RESUMEN
BACKGROUND: Recurrence of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection after liver transplantation is a clinical problem. Polyclonal immunoglobulins against hepatitis B surface antigen (HBIGs) prevent the recurrence of HBV infection, but no effective prophylaxis is available for HCV infection. Before screening of blood donors was introduced in France, HBIGs may have contained antibody to HCV (anti-HCV). OBJECTIVE: To determine the influence of HBIG on the occurrence of hepatitis C after liver transplantation before and after 1990. DESIGN: Retrospective cohort study. SETTING: Liver transplantation unit of a university hospital. PATIENTS: 428 consecutive patients who had liver transplantation because of cirrhosis between 1984 and 1994. MEASUREMENTS: Detection of serum HCV RNA before and 1 year after transplantation and findings on liver graft biopsy. RESULTS: Among the 218 patients who had HCV infection before transplantation, the incidence of HCV viremia after transplantation was lower in those receiving HBIG than in those not receiving HBIG (25 of 46 patients [54%] compared with 162 of 172 patients [94%]; P < 0.001). In patients receiving HBIG, the incidence of HCV viremia after transplantation was lower among those who had transplantation before March 1990 than among those who had transplantation after this date (15 of 33 patients [45%] compared with 10 of 13 patients [77%]; P = 0.05). Among the 210 patients without HCV infection before transplantation, acquired infection was significantly less frequent in those receiving HBIG than in those not receiving HBIG (18 of 68 patients [26%] compared with 40 of 86 patients [47%]; P < 0.001). Passively transmitted anti-HCV was transiently detected in patients receiving HBIG before March 1990. Multivariate analysis in patients with HCV infection before transplantation showed that the absence of HBIG and transplantation after March 1990 were independent significant risk factors for chronic hepatitis C after transplantation. CONCLUSIONS: Polyclonal immunoglobulins that are treated for viral decontamination and contain anti-HCV could prevent HCV infection.
Asunto(s)
Antígenos de Superficie de la Hepatitis B/inmunología , Anticuerpos contra la Hepatitis C/administración & dosificación , Hepatitis C/prevención & control , Trasplante de Hígado/inmunología , Viremia/prevención & control , Adulto , Análisis de Varianza , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Hepacivirus/aislamiento & purificación , Hepatitis C/epidemiología , Humanos , Incidencia , Cirrosis Hepática/cirugía , Masculino , Persona de Mediana Edad , ARN Viral/sangre , Recurrencia , Estudios Retrospectivos , Estadística como Asunto , Viremia/epidemiologíaRESUMEN
BACKGROUND AND OBJECTIVES: Citrate reactions are uncomfortable and potentially dangerous to apheresis donors. Reduction of citrate increases comfort, but may lead to platelet clumping. MATERIALS AND METHODS: We describe a protocol for stepwise reduction of the volume of ACD-A injected during plateletpheresis. This protocol has been carried out in 45 healthy donors with the Cobe 2997 (Cobe) cell separator, and in 35 with the Fenwal-CS 3000 (CS). RESULTS: Using this protocol, during the first hour of platelet collection, ionised calcium decreased on average by 18% for CS and by 18.4% for Cobe. During the second hour, Ca2+ and citrate ion concentration did not change with either Cobe or CS (about 65% of citrate ion load is eliminated). We observed mild signs of neuromuscular hyperexcitability in only 22% and 28% of donors with Cobe and CS, respectively. We also found a significant reduction of phosphate ions (p < 0.0001) at the end of the procedures. CONCLUSIONS: With this stepdown citrate reduction protocol, we obtained a significant reduction of injected citrate without the complication of platelet clumps.
