Cryopreservation of islets of Langerhans

Development of techniques for cryopreservation of pancreatic islets of Langerhans could potentially allow for increased freedom from the time restrictions presently affecting viability in islet cell transplantation. While several investigators have attempted islet cell freezing and have obtained favorable in vitro results after thawing, there have been few reported in vivo successes with islets transplanted after freezing. We have developed a simple system for freezing islet cell pancreatic fragments to ?196 °C and have either stored them in liquid nitrogen for 24 hr or immediately thawed the islets prior to transplantation. In addition, antilymphoblast globulin has been used as graft pretreatment modality in order to modify islet cell immunogenicity. We found that ALG was effective in prolongation of graft survival after freezing as well as on fresh nonfrozen transplants. The use of freezing and ALG appears, therefore, to have a favorable effect on the immunogenicity of the pancreatic islet cell allograft.     

Preparation and biocompatibility of demineralized bone matrix/sodium alginate putty

Demineralized bone matrix (DBM) powder is widely used for bone regeneration due to its osteoinductivity and osteoconductivity. However, difficulties with handling, tendency to migrate from graft sites and lack of stability after surgery sometimes limit the clinical utility of this material. In this work, the possibility of using sodium alginate (ALG) carrier to deliver DBM powder was assessed. DBM–ALG putty with the DBM:ALG weight ratio of 5:5, 6:4, 7:3, 8:2 were prepared, respectively. The properties of the formed composite, including discrete degree, washout property, pH, equilibrium swelling as well as cytotoxicity in vivo, were adopted to ascertain the optimal ratio of DBM and ALG. The discrete diameter increased from 1.25 cm (5:5) to 2.08 cm (8:2) with the increase of DBM content. There was significant difference between the 8:2 group and the other groups in discrete diameter. The ratio of DBM had a significant effect on the swelling value. The pH of composites showed an increase trend with the DBM ratio’s increase, when the ratio reached 7:3, the pH (7.22) was approximately equal to the body fluid. The proliferation of MC3T3-E1 cells was inhibited in the 5:5, 6:4 and 7:3 groups, while a slightly increased in the 8:2 group. The DBM–ALG with the optimal ratio of 7:3 was confirmed based on the results of the above mentioned. The histocompatibility of DBM–ALG (7:3) was examined using a rat model in which the materials were implanted subcutaneously, compared with the polyethylene, ALG and DBM. The study in vivo showed DBM–ALG (7:3) had a lower inflammatory response than DBM, a higher vascularization than ALG. The osteoinduction of DBM–ALG (7:3) was evaluated by co-culturing with MC3T3-E1 in vitro, compared with the DMEM, ALG and DBM. The results indicated calcification area in the DBM–ALG group was similar to that in the DBM group, larger than ALG group and DMEM group. The DBM–ALG (7:3) putty is promising as a directly injectable graft for repair of bone defect.     

Continuous ambulatory peritoneal dialysis and renal transplantation: a five year experience.

Continuous ambulatory peritoneal dialysis is a new and increasingly popular method of routine dialysis, but its effect on renal transplantation is uncertain. A non-randomised comparison was made of the outcome of grafting in patients who had been treated before transplantation with continuous ambulatory peritoneal dialysis with that in patients treated with haemodialysis. During the five years, 1979-84, after continuous ambulatory peritoneal dialysis was introduced to Newcastle upon Tyne 220 patients have received transplants after either continuous ambulatory peritoneal dialysis (61 patients) or haemodialysis (159 patients). During follow up no significant differences occurred in survival of patients or grafts between the two treatment groups. One year after transplantation the percentages of survivors who had received continuous ambulatory peritoneal dialysis and haemodialysis were 88% and 91% respectively, and overall graft survival was 66% and 72%, respectively. A multiple regression model was used to allow for differences among patients--for example, duration of dialysis and number of preoperative transfusions--on the survival of grafts. When only first cadaver grafts were considered (in 152 patients) graft survival (non-immunological failures excluded) was not significantly different between the patients treated with continuous ambulatory peritoneal dialysis and haemodialysis. Continuous ambulatory peritoneal dialysis is not a risk factor in renal transplantation, and its continued use in treatment of potential renal graft recipients is recommended.     

