Diagnosing acute liver graft rejection: experimental application of an implantable telemetric impedance device in native and transplanted porcine livers

BACKGROUND AND AIMS: Diagnosis of acute rejection is a complex and persistent problem in liver transplantation. Focused on the use of proprietary impedance technology a porcine liver model was designed to provide immediate information for differentiation of normal and acute rejecting tissue by an implantable telemetric device. METHODS: Electrical impedance was analyzed by electrodes implanted in vitro and in vivo in the liver of pigs, where impedance is derived from measurements of voltage transients produced in response to programmed current pulses. Consequent electric recordings in porcine livers after transplantation and after mere laparotomy were evaluated in relation to biochemical parameters and histological results of liver biopsies. RESULTS: Acute rejection was correctly predicted in all cases and correctly excluded in the remaining 32 biopsy related impedance recordings (P<0.004). Impedance measurements not only correlated with the diagnosis from liver biopsy specimen (r=0.84, P<0.0001) but also exemplified the severity of histological acute rejection. CONCLUSION: Impedance analysis reveals evident physiologic relation of acute liver graft rejection and electrical organ properties. Electrodes implanted in transplanted porcine livers allow running less invasive monitoring and thus early detection of rejection. The technology may have broad value in providing an immediate diagnosis of acute rejection, reducing unnecessary patient anxiety and eliminating the significant expenses associated with multiple referrals, expensive sample handling and tissue analysis.     

Basics of immune responses in transplantation in preparation for application of composite tissue allografts in plastic and reconstructive surgery: part I

Currently, composite tissue allografts are applied only occasionally as a reconstructive option in the field of plastic and reconstructive surgery. Composite tissue allografts offer a unique potential for coverage of large multitissue defects. However, compared with the relatively homogenous tissue of solid organ transplants, the heterogenicity of tissue components of composite tissue allografts may generate high immunologic responses. Modern immunosuppressive agents significantly improve successful allograft acceptance. However, chronic allograft rejection and immunosuppressive drug toxicity are still major problems in the clinical practice of transplantation. The major goals of transplantation immunology are (1) to develop tolerance to allograft transplants and (2) long-term drug-free survival. A number of experimental protocols were designed to develop tolerance; however, none of them has been proven to induce tolerance in clinical transplantation. In this article, the authors outline the mechanisms of allograft acceptance and rejection and barriers to transplantation tolerance. Novel immunosuppressive protocols are discussed in this review. This basic immunologic knowledge of allograft acceptance and rejection will allow plastic surgeons to apply composite tissue allograft transplants to plastic and reconstructive surgery.     

Posttransplant administration of donor leukocytes induces long-term acceptance of kidney or liver transplants by an activation-associated immune mechanism

Donor leukocytes play a dual role in rejection and acceptance of transplanted organs. They provide the major stimulus for rejection, and their removal from the transplanted organ prolongs its survival. Paradoxically, administration of donor leukocytes also prolongs allograft survival provided that they are administered 1 wk or more before transplantation. Here we show that administration of donor leukocytes immediately after transplantation induced long-term acceptance of completely MHC-mismatched rat kidney or liver transplants. The majority of long-term recipients of kidney transplants were tolerant of donor-strain skin grafts. Acceptance was associated with early activation of recipient T cells in the spleen, demonstrated by a rapid increase in IL-2 and IFN-gamma at that site followed by an early diffuse infiltrate of activated T cells and apoptosis within the tolerant grafts. In contrast, IL-2 and IFN-gamma mRNA were not increased in the spleens of rejecting animals, and the diffuse infiltrate of activated T cells appeared later but resulted in rapid graft destruction. These results define a mechanism of allograft acceptance induced by donor leukocytes that is associated with activation-induced cell death of recipient T cells. They demonstrate for the first time that posttransplant administration of donor leukocytes leads to organ allograft tolerance across a complete MHC class I plus class II barrier, a finding with direct clinical application.     