Asunto(s)
Calcio/sangre , Ácido Cítrico/sangre , Plaquetoferesis/métodos , Proteínas Sanguíneas/análisis , Femenino , Humanos , Concentración de Iones de Hidrógeno , Recuento de Leucocitos , Masculino , Parestesia/inducido químicamente , Fosfatos/análisis , Agregación Plaquetaria , Recuento de Plaquetas , Factores de TiempoRESUMEN
BACKGROUND/AIMS: The aim of this study was to clarify the aetiology of apparent de novo HBV infection after liver transplantation. METHODS: Twenty out of 570 HBsAg negative patients (3.5%) became HBsAg positive after transplantation and were studied. Donor and recipient sera were retrospectively tested for HBsAg, anti-HBs, anti-HBc, and HBV DNA by PCR. Donor and recipient livers were tested for HBV DNA by PCR on paraffin-embedded tissue. RESULTS: Group 1: HBV infection of donor origin (eight patients): one donor serum was HBsAg positive, three were serum HBV DNA positive, four were liver HBV DNA positive. Group 2: reactivation of latent HBV infection (eight patients) with detection of HBV DNA in pretransplant serum (seven patients) or in native liver (one patient): three were anti-HBs positive, two anti-HBc positive, and three with fulminant hepatitis had no serological HBV markers. Group 3: undetermined origin (four patients) defined by absence of HBV DNA in pretransplant donor and/or recipient sera and liver; however, acquired infection was suspected from two anti-HBs and anti-HBc positive donors. Two patients became HBsAg negative, and five HBV DNA negative. One died from HBV-cirrhosis and two were retransplanted. In the others, the last histology showed cirrhosis (three), chronic hepatitis (nine), acute hepatitis (one), and non-specific change (four patients). CONCLUSIONS: The prevalence of de novo HBV infection in liver transplant patients was 3.5%; the aetiology was determined in 16/20 patients: from the donor in eight, and from the recipient in eight. One should be cautious when donors or recipients are anti-HBc or both anti-HBs and anti-HBc positive.
Asunto(s)
ADN Viral/análisis , Virus de la Hepatitis B/genética , Hepatitis B/etiología , Trasplante de Hígado/efectos adversos , Adulto , Antivirales/uso terapéutico , Biomarcadores , Femenino , Estudios de Seguimiento , Rechazo de Injerto/inmunología , Rechazo de Injerto/patología , Rechazo de Injerto/terapia , Hepatitis B/epidemiología , Hepatitis B/transmisión , Anticuerpos contra la Hepatitis B/análisis , Antígenos de Superficie de la Hepatitis B/inmunología , Virus de la Hepatitis B/inmunología , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Reacción en Cadena de la Polimerasa , Prevalencia , Recurrencia , Reoperación , Estudios Retrospectivos , Tasa de Supervivencia , Trasplante Homólogo/patología , Resultado del TratamientoAsunto(s)
Anticuerpos Antiidiotipos/sangre , Transfusión Sanguínea , Antígenos HLA-DR , Prueba de Histocompatibilidad , Trasplante de Riñón/inmunología , Linfocitos T Citotóxicos/inmunología , Adulto , Formación de Anticuerpos , Linfocitos B/inmunología , Femenino , Francia , Antígenos de Histocompatibilidad Clase I , Humanos , Inmunoglobulina G/sangre , Inmunoglobulina M/sangre , Fallo Renal Crónico/inmunología , Fallo Renal Crónico/cirugía , Masculino , Persona de Mediana Edad , Diálisis Renal , Linfocitos T/inmunología , Listas de EsperaRESUMEN
A retrospective analysis was undertaken to determine if the incidence, timing, and severity of acute and chronic rejection were influenced by the primary disease necessitating transplantation. Of the 875 liver transplantations performed between 1984 and 1992, 768 were primary transplantations and 107 were retransplantations. Among the former, 330 patients that were liver transplant recipients for a chronic liver disease without cancer in the native liver received an ABO-compatible and cross-match-negative graft and were given a cyclosporine- or tacrolimus-based immunosuppression. These included primary biliary cirrhosis (PBC, 66 patients), primary sclerosing cholangitis (PSC, 23 patients), alcoholic cirrhosis (ALC, 21 patients), autoimmune cirrhosis (AIC, 17 patients), hepatitis B virus-induced cirrhosis (HBV-C, 116 patients) and hepatitis C virus-induced cirrhosis (HCV-C, 87 patients). The incidence of acute (48% +/- 3% [SE] at 1 year) and chronic rejection (10% +/- 2% at 3 years) was comparable in patients who have undergone transplantation for PBC, PSC, AIC, and HCV-C. However, the incidence of acute (but not chronic) rejection was significantly lower in patients who have undergone transplantation for ALC (29% at 1 year). This reduced incidence of acute rejection was associated with an increased incidence of bacterial infections. In patients who have undergone transplantation for HBV-C (the majority of whom had received long-term anti-hepatitis B surface antigen [HBs] immunoglobulins), the incidence of both acute (21% at 1 year) and chronic rejection (0% at 3 years) was significantly lower, whereas the incidence of septic complications was comparable with that in the other groups. The incidence of acute rejection in patients who have undergone transplantation for nonviral disease receiving polyclonal human anti-cytomegalovirus (CMV) immunoglobulins was also significantly lower than that of patients who did not receive the immunoglobulins (19% vs. 48% at 3 months; P = .01), and this was identical to that of patients who have undergone transplantation for viral disease receiving polyclonal human anti-HBs immunoglobulins (19% at 3 months). These results show that the risk of rejection is unequal among patients, being lower in patients who have undergone transplantation for ALC (probably as a result of a state of nonspecific hyporesponsiveness) and in patients who have undergone transplantation for HBV-C (possibly as a result of long-term administration of polyclonal human immunoglobulins).
