transplanted with 500 islets; group 4 (Px) had a 95% pancreatectomy; and group 5 (normal) was neither transplanted nor pancreatectomized. Blood glucose was normal in Tx-Px and Tx groups at all times. Px-Tx and Px groups developed severe hyperglycemia after pancreatectomy that was corrected in Px-Tx group in 83% of rats 28 d after transplantation. Replication of transplanted beta cells increased in Tx-Px (1.15 +/- 0.12%) and Px-Tx (0.85 +/- 0.12%) groups, but not in Tx group (0.64 +/- 0.07%) compared with normal pancreatic beta cells (0.38 +/- 0.05%) (P < 0.001). Mean beta cell size increased in Tx-Px (311 +/- 14 microns2) and Px-Tx (328 +/- 13 microns2) groups compared with Tx (252 +/- 12 microns2) and normal (239 +/- 9 microns2) groups (P < 0.001). Transplanted beta cell mass increased in Tx-Px (1.87 +/- 0.51 mg) and Px-Tx (1.55 +/- 0.21 mg) groups compared with Tx group (0.78 +/- 0.17 mg) (P < 0.05). In summary, changes in transplanted beta cells prevented the development of hyperglycemia in Tx-Px rats. Transplanted beta cells responded to increased metabolic demand increasing their beta cell mass.

Prospective monitoring of a CD4+ CD25high CD45RO+ CD127high T-cell population after first kidney transplantation following thymoglobulin or basiliximab induction

Background: Recent data have suggested that a population of CD4+ CD25high T cells, phenotypically characterized by the expression of CD45RO and CD127, is significantly expanded in stable liver and kidney transplant recipients and represents alloreactive T cells. Induction therapies may have an impact on this alloreactive T cell population. In this study, we prospectively analyzed CD4+ CD25high CD45RO+ CD127high T cells after induction with either thymoglobulin or basiliximab. Patients and methods: A total of twenty-seven kidney transplant recipients were prospectively enrolled; 14 received thymoglobulin induction followed by a 4-day course of steroids with tacrolimus and mycophenolate mofetil («thymo group»), and 13 received basiliximab induction followed by standard triple immunosuppression (tacrolimus, mycophenolate mofetil and prednisone) («BSX group»). Phenotypical analysis by flow cytometry of the expression of CD25, CD45RO and CD127 on peripheral CD4+ T cells was performed at 0, 3 and 6 months after transplantation. Twenty-four healthy subjects (HS) were studied as controls. Results: There were no differences in baseline characteristics between the groups; at 6 months, patient survival (100%), graft survival (100%), serum creatinine (thymo group versus BSX group: 129 versus 125 micromol/l) and acute rejection (2/14 versus 2/13) were not significantly different. Thymo induction produced a prolonged CD4 T cell depletion. As compared to pre-transplantation values, an expansion of the alloreactive T cell population was observed at 3 months in both thymo (mean: from 6.38% to 14.72%) and BSX (mean: from 8.01% to 18.42%) groups. At 6 months, the alloreactive T cell population remained significantly expanded in the thymo group (16.92 ± 2.87%) whereas it tended to decrease in the BSX group (10.22 ± 1.38%). Conclusion: Overall, our results indicate that the expansion of alloreactive T cells occurs rapidly after transplantation in patients receiving either thymo or BSX induction. Whether differences at later timepoints or whether different IS regimens may modify this alloreactive population remains to be studied.