Telemetric impedance analysis of the liver: evaluation of a noninvasive device for diagnosis of acute graft rejection after experimental liver transplantation]

Allograft rejection and its differentiation from other causes of organ dysfunction remains a diagnostic problem in liver transplant patients. Currently, acute rejection can be prevented only by a combination of diagnostic and therapeutic modalities. The diagnostic potential of a novel implantable telemetric rejection monitoring device has been assessed on the basis of the noninvasive impedance analysis in normal and liver transplanted pigs. The electric impedance data were correlated with biochemical and histological parameters. Acute rejection was correctly predicted in n = 4, and correctly excluded in n = 32, biopsy-related impedance recordings (p = 0.004). A correlation between impedance measurements and severity of histological findings r = 0.84; p = 0.0001) was confirmed. Only the biochemical parameters SGLDH and serum bilirubin revealed a comparable correlation. Impedance gradient analysis revealed evidence of a physiological relationship between liver function and the electrical properties of the organ. Telemetric impedance analysis would appear a promising means of assessing acute rejection noninvasively.     

Organ transplantations: from basic research to clinical applications. A personal odyssey

This article is a summary of the impact on contemporary medicine of organ and tissue transplantation. The article describes how, via trial and error, and beginning from basic research, the results of organ transplantation have steadily increased as has the number of organs that can be transplanted. Currently, the short-term results of most organ transplants, with the notable exception of the pancreas and the lung, are close to perfect; very few organs are lost any longer due to acute rejection. There is, however, little information on long-term results using the current modalities of immunosuppression, particularly on the effect of chronic rejection on late graft survival.     

Development of hematopietic and lymphoid tissues in conjoint bone marrow and thymus transplants]

The model of heterotopic transplantation of the mixture of bone marrow and thymus fragments was used to study the interaction of hemopoietic and lymphoid tissues under their direct contact. The bone marrow and thymus fragments of adult mice F1 (CBAXXC57BL) were transplanted separately or in the mixture under the kidney capsule of mice of the same strain. During the whole period of observation (from 10 days up to 14 months), the development of bone marrow and thymus fragments in the joint transplants proceeded independently, no "mixed" stroma appeared, and the stroma of each organ ensured the differentiation characteristic of its organ. The development of joint transplants somewhat differs from that of isolated transplants: on the 10th day a greater amount of hemopoietic tissues was noted in the former; the bone marrow component increases continuously up to 6 months (vs. 1--2 months in the isolated transplants); the bone and hemopoietic tissues predominate in the joint transplants by 14 months, the amount of thymic tissue markedly decreases but it does not disappear completely.     

Early chemokine cascades in murine cardiac grafts regulate T cell recruitment and progression of acute allograft rejection

The identification of early inflammatory events after transplant in solid tissue organ grafts that may direct T cell recruitment and promote acute allograft rejection remain largely unknown. To better understand temporal aspects of early inflammatory events in vascularized organ grafts, we tested the intragraft expression of four different chemokines in heterotopically transplanted A/J (H-2(a)) and syngeneic heart grafts in C57BL/6 (H-2(b)) recipient mice from 1.5 to 48 h after transplant. Similar temporal expression patterns and equivalent levels of chemokine expression were observed in both syngeneic and allogeneic cardiac allografts during this time period. Expression of the neutrophil chemoattractant growth-related oncogene alpha (KC) was observed first and reached peak levels by 6 h after transplant and was followed by the monocyte/macrophage chemoattractant protein-1 (JE) and then macrophage inflammatory proteins 1beta and 1alpha. Administration of rabbit KC antiserum to allograft recipients within 30 min of cardiac transplantation attenuated downstream events including intra-allograft expression of the T cell chemoattractants IFN-gamma-inducible protein-10 and monokine induced by IFN-gamma, cellular infiltration into the allograft, and graft rejection. Similarly, depletion of recipient neutrophils at the time of transplantation significantly extended allograft survival from day 8 to 10 in control-treated recipients up to day 21 after transplant. These results indicate the induction of highly organized cascades of neutrophil and macrophage chemoattractants in cardiac grafts and support the proposal that early inflammatory events are required for optimal recruitment of T cells into allografts during the progression of acute rejection of cardiac allografts.     