Asunto(s)
Infecciones Bacterianas/epidemiología , Rechazo de Injerto/epidemiología , Inmunoglobulinas/fisiología , Hepatopatías/cirugía , Trasplante de Hígado , Complicaciones Posoperatorias , Adulto , Femenino , Rechazo de Injerto/fisiopatología , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Incidencia , Hepatopatías/clasificación , Hepatopatías Alcohólicas/cirugía , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Retrospectivos , Factores de TiempoAsunto(s)
Sistema del Grupo Sanguíneo ABO , Incompatibilidad de Grupos Sanguíneos , Trasplante de Hígado/inmunología , Análisis Actuarial , Enfermedad Aguda , Estudios de Seguimiento , Rechazo de Injerto/epidemiología , Supervivencia de Injerto , Humanos , Trasplante de Hígado/mortalidad , Factores de TiempoRESUMEN
The aim of this study was to assess the long term results of 43 ABO-incompatible liver transplantations performed in 40 patients. The 5-year patient and graft survival rates were 50 and 20%, respectively. In the group of patients transplanted in emergency for fulminant or subfulminant liver failure, ABO incompatibility had no significant impact on patient survival (P = 0.09). Graft survival, however, was significantly impaired (P = 0.0002) through a greater incidence of hyperacute rejection (20%), vascular thrombosis, and biliary injury (56%). Increasing the magnitude of immunosuppression and postoperatively reducing the titer of anti A/B antibodies by plasmapheresis had little influence on the incidence of these complications and were associated with a greater incidence of septic complications. These results indicate that the use of ABO-incompatible liver grafts is a life-saving procedure in patients with life-threatening acute liver failure, but at a high price. Justification for accepting or not accepting an ABO-incompatible graft in these emergency situations depends on the personal choice in giving priority to saving the patient in an acute life-threatening condition or to giving the graft the best chance of success. To avoid this difficult choice, efforts should aim at expanding the pool of grafts available in emergency, at developing artificial support devices that could allow to safely delay transplantation, or at more efficiently controlling the humoral response.