Tissue Typing,Antilymphocyte Globulin,and Prophylactic Graft Irradiation in Cadaver Kidney Transplantation

In a series of 27 recipients of cadaver kidney grafts, 26 were at the time of writing alive, 3 to 25 months after transplantation, and 25 patients were alive with functioning first grafts. The one-year patient survival in 18 patients was 94% and the one-year graft survival was 89%. There was no beneficial correlation between tissue matching and the frequency of major early rejection episodes or graft function 12 or more months after transplantation. Antilymphocyte globulin administration was associated with a lower incidence of early rejection episodes, but this was not statistically significant. A combination of prophylactic graft irradiation and antilymphocyte globulin administration for at least the first two weeks was associated with a significantly reduced frequency of major early rejection episodes and appreciably better graft function at 12 months. This effect could not be ascribed to better tissue matching.     

Phosphate and pepsin adsorptions by a new boehmite compound and aluminum hydroxide

A new microcrystalline compound of aluminum oxide hydroxide (tentatively named PT-A) was synthesized in the hope of providing a better phosphate adsorbent for future clinical use than the currently marketed aluminum hydroxide gels (ALG). An X-ray diffraction study demonstrated a boehmite structure in PT-A but an amorphous structure in ALG. PT-A was more stable in pH change than ALG; in elution tests in artificial gastric and intestinal solutions, aluminum ion eluted from PT-A was maximally 10% of the amount from ALG at pH 1.2; and was undetectable at pH 6.8, at which point ALG still showed some aluminum elution. Phosphate-adsorbing efficacy of PT-A and ALG in vitro was about the same at pH 1.2; however, it was four times greater in PT-A than in ALG at pH 6.8, indicating that PT-A will be effective in the intestine. PT-A also adsorbed pepsin but the amount was at most the same or much less than that adsorbed by ALG, which depended on pH in solution.     

Fanconi anemia: contribution of molecular analyses to the identification of bone marrow graft donors and the study of chimerism in grafted patients

We report on the effectiveness of molecular studies regarding Fanconi anemia (FA) for a better selection of bone marrow graft donors and for post-transplant follow up. Ten unrelated FA patients and their families were analyzed by microsatellite markers. In 9 cases, the cytogenetic investigation of potential human leukocyte antigen (HLA)-identical related donors was normal, and the molecular analyses confirmed that they were also either normal or heterozygous carriers. For 1 patient, cytogenetic analysis of an HLA-identical sibling donor yielded ambiguous results with a relatively high number of chromosomal breakages using cross-linking agents. However, genotyping of this potential donor demonstrated his heterozygous state. Nine patients have received allogeneic bone marrow transplantation from HLA-matched related donors. Microsatellite analysis showed complete chimerism (CC) in all cases. The median follow up was 54 months (range 8-144 months). One patient out of 9 with CC rejected her graft without prior detection of a transitional mixed chimerism. Among these patients, 1 died 25 months after the transplantation of a chronic graft-versus-host-disease (GVHD). We conclude that, when the cytogenetic studies are not conclusive, molecular analyses are crucial to distinguish heterozygous carriers from asymptomatic FA Tunisian patients. Molecular analyses also allowed the evaluation of hematopoietic chimerism after allogeneic bone marrow transplantation and might be of value to identify patients with a high risk for graft rejection.     