Piscine islet xenotransplantation

Tilapia, a teleost fish species with large anatomically discrete islet organs (Brockmann bodies; BBs) that can be easily harvested without expensive and fickle islet isolation procedures, make an excellent donor species for experimental islet xenotransplantation research. When transplanted into streptozotocin-diabetic nude or severe combined immunodeficient mice, BBs provide long-term normoglycemia and mammalian-like glucose tolerance profiles. However, when transplanted into euthymic recipients, the mechanism of islet xenograft rejection appears very similar to that of islets from "large animal" donor species such as the very popular fetal/neonatal porcine islet cell clusters (ICCs). Tilapia islets are more versatile than ICCs and can be transplanted (1) into the renal subcapsular space, the cryptorchid or noncryptorchid testis, or intraportally as neovascularized cell transplants; (2) as directly vascularized organ transplants; or (3) intraperitoneally after microencapsulation. Unlike the popular porcine ICCs, BBs function immediately after transplantation; thus, their rejection can be assessed on the basis of loss of function as well as other parameters. We have also shown that transplantation of tilapia BBs into nude mice can be used to study the possible implications of cross-species physiological incompatibilities in xenotransplantation. Unfortunately, tilapia BBs might be unsuitable for clinical islet xenotransplantation because tilapia insulin differs from human insulin by 17 amino acids and, thus, would be immunogenic and less biologically active in humans. Therefore, we have produced transgenic tilapia that express a "humanized" tilapia insulin gene. Future improvements on these transgenic fish may allow tilapia to play an important role in clinical islet xenotransplantation.     

In vivo microscopic assessment of cremasteric microcirculation during hindlimb allograft rejection in rats.

Experimental and clinical studies of vascular allogenic extremity transplantation have yielded disappointing results and have not been clinically useful. With recent advances in transplantation immunology, considerable interest has focused on the understanding of leukocyte-endothelial interaction at the microcirculatory level. The objective of this study was to characterize the alterations in leukocyte-endothelial interaction in the early stages of rat hindlimb allograft rejection. To study the changes at the microcirculatory level, a new microsurgical model was developed; the cremaster muscle was incorporated into the transplanted hindlimb. The purpose of this study was to report on the microcirculatory changes during rat hindlimb allograft rejection. A total of 24 transplantations were performed among the four experimental groups. In a control group, 12 rat hindlimb-cremaster grafts were transplanted between genetically identical animals, Lewis to Lewis. Microcirculatory measurements of graft survival were taken at 24 hours (group 1A, n = 6) and at 72 hours (group 1B, n = 6). In the rejection control group, 12 transplantations were performed across a major histocompatibility barrier between Lewis-Brown Norway and Lewis rats. Microcirculatory measurements were taken at 24 (group 2A, n = 6) and 72 hours (group 2A, n = 6) as above. The following parameters were evaluated to discover the leukocyte-endothelial interaction: endothelial edema index and the number of rolling, adherent, and transmigrating leukocytes and lymphocytes in the postcapillary venule. Physical signs of limb rejection, such as edema, erythema, scaling, plaque formation on the skin, hair loss, and skin surface temperature, were monitored. Microcirculatory signs of rejection included the following. There was a significant increase in the number of adherent leukocytes in allograft transplants at both 24 hours (205 percent; 2.05 +/- 0.38) and 72 hours (431 percent; 9.11 +/- 3.41) when compared with isograft controls (1.00 +/- 0.89 at 24 hours; 2.11 +/- 0.34 at 72 hours) (p < 0.05). The activation of leukocyte transmigration increased more than 7-fold in muscle allografts at 24 hours (0.55 +/- 0.25 versus 4.16 +/- 1.89) and more than 6-fold at 72 hours (0.72 +/- 0.38 versus 4.38 +/- 1.28) after transplantation (p < 0.05). Endothelial edema index, a measure of endothelial swelling and cellular deposit accumulation, increased more than 119 percent in the allograft group 72 hours after transplantation (1.23 +/- 0.07 versus 1.46 +/- 0.09) (p < 0.05). The first clinical signs of limb rejection were scaling of the skin or hair loss; they were observed between the seventh and ninth postoperative days. The composite rat hindlimb-cremaster model presented in this study introduces a new in vivo approach to monitor acute graft rejection using the intravital microscopy system. This is a valuable model for defining the timing, sequence, and correlation between immunologic events and clinical signs during the acute phase of allograft rejection.     