Asunto(s)
Sistema del Grupo Sanguíneo ABO , Incompatibilidad de Grupos Sanguíneos , Supervivencia de Injerto , Trasplante de Hígado/inmunología , Análisis Actuarial , Adulto , Transfusión Sanguínea , Femenino , Rechazo de Injerto/epidemiología , Encefalopatía Hepática/cirugía , Humanos , Terapia de Inmunosupresión/métodos , Fallo Hepático/cirugía , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Plasmaféresis , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Sepsis/epidemiología , Factores de Tiempo , Donantes de TejidosRESUMEN
A randomized double-blind controlled trial was conducted to determine the efficacy of passive immunotherapy in the treatment of symptomatic human immunodeficiency virus (HIV) infection. This trial included 86 symptomatic patients randomized to receive plasma rich in anti-HIV-1 antibody or standard seronegative plasma. Each patient in both groups received a 300-ml infusion every 14 days over a 1-year period, and every 28 days thereafter, in addition to zidovudine and other conventional prophylactic treatments. Plasma donors were selected among symptomless seropositive individuals with a CD4 lymphocyte count > or = 400 x 10(6) cells per liter, a negative p24 antigen assay, and a high concentration of anti-p24 antibody. The plasmas were heat-inactivated before infusion. During the study period (day 28-day 365) scheduled by the protocol, clinical benefit from passive immunotherapy was observed in delaying the appearance of the first AIDS-defining event (P < 0.009) and reducing the cumulative incidence of such events, which was estimated 3-fold higher in the control group compared to the treatment group. Seven deaths occurred in the treatment group vs. 11 in the control group (P = 0.27). A total of 47 patients died or exhibited new AIDS-defining events, 18 in the treatment group and 29 in the control group (P = 0.009). No clinical benefit was observed after the 1-year period with infusions performed every 4 weeks. These results indicate a favorable effect of passive immunotherapy on the evolution of advanced AIDS.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/terapia , Transfusión Sanguínea , Anticuerpos Anti-VIH/uso terapéutico , Inmunoglobulinas Intravenosas/uso terapéutico , Adulto , Método Doble Ciego , Femenino , Seronegatividad para VIH , Humanos , Inmunoterapia Adoptiva , Masculino , Persona de Mediana EdadRESUMEN
Liver transplantation for liver diseases related to hepatitis B virus (HBV) and hepatitis delta virus (HDV) remains problematic because of the risk of viral recurrence. We report here the long-term virological outcome of patients transplanted for HDV-related liver cirrhosis (HDV cirrhosis). From December 1984 to December 1990, 76 patients with HDV cirrhosis underwent liver transplantation. Before transplantation, all the patients were HBsAg-positive/anti-HDV positive, and all but one were HBV DNA-negative by dot blot hybridization. HDV RNA was detected by HDV RT-PCR and liver HDAg by fluorescent HDV Ab. After transplantation, all the patients except four received continuous long-term anti-HBs passive immunoprophylaxis. The actuarial 5-year survival was 88%. All patients who did not receive anti-HBs immunoprophylaxis remained HBsAg-positive and developed hepatitis. Among the 68 patients receiving antiHBs immunoprophylaxis with a minimum follow-up of 2 months, HBsAg reappeared in 7 (10.3%) after a mean of 17 months. These seven patients developed hepatitis, with simultaneous HBV and HDV replication; and four cleared later HBsAg. Patients without HBV reinfection were studied for HDV reinfection: liver HD Ag or serum HDV RNA were present in 88% of the patients during the first year, without developing hepatitis; however, they were no longer detectable after 2 years in 95% of the patients. In conclusion, liver transplantation for HDV cirrhosis gives good results, with a 5-year actuarial survival of 88%.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Hepatitis D/complicaciones , Cirrosis Hepática/cirugía , Cirrosis Hepática/virología , Trasplante de Hígado , Análisis Actuarial , Adulto , Enfermedad Crónica , ADN Viral/sangre , Femenino , Estudios de Seguimiento , Hepatitis B/complicaciones , Hepatitis B/terapia , Antígenos de Superficie de la Hepatitis B/sangre , Virus de la Hepatitis B/genética , Hepatitis D/terapia , Virus de la Hepatitis Delta/genética , Humanos , Inmunoterapia Adoptiva , Cirrosis Hepática/sangre , Cirrosis Hepática/mortalidad , Masculino , Persona de Mediana Edad , ARN Viral/sangre , Recurrencia , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Orthotopic liver transplantation in patients with hepatitis B-related cirrhosis is commonly complicated by reinfection with the hepatitis B virus, with rapidly progressive liver disease and poor survival rate. We assessed the efficacy of prior therapy with recombinant interferon-alpha on the prevention of posttransplantation hepatitis B virus reinfection. Twenty-two patients with hepatitis B-related cirrhosis waiting for liver transplantation received 3 MU (decreased to 1.5 MU in cases of intolerance) of recombinant interferon-alpha until transplantation. The rates of posttransplantation hepatitis B virus reinfection and survival in this group were compared with those in a group of 26 patients previously given transplants for the same disease but not given interferon therapy. The same protocol of HBs antibody passive immunoprophylaxis was applied after transplantation in both groups. Recombinant interferon-alpha was administered for 14 +/- 7 wk. The treatment had an antiviral effect, with disappearance of serum hepatitis B virus DNA in seven of the eight patients initially positive for hepatitis B virus DNA and disappearance of HBeAg in two of the three patients initially positive for HBeAg. Serum hepatitis B virus DNA remained detectable with polymerase chain reaction at transplantation in 56% of the interferon-treated patients. After transplantation, hepatitis B virus reinfection was more frequent in polymerase chain reaction-positive than in polymerase chain reaction-negative patients (78% vs. 17%, p < 0.05). One patient's condition deteriorated during interferon treatment; this patient was not given a transplant. Two patients (in whom hepatitis B virus DNA disappeared from serum) improved so markedly during treatment that they were not given transplants.