Beneficial Effect of Insulin Treatment on Islet Transplantation Outcomes in Akita Mice

Islet transplantation is a promising potential therapy for patients with type 1 diabetes. The outcome of islet transplantation depends on the transplantation of a sufficient amount of β-cell mass. However, the initial loss of islets after transplantation is problematic. We hypothesized the hyperglycemic status of the recipient may negatively affect graft survival. Therefore, in the present study, we evaluated the effect of insulin treatment on islet transplantation involving a suboptimal amount of islets in Akita mice, which is a diabetes model mouse with an Insulin 2 gene missense mutation. Fifty islets were transplanted under the left kidney capsule of the recipient mouse with or without insulin treatment. For insulin treatment, sustained-release insulin implants were implanted subcutaneously into recipient mice 2 weeks before transplantation and maintained for 4 weeks. Islet transplantation without insulin treatment did not reverse hyperglycemia. In contrast, the group that received transplants in combination with insulin treatment exhibited improved fasting blood glucose levels until 18 weeks after transplantation, even after insulin treatment was discontinued. The group that underwent islet transplantation in combination with insulin treatment had better glucose tolerance than the group that did not undergo insulin treatment. Insulin treatment improved graft survival from the acute phase (i.e., 1 day after transplantation) to the chronic phase (i.e., 18 weeks after transplantation). Islet apoptosis increased with increasing glucose concentration in the medium or blood in both the in vitro culture and in vivo transplantation experiments. Expression profile analysis of grafts indicated that genes related to immune response, chemotaxis, and inflammatory response were specifically upregulated when islets were transplanted into mice with hyperglycemia compared to those with normoglycemia. Thus, the results demonstrate that insulin treatment protects islets from the initial rapid loss that is usually observed after transplantation and positively affects the outcome of islet transplantation in Akita mice.     

Survival of cultured allogeneic keratinocytes transplanted to deep dermal bed assessed with probe specific for Y chromosome.

To determine the survival of cultured allogeneic keratinocytes transplanted to a deep dermal bed 24 tattoos that had been removed by deep shave excision in 19 patients were grafted with sheets of cultured allogeneic keratinocytes from donors of the opposite sex. Cells carrying the Y chromosome were identified in biopsy specimens taken from the graft site by in situ DNA hybridisation with a biotinylated Y probe (pHY 2.1) and visualised with a technique using immunoperoxidase. The cultured allograft sites were biopsied one, two, and three weeks after transplantation. No male cells were identified in any biopsy specimen from female patients who were given transplants of male cultured keratinocytes, and all biopsy specimens from male patients, who received female cultured keratinocytes, showed percentages of male cells within the normal range for male skin. The beneficial effects of cultivated allogeneic keratinocytes result from effects on wound healing other than forming a successful graft that "takes."     

Achieving donor-specific hyporesponsiveness is associated with FOXP3+ regulatory T cell recruitment in human renal allograft infiltrates

Exploring new immunosuppressive strategies inducing donor-specific hyporesponsiveness is an important challenge in transplantation. For this purpose, a careful immune monitoring and graft histology assessment is mandatory. Here, we report the results of a pilot study conducted in twenty renal transplant recipients, analyzing the immunomodulatory effects of a protocol based on induction therapy with rabbit anti-thymocyte globulin low doses, sirolimus, and mofetil mycophenolate. Evolution of donor-specific cellular and humoral alloimmune response, peripheral blood lymphocyte subsets and apoptosis was evaluated. Six-month protocol biopsies were performed to assess histological lesions and presence of FOXP3+ regulatory T cells (Tregs) in interstitial infiltrates. After transplantation, there was an early and transient apoptotic effect, mainly within the CD8+ HLADR+ T cells, combined with a sustained enhancement of CD4+ CD25(+high) lymphocytes in peripheral blood. The incidence of acute rejection was 35%, all steroid sensitive. Importantly, only pretransplant donor-specific cellular alloreactivity could discriminate patients at risk to develop acute rejection. Two thirds of the patients became donor-specific hyporesponders at 6 and 24 mo, and the achievement of this immunologic state was not abrogated by prior acute rejection episodes. Remarkably, donor-specific hyporesponders had the better renal function and less chronic renal damage. Donor-specific hyporesponsiveness was inhibited by depleting CD4+ CD25(+high) T cells, which showed donor-Ag specificity. FOXP3+ CD4+ CD25(+high) Tregs both in peripheral blood and in renal infiltrates were higher in donor-specific hyporesponders than in nonhyporesponders, suggesting that the recruitment of Tregs in the allograft plays an important role for renal acceptance. In conclusion, reaching donor-specific hyporesponsiveness is feasible after renal transplantation and associated with Treg recruitment in the graft.     