Transplantation of fetal neocortex in rhesus monkey

A feasibility study of neural transplantation in adult rhesus monkey was undertaken. Fresh and preserved neocortex containing multiplying and maturing neurons obtained from 55–70 gestation days were transplanted into the striatum, cerebellum and cerebral cortex of adult monkeys. Tissues were preserved for 4 days either at subzero temperature in the freezer compartment of the ordinary refrigerator in Ringer lactate or incubated in culture medium. While 2 monkeys out of 5 injected with preserved tissue had successful transplants after 4 months, all the 10 monkeys injected with fresh tissue had no transplants. The size of the two surviving transplants was small. The neurons in the transplants were mainly in clusters. Many of the cells were immature and some showed early degenerative changes. Neuronal processes were restricted to the transplants and thus showed lack of morphological integration with the host tissue. Further studies are in progress to define the nature of the embryonic tissue of primate which can grow and survive and also the role of neural grafts in functional recovery following experimental lesions of the brain regions.     

Antibody immunosuppressive therapy in solid-organ transplant: Part I

Currently, a wide variety of both polyclonal and monoclonal antibodies are being routinely utilized to prevent and treat solid organ rejection. More commonly, these agents are also administered in order to delay introduction of calcineurin inhibitors, especially in patients with already compromised renal function. While these antibody therapies dramatically reduced the incidence of acute rejection episodes and improved both short and long-term graft survival, they are also associated with an increased incidence of opportunistic infections and neoplastic complications. Therefore, effective patient management must necessarily balance these risks against the potential benefits of the therapy.Key words: monoclonal, polyclonal, induction, transplants, kidney, lung, liver, heart, rejection, complications     

Vascularization of normal human thyroid tissue transplanted to nude mice

The vascularization of normal human thyroid tissue transplanted to nude, athymic mice was examined by light, electron microscopy and autoradiography after continuous infusion of 3H-thymidine during 2, 4 and 6 days after transplantation. Labelled vascular sprouts were found in the surrounding host connective tissue after 2 days, in between peripheral follicles after 4 days and in central parts of the transplants after 6 days. The autoradiographic observations indicate that the sprouts originated from the surrounding host tissue. The amount of sprouts increased up to a maximum after 2 weeks of transplantation. At this time large interfollicular areas were occupied by sprouts. At later observations (3-5 weeks) sprouts occurred together with typical fenestrated capillaries. After 7 weeks all sprouts had differentiated into mature vessels. Our observations suggest that the transplanted thyroid tissue induces the formation of vascular sprouts in the surrounding host connective tissue. The sprouts then penetrate and vascularize the thyroid tissue.     

Serial Estimation of Urinary Fibrin/Fibrinogen Degradation Products in Kidney Transplantation

The urinary excretion of fibrin/fibrinogen degradation products (F.D.P.) of 81 human cadaver kidney transplants has been measured serially by the techniques of tanned red cell haemagglutination inhibition immunoassay and immunonephelometry. Acute rejection episodes in functioning transplants have been associated with increased F.D.P. excretion which in 80% of cases has preceded clinical diagnosis by periods of one to seven days. Recovery from these episodes has been associated with a rapid fall of F.D.P. excretion to undetectable levels. The level of F.D.P. excretion during a rejection episode is a guide to its ultimate outcome. Irreversibly rejected kidneys excrete high levels of F.D.P. for long periods. Viable kidney transplants with prolonged oliguric phases can be distinguished, while still oliguric, from rejected kidneys by their low F.D.P. excretion. F.D.P. cannot usually be detected in the urine of well-functioning transplants. Episodes of raised F.D.P. excretion in the absence of acute clinical rejection, however, occur occasionally and may be associated with permanent impairment of renal function.     

Use of athymic nude mice for in vivo studies of human growth-hormone-secreting pituitary adenomas.

Human growth hormone (hGH)-secreting pituitary adenoma tissue of 31 acromegalic patients was transplanted subcutaneously onto 291 athymic nude mice. 37% of the transplanted adenoma fragments could be maintained vital up to 46 days. Histological examinations of the transplants revealed neither alterations in their morphological characteristics nor signs of growth. A maintenance or linear decline of hGH secretion of the transplants related to their vitality was observed by hGH radioimmunoassay. Estimation of graft vitality was improved by GH-releasing hormone (GHRH) stimulation in regular intervals. The rate of pituitary adenomas responding to GHRH was as high as in a major collective of acromegalic patients. Our method of positive selection of vital xenotransplanted hGH-secreting pituitary adenomas via hGH detection at regular intervals in combination with GHRH stimulation gives the opportunity of reliable in vivo research with these tumors.     

Über den Einfluß der Kulturdauer im larvalen Wirt auf die Entwicklungsleistungen implantierter männlicher Genitalimaginalscheiben vonEphestia,kuehniella Z.