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Hepatitis B/terapia , Interferón Tipo I/uso terapéutico , Cirrosis Hepática/cirugía , Trasplante de Hígado , Adulto , ADN Viral/sangre , Femenino , Hepatitis B/etiología , Hepatitis B/prevención & control , Virus de la Hepatitis B/genética , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/microbiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Proteínas Recombinantes , RecurrenciaRESUMEN
In an attempt to reduce anti-HLA immunization in 15 patients awaiting for renal grafts and who were immunized against 65% of a panel of lymphocytes (titre 1/8 to 1/128), were given 5 to 7 sessions of immunoadsorption on protein A columns, immunosuppressor drugs (corticosteroids: 1 mg/kg/day + cyclophosphamid: 2 mg/kg/day) and intravenous polyclonal immunoglobulins. The antibody titres decreased in all patients, but this protocol did not sufficiently block resynthesis of antibodies. Among the 12 patients who were transplanted, the graft functioned correctly in 8 after a follow-up of 3 months to 3 years. Three early graft failures occurred in the group of 5 patients whose had had a positive cross-match before treatment. This treatment did not appear to increase the frequency of infectious complications immediately after transplantation.
Asunto(s)
Antígenos HLA/inmunología , Inmunoglobulina G , Técnicas de Inmunoadsorción , Trasplante de Riñón , Plasmaféresis , Adulto , Femenino , Rechazo de Injerto/inmunología , Rechazo de Injerto/prevención & control , Humanos , Inmunoglobulinas Intravenosas/uso terapéutico , Terapia de Inmunosupresión , Inmunosupresores/uso terapéutico , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios , Sefarosa , Proteína Estafilocócica AAsunto(s)
ADN Viral/análisis , Antígenos de Superficie de la Hepatitis B/sangre , Virus de la Hepatitis B/aislamiento & purificación , Hepatitis B/complicaciones , Inmunización Pasiva , Cirrosis Hepática/cirugía , Trasplante de Hígado/patología , Biopsia , ADN Viral/sangre , ADN Viral/genética , Hepatitis B/prevención & control , Hepatitis B/cirugía , Virus de la Hepatitis B/genética , Humanos , Hibridación in Situ , Cirrosis Hepática/microbiología , Trasplante de Hígado/fisiología , Trasplante HomólogoRESUMEN
End-stage renal disease (ESRD) patients with high levels of anti-HLA panel reactive antibodies (PRA) represent an increasing group in which sensitization, induced by pregnancies, previous transplants, and blood transfusions, considerably delay the opportunity to receive a graft. Currently, more than 50% of the 4700 patients awaiting transplantation in France are sensitized, of which 33% are defined as hyperimmunized (PRA greater than = 80%), and only 9.5% of the total number of transplants have been done in highly sensitized recipients. The magnitude of this problem, similar in Europe and North America, explains why more active strategies for managing hyperimmunized patients have been introduced during the past decade. Clearly, the simplest is finding of a well-matched organ that does not carry the HLA antigens against which the recipient has generated antibody, but that is limited by the number of shared grafts. The second is the development of a new cross-matching technique prior to transplantation. Attempts at immunoregulation of secreting B cell clones have been carried out using either hypertransfusions or injection of polyclonal Ig. Finally, removal and prevention of the resynthesis of HLA antibodies is a most attractive approach using immunoadsorption (IA) system with sepharose-bound protein-A columns. In our unit, fifteen ESRD patients with high levels of PRA were treated with IA. Infectious complications were not observed after IA and transplantation, and the procedure was well tolerated. In spite of the use of adjunctive immunosuppressive treatment with cyclophosphamide and prednisolone, this method produced only variable effects in lowering PRA levels, and was hampered by high de novo resynthesis of anti-HLA antibodies.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Antígenos HLA/inmunología , Inmunización , Trasplante de Riñón , Anticuerpos/aislamiento & purificación , Linfocitos B/inmunología , Supervivencia de Injerto , Prueba de Histocompatibilidad , HumanosRESUMEN
We have investigated hepatitis C virus (HCV) viremia before and after orthotopic liver transplantation (OLT). 38 patients were examined; 16 were anti-HCV positive and 22 anti-HCV negative pre-OLT in a RIBA-2 test (Ortho Diagnostic Systems Inc., Westwood, MA). HCV-RNA was detected using a modified nested polymerase chain reaction in 14/38 and 10/38 patients before and after OLT, respectively. 7 of these 14 subjects who were HCV-RNA positive before OLT were also positive for serum hepatitis B surface antigen. After OLT, six patients became HCV-RNA positive, likely as a result of transfusions, while four developed a probable recurrence of HCV infection. Infection of the liver graft by the same strain of HCV was indeed demonstrated by sequence analysis of a hypervariable domain (in the envelope region) in two cases. This establishes the possibility of HCV recurrence and shows the usefulness of polymerase chain reaction as the only assay currently capable of identifying HCV infection after OLT.