Comparison of the immunosuppressive effect of fractionated total lymphoid irradiation (TLI) vs conventional immunosuppression (CI) in renal cadaveric allotransplantation

Beginning in November 1981, eight patients with end stage diabetic nephropathy underwent renal cadaveric transplantation after TLI. Transplantation was done between 2 to 11 days after the end of a fractionated TLI to a total dose of 20 to 30 Gy. During the same observation period, 60 nondiabetic patients with end stage renal disease of different origin also received a cadaveric kidney graft, with a conventional regimen of immunosuppression that consists of anti-lymphocyte-globulin, tapering high doses of prednisone, and azathioprine. In the TLI-treated group only a low maintenance dose of prednisone (15 mg) was given. Immunologic monitoring was performed after transplantation at regular intervals and was compared in both groups. Phytohemagglutinin (PHA)-, concanavalin A (con A)-, and pokeweed mitogen (PWM)-induced blastogenesis, as well as the mixed lymphocyte reaction (MLR) and the cell-mediated lympholysis (CML) decreased progressively during the first months after conventional immunosuppression to 50% of the pretransplantation level, and remained there for the first year after transplantation. These tests were much more impaired after TLI (less than 15% of pre TLI value) and again no recovery occurred during the first year. Natural killer (NK) cell activity progressively decreased from a mean value of 53% lysis before transplantation to 15% lysis at the end of the first year after transplantation in the conventionally treated patients. In TLI-treated patients, however, the NK activity, which declined during irradiation from 46% specific lysis to 12%, recovered rapidly after TLI to reach levels of 35 to 40% of specific lysis from the second month on after TLI. In both groups of patients the ratio of helper-inducer (TH) to suppressor-cytotoxic (TS) lymphocytes, as determined with monoclonal antibodies, progressively declined during the first 2 mo after transplantation to a low value of about 1.2. In TLI-treated patients however, this fall progressed further, so that very low levels (less than 0.6) were noticed from the third month on after TLI. The decline of the TH:TS ratio after TLI is due to an absolute increase in the number of suppressor cells. This is in contrast with the conventionally treated patients, where the low ratio is mainly provoked by a more important decrease of the helper cell population. These changes in the balance between TH and TS subpopulations are more frequently associated with positive functional suppressor cell assays in the TLI-treated patients.(ABSTRACT TRUNCATED AT 400 WORDS)     

ALG2 inhibits the epithelial-to-mesenchymal transition and stemness of ovarian granulosa cells through the Wnt/β-catenin signaling pathway in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is an endocrine disorder that affects fertility in women of reproductive age, and a leading cause of anovulatory infertility. Ovarian granulosa cells are a major functional cell type in the ovary that undergo epithelial-to-mesenchymal transition (EMT) to initiate ovulation. Protein glycosylation, catalyzed by specific glycosyltransferases, has been implicated in reproductive events, such as embryo implantation, endometrial receptivity, and decidualization, etc. However, the relationship between glycosylation and EMT-mediated ovulation in PCOS is not well understood. To clarify the role of cobalt chloride (CoCl₂) and α-1,3/1,6-mannosyltransferase (ALG2) in PCOS, transwell assay, Real-time PCR, Western blot, immunofluorescence, and sphere formation assay were applied to assess cell migration, invasion, EMT, and stemness of ovarian granulosa cells. Enzyme-linked immunosorbent assay (ELISA) was performed to measure the serum level of ALG2 in PCOS patients. We found that CoCl₂ promoted the migration, invasion, EMT, and stemness of ovarian granulosa cells by downregulating the expression of ALG2. Upregulation of ALG2 rescued the effects of CoCl₂ partially, and inhibited the EMT and stemness of ovarian granulosa cells by inactivating the Wnt/β-catenin signaling pathway. Moreover, the serum level of ALG2 was increased in patients with PCOS. Elevated ALG2, in combination with testosterone, represented better diagnostic value for PCOS as a multimarker than ALG2 or testosterone alone as a single marker. Thus, ALG2, downregulated by CoCl₂, was increased in PCOS patients which inhibited the EMT and stemness of ovarian granulosa cells by deactivating the Wnt/β-catenin signaling pathway. The combination of ALG2 and testosterone might thus act as a novel but promising biomarker for PCOS detection.     