Asunto(s)
Hepatitis C/etiología , Trasplante de Hígado/efectos adversos , Secuencia de Bases , Hepacivirus/genética , Humanos , Datos de Secuencia Molecular , Reacción en Cadena de la Polimerasa , ARN Viral/análisis , RecurrenciaRESUMEN
Controversy surrounds the indication of liver transplantation in patients with hepatitis B virus infection. The major problem is the very high risk of infection of the graft. Some investigators have suggested that the presence of HBsAg is a contraindication to liver transplantation. Between February 1975 and December 1990, 178 HBs positive patients were transplanted at Paul Brousse Hospital in Professor H. Bismuth's Department, 137 for post hepatitis cirrhosis and 41 for fulminant hepatitis. Since April 1984 we have decided long term immunoprophylactic therapy for all patients with HBs infection. But only from August 1987 our supply of purified anti HBs immunoglobulin has been adequate to treat all our patients according to the following protocol: 10.000 IU during the peroperative phase, 10.000 IU immediately after intervention, 10.000 IU every day for the first 6 days, 10.000 IU when the anti HBs levels were under 150 IU/l. One hundred thirty-nine patients were treated by this method. 110 cleared HBs antigen from their sera and their liver were biologically and histologically free of B virus infection. 29 patients showed reappearance of HBs antigen in their sera and nearly all of them developed objective, histologically confirmed, graft lesions. These lesions are those of classical infection: acute hepatitis, active chronic hepatitis and cirrhosis. So 79% of patients were successfully treated with a follow up of 45 months to 6 months. We also studied the prognostic factors under treatment. The study shows: in the case of fulminant hepatitis, 93% success versus 77% in post hepatitis cirrhosis; in the case of Delta superinfection, 94% success versus 66% with pure B infection; in the absence of HBVDNA in the patient's sera before transplantation, 92% success versus 20% in the presence of HBVDNA. For a better understanding of the overall results, the two following parameters have to be considered: some patients relapsed after stopping their treatment, some other patients, despite repositivation of HBs antigen in their sera showed a paradoxal good evolution. These considerations enable us to obtain HBVDNA positive patients: 10% success, HBVDNA negative patients: Fulminant hepatitis: 100% success B Delta post hepatitis cirrhosis: 100% success B post hepatitis cirrhosis: 92% success.
Asunto(s)
Antígenos de Superficie de la Hepatitis B/análisis , Hepatitis B/cirugía , Inmunoterapia , Trasplante de Hígado/inmunología , Humanos , RecurrenciaRESUMEN
To reduce anti-HLA immunization, 15 patients waiting for a renal graft received the following treatment: 5 to 7 immunoadsorption sessions on protein A-Sepharose columns, immunosuppressive drugs (corticosteroids 1 mg/kg (bw/day+cyclophosphamide 2 mg/kg bw/day) and iv polyclonal immunoglobulins. Before this treatment, panel-reactive antibodies ranged from 65 to 100% and antibody titers varied from 1/8 to 1/128. In all patients, antibody, titers were decreased. However, antibody resynthesis was incompletely blocked by this protocol. Eight out of 12 grafted patients had a functional kidney transplant 3 months to 3 years post-grafting. There early kidney failures occurred in the subgroup of 5 patients who had had historical positive cross matches prior to treatment. This treatment did not seem to increase the frequency of infectious complications before or after grafting.
Asunto(s)
Anticuerpos , Antígenos HLA/inmunología , Técnicas de Inmunoadsorción , Trasplante de Riñón , Adulto , Femenino , Supervivencia de Injerto , Humanos , Inmunoglobulina G , Masculino , Diálisis Renal/efectos adversos , Sefarosa , Proteína Estafilocócica ARESUMEN
Fifteen end-stage renal disease patients with high titres of panel reactive (PRA) antibodies were treated with immunoadsorption (IA) on sepharose-bound protein A columns in order to remove anti-HLA antibodies and facilitate transplantation. Infectious complications were not observed after IA and transplantation, and the procedure was well tolerated. In spite of the use of adjunctive immunosuppressive treatment with cyclophosphamide and prednisolone, this method produced only variable effects in lowering panel reaction antibodies, and was hampered by high de novo resynthesis of anti-HLA antibodies. Patients whose pre-IA antibody titre was greater than or equal to 1:64 clearly did not benefit from the procedure, but other immunological criteria were not predictive of efficacy. Twelve patients were transplanted on the basis of a negative cross-match with current serum, historical sera being retrospectively tested. Surprisingly, seven patients received a well-matched graft with both pre- and post-IA negative cross-matching. Graft survival was 86% in this group. Conversely, in the group of five transplants which were performed in recipients having a positive historical cross-match with the donor, graft survival was only 40%. One patient died with a functional graft, and two grafts failed due to hyperacute humoral rejection. Humoral rejection in a third patient was successfully treated by a second IA course and administration of polyclonal IgG. We conclude that IA is a safe procedure for managing hyperimmunized transplant candidates. However, its efficacy remains variable, and a better definition of patients who should benefit from IA needs to be found.
Asunto(s)
Anticuerpos/aislamiento & purificación , Antígenos HLA/inmunología , Trasplante de Riñón , Adsorción , Adulto , Femenino , Rechazo de Injerto , Prueba de Histocompatibilidad , Humanos , Fallo Renal Crónico/cirugía , Masculino , Persona de Mediana EdadRESUMEN
We have carried out a retrospective study over 308 liver transplant patients (31 of them have had a retransplantation) in Professor Bismuth's Department at Paul Brousse Hospital. The purpose of the study was a search for the possible effect of donor/recipient major histocompatibility complex on the evolution of the transplantation. We chose to study four parameters: early acute rejection; chronic rejection; retransplantation cases and death frequency; graft survival. We observed the following: for HLA A locus: in cases of total or partial compatibility there are more moderate early acute rejections than in the case of incompatibility (p less than 0.02); for HLA B locus: in the case of total compatibility there are more chronic rejections than in cases of partial or total incompatibility (p less than 0.03); for joint A and B locus: the results are similar to those of A locus (p less than 0.03); for HLA class I: we observed no effect either on graft survival or on retransplantation cases or on death frequency; for HLA DR: we did not find any effect on the studied parameters. Considering the low statistical significance of these results and in order to confirm our analysis, we have started a prospective study in collaboration with two other European Transplantation Centers.
Asunto(s)
Antígenos HLA/inmunología , Trasplante de Hígado/inmunología , Complejo Mayor de Histocompatibilidad , Rechazo de Injerto , Humanos , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
We examined 1,053 blood samples from 48 donors, for the effect of gradual reduction of citrate. We observed that: 1--Platelet count does not show any significant variation between 1/8 to 1/18 ratio. 2--In 13.3% of the cases, platelet clumping starts at 1/18 ratio. 3--There was no significant variation of the thrombin plasma level between 1/8 to 1/16 ratio (by measuring thrombin/ATIII complex). Our results show clearly that we can reduce the citrate ratio to 1/14 without expecting any adverse effect. Therefore we designated 1/14 as the security ratio. Parallel to this we also found that the average level +/- SD of ionized calcium is 100 +/- 10 muMol at 1/14 ratio.