The cytogenetic action of antilymphocyte globulin on the lymphocytes of bronchial asthma patients

Chromosomal aberration levels and frequencies of sister chromatid exchanges (SCE) in peripheral blood lymphocytes were investigated for patients with bronchial asthma treated with antilymphocyte globulin (ALG). The significant elevation of chromosomal aberration levels and SCE frequencies were revealed as compared to the healthy controls. The significant differences in chromosomal aberration levels were not observed before and after the courses of ALG therapy. At the same time the SCE frequencies appeared to be significantly decreased after the course of ALG therapy. The similar effects were observed in studies in vitro. The data obtained may suggest that ALG at the used doses does not cause any significant cytogenetic damages in the examined patients.     

Association of human cytomegalovirus viremia with human leukocyte antigens in liver transplantation recipients

Human cytomegalovirus (HCMV) reactivation is a common complication after liver transplantation (LT). Here, we investigated whether human leukocyte antigen (HLA)-matching was related to HCMV infection and subsequent graft failure after LT for hepatitis B virus cirrhosis. This retrospective study reviewed 91 LT recipients. All the patients were grouped according to HLA-A, HLA-B, and HLA-DR locus matching. Clinical data were collected, including complete HLA-typing, HCMV viremia, graft failure, and the time of HCMV viremia. HLA typing was performed using a sequence-specific primer-polymerase chain reaction kit. HCMV was detected by pp65 antigenemia using a commercial kit. The incidence of HCMV infection post-LT was 81.32%. Graft failure was observed in 16 of 91 (17.6%) patients during the 4-year study. The incidence of HCMV viremia was 100% (5/5), 91.4% (32/35), and 72.5% (37/51) in HLA-A two locus, one locus, and zero locus compatibility, respectively. Nevertheless, the degree of the HLA-A, HLA-B, or HLA-DR match did not influence the time of HCMV viremia, graft failure, or the time of graft failure after a diagnosis of HCMV viremia (all P > 0.05). An interesting discovery was that the risk of HCMV viremia tended to be higher in patients with better HLA-A compatibility. Graft failure, time of HCMV viremia, and graft failure after a diagnosis of HCMV viremia appear to be independent of HLA allele compatibility.     

Immunosuppressive properties of sera and urine dialysates from kidney-graft recipients treated with azathioprine,prednisolone, and niridazole

Niridazole, an antischistosomal agent, was given to renal transplant recipients in addition to azathioprine and prednisolone, as there is experimental evidence that this combination of drugs is highly immunosuppressive. Sera obtained from kidney-graft recipients during the first two weeks after transplantation were examined for their ability to inhibit the one-way mixed lymphocyte reaction (MLR). Sera from seven patients receiving azathioprine, prednisolone, and niridazole (triple-drug treatment), five patients receiving azathioprine and prednisolone, and two other patients treated with niridazole alone for schistosomiasis produced MLR inhibition by comparison with pretreatment (control) sera.A mean of 78% inhibition was observed with sera taken after one day''s treatment with the three-drug combination, whereas this level of in-vitro immunosuppression occurred only after eight days of treatment with azathioprine and prednisolone. Niridazole alone produced an effect similar to azathioprine and prednisolone. Concentrated dialysate of urine from a patient receiving triple-drug treatment not only inhibited the MLR but also significantly prolonged the survival of heterotopic heart allografts in rats, whereas dialysate from the same patient after niridazole had been stopped gave less MLR inhibition and failed to prolong heart allograft survival.Since niridazole thus increased the in-vitro and in-vivo immunosuppressive action of azathioprine and prednisolone, we suggest that this triple-drug combination might be useful for preventing early acute kidney graft rejection.     

Orthotopic liver retransplantation--case report

We report a case of orthotopic liver retransplantation (OLRT) in a patient who was suffering from rejection and graft failure after orthotopic liver transplantation (OLT). The patient was a 32-year old female who had diagnosed liver lesion--hepatic cirrhosis. Within two months, with presented condition as a terminal stage of her disease, she underwent the OLT and immunosuppressive postoperative management. Two months after the OLT, in the one-week period, the patient underwent two new operations because of obstructive icterus due to fulminant cholangitis and subhepatic abscess. In spite of this operative and conservative treatment the patient's condition did not improve. Because of graft failure due to bile duct necrosis, she underwent an ORLT operation and her condition is satisfactory, till now. We confirmed that the overall impact of retransplatation persists because patients undergoing elective retransplatation have significantly better prognosis than those requiring an emergency operation.     

The impact of transportation time on apoptosis in allogeneic stem cell grafts and the clinical outcome in malignant patients with unrelated donors

BackgroundThe quality of cells in peripheral blood stem cell (PBSC) grafts is important for allogeneic stem cell transplantation outcome. The viability of PBSC grafts may decrease during transportation time between donor and transplant center. We hypothesize that the graft viability based on apoptosis and necrosis in the graft may better reflect graft quality and clinical outcome.MethodsPBSC graft viability from unrelated donors was analyzed in 91 patients. Viable cells were defined as 7-aminoactinomycin D– and Annexin V–negative. The clinical outcome, including survival, transplant-related mortality and graft-versus-host disease (GvHD), was correlated to graft viability.ResultsGrafts transported for 1 day had a median viability of 86.4% (range 63.8 to 98.9%), and grafts transported for 2 days had median viability of 83.2% (range 52.8% to 96.2%) (P = .003). Grafts were divided into two groups based on the median graft viability of 85.1%. Patients who received low viability grafts had lower 1-year survival of 63.7% compared with 88.9% for those who received high viability grafts (P = .007). In the multivariate analysis, transplant-related mortality (TRM) was higher in the low viability group (P = .03), whereas overall survival was not significantly associated with graft viability. The incidence of acute GvHD grade II to IV, chronic GvHD and relapse risk remained comparable between the groups.ConclusionLow graft viability was an independent predictor of 1-year survival and TRM after adjusting for multiple confounders. Better graft quality markers are important for the detection of clinically important variations in the stem cell graft.     

Anti-thoracic duct lymphocyte globulin stimulates human megakaryocytopoiesis in vitro

Anti-thoracic duct lymphocyte globulin (ALG) therapy is effective in patients with aplastic anemia. We examined the effect of ALG on human megakaryocyte progenitor cells (colony-forming unit-megakaryocyte, CFU-Meg) in vitro. Normal human bone marrow mononuclear cells (MNC) were cultured in plasma clots with varying concentrations of ALG or non-immunized horse IgG. After 12 days of culture, significant megakaryocyte colony formation was observed in cultures containing ALG but not in cultures containing non-immunized horse IgG. The peak stimulatory effect seemed to occur with 10-25 micrograms/ml of ALG. When marrow MNC, depleted of adherent and T cells, were cultured in plasma clots with ALG, its stimulatory effect on megakaryocytopoiesis decreased markedly. Finally, it was demonstrated that ALG stimulated marrow MNC to produce a factor stimulatory for CFU-Meg. The in vitro megakaryocytopoietic stimulatory effect of ALG may be related to its clinical efficacy in some patients with aplastic anemia.     

Long-term therapy using horse anti-dog lymphocyte globulin without sensitization against horse protein]

Eight mongrel dogs received a standard daily i.v. infusion of 20 mg/kg b.w. deaggregated horse-anti-dog-lymphocyte-globulin (ALG) and additional prednisolone (1 mg/kg b.w. daily i.v.) over a maximum period of 82 days following pretreatment with deaggregated normal horse IgG. No sensitization against horse protein was observed during therapy of afterwards as proved by lack of humoral antibodies against horse antigens, maintained lymphopenia, good compatibility, longterm prolongation of xenogeneic skin graft survival (85.6+/-20.6 days, n=8' untreated controls 12.5+/-1.3 days, n=4) and longterm suppression of cytotoxic antibodies against donor lymphocytes. The level of preformed agglutinating antibodies against horse erythrocytes was significantly reduced, while preformed antibodies against other species remained normal. The immune response to a challenge injection of anti-lymphocyte-serum (ALS) 6-11 weeks after termination of treatment was significantly lower in the ALG treated animals as compared to the control group. These results suggest the involvement of a specific mechanism of unresponsiveness against ALG other than immunosuppression only. It is concluded, that by the described method sensitization against ALG can be prevented during longterm treatment.     

Successful liver transplantation in babies under 1 year.

OBJECTIVE--To review the outcome of liver transplantation in babies aged less than 1 year. DESIGN--Prospective evaluation of survival, clinical complications, and nutritional and developmental status before and one year after liver transplantation. SETTING--The Children''s Hospital and Queen Elizabeth Hospital, Birmingham. SUBJECTS--All 25 babies who received liver transplantation from January 1989 to December 1992 were included. Median age was 9 months and median weight was 7.0 kg. Seven babies were assessed but were not given transplants because they died while on the waiting list (two) or had severe extrahepatic disease (five). RESULTS--24 babies had severe decompensated liver disease and 20 were severely malnourished despite nutritional support. Six babies received a whole liver graft and 19 received a reduction hepatectomy. Postoperative complications included primary nonfunction of the transplanted liver (one baby), hepatic artery thrombosis (two), biliary obstruction (seven), acute and chronic rejection (six), and sepsis (18). Three babies required a second transplant; all survived. Three babies, two of whom presented with fulminant hepatic failure, died. The overall actuarial survival rate (4 months to 4 years) is 88%. Review at 12 months showed a dramatic improvement in growth (p < 0.001) and normal psychosocial development with good quality of life. CONCLUSION--The improvement in survival rates and quality of life in this group of very sick babies is related not only to the development of reduction hepatectomy but also to advances in medical and nursing expertise. Early referral for liver transplantation is justified even if babies are critically ill.     

Renal transplantation in patients treated with haemodialysis and short term and long term continuous ambulatory peritoneal dialysis.

Forty two adult patients who had been treated with continuous ambulatory peritoneal dialysis for one to 142 weeks (mean (SD) 38 (36)) received a total of 44 allografted kidneys. Twenty one had been treated with continuous ambulatory peritoneal dialysis for less than 26 weeks (mean 11 (8)) and the other 21 for longer than 26 weeks (mean 64 (35)). These two groups were compared with 55 patients who had been treated with haemodialysis and received a total of 63 grafts. In the group of patients treated with continuous ambulatory peritoneal dialysis azathioprine and low dose prednisolone were used as the immunosuppressive regimen for 20 transplantations in 18 patients, and 24 patients receiving 24 grafts were treated with cyclosporin A and low dose prednisolone. In the group of patients treated with haemodialysis 38 patients receiving 43 grafts were treated with azathioprine and low dose prednisolone, and 20 patients receiving 20 grafts were treated with cyclosporin A and low dose prednisolone. Actuarial survival of patients and grafts at two years was 95% and 72%, respectively, in the continuous ambulatory peritoneal dialysis group compared with 89% and 58%, respectively, in the haemodialysis group. No difference was found in graft survival between short term treatment with continuous ambulatory peritoneal dialysis (72% graft survival) and long term treatment (65% graft survival). In conclusion, continuous ambulatory peritoneal dialysis is suitable treatment for patients awaiting renal transplantation.