Summary Complete and bisected male genital disks (HO) from full-grown (T9) larvae were transplanted either into larvae and pharate pupae of different age (T4, T7, T9 larvae, A1–A5 pharate pupae) or repeatedly transferred into full-grown larvae before being implanted into a final larval host. After metamorphosis of the hosts, most of the complete transplants and regenerated HO halves showed normal morphological features, but the implanted genitals from old pharate pupae (A4 and A5) were abnormally differentiated. Frequency of Regeneration. After transplanting both halves of the bisected HO into T9 hosts, three groups of results were observed: (1) each of the two halves regenerated into a complete genital organ; (2) only one half regenerated; (3) neither of the two halves regenerated. In the pharate pupae no regeneration of the implanted halves took place. If the lapse of time between the transplantation and, the onset of metamorphosis (=onset of pharate pupae phase) was long enough by transplanting into young larvae (T4) or by repeatedly transferring into old larvae and subsequent transplantation into a final larval host, all the implanted halves were able to regenerate. Size of the Implanted Genital Organs After prolonging the in vivo culture in larval hosts by implanting into young larvae or repeatedly transferring into old larvae, it was found that the regenerated genitalia grew to the same size as the complete transplants, but the size of the complete transplants increased, if at all, only insignificantly. Duration of Development of the Hosts. Regeneration of one HO half implanted into a full-grown larva caused an average delay of further development of about 2 days. An additional delay was recorded when both halves had regenerated. However, no delay was observed when HO halves implanted into young (T4) larvae regenerated, and no delay occurred in the final hosts when the repeatedly transferred halves had reached a certain stage of regeneration.The developmental capacities of the tranplanted disks and the control of metamorphosis by regenerating disks are discussed.

     

Clonal CD8+ T Cell Persistence and Variable Gene Usage Bias in a Human Transplanted Hand

Immune prophylaxis and treatment of transplanted tissue rejection act indiscriminately, risking serious infections and malignancies. Although animal data suggest that cellular immune responses causing rejection may be rather narrow and predictable based on genetic background, there are only limited data regarding the clonal breadth of anti-donor responses in humans after allogeneic organ transplantation. We evaluated the graft-infiltrating CD8⁺ T lymphocytes in skin punch biopsies of a transplanted hand over 178 days. Profiling of T cell receptor (TCR) variable gene usage and size distribution of the infiltrating cells revealed marked skewing of the TCR repertoire indicating oligoclonality, but relatively normal distributions in the blood. Although sampling limitation prevented complete assessment of the TCR repertoire, sequencing further identified 11 TCR clonal expansions that persisted through varying degrees of clinical rejection and immunosuppressive therapy. These 11 clones were limited to three TCR beta chain variable (BV) gene families. Overall, these data indicate significant oligoclonality and likely restricted BV gene usage of alloreactive CD8⁺ T lymphocytes, and suggest that changes in rejection status are more due to varying regulation of their activity or number rather than shifts in the clonal populations in the transplanted organ. Given that controlled animal models produce predictable BV usage in T lymphocytes mediating rejection, understanding the determinants of TCR gene usage associated with rejection in humans may have application in specifically targeted immunotherapy.     

Atrial natriuretic factor (ANF) levels are elevated in rats bearing rejecting heart-lung allografts

Intra-abdominal heart-lung grafts were transplanted into 8 rats across a major histocompatibility barrier. Four of the 8 rats were treated with Cyclosporin A (CsA) to prevent rejection. Atrial natriuretic factor (ANF) levels measured 6 days after transplantation revealed a significantly (p less than .005) higher mean ANF concentration in rats bearing a rejecting heart-lung allograft (642 +/- 148.0 pg/ml) compared to rats bearing a heart-lung allograft not undergoing rejection (200.8 +/- 13.07 pg/ml). ANF might be a useful noninvasive marker in the diagnosis of rejection in heart and heart-lung transplants.     

Neoplastic cell spreading in rodent transplantable tumor models. I. Ehrlich tumor

Ehrlich ascites tumor cells were ectopically transplanted in femoral muscles of tumor-free Swiss and BALB/c mice with the same modality used for i.p. serial transplantations of the ascitic form. A solid tumor developed (100% takes as i.p. grafts) locally invading surrounding tissues and leading to death within 30-40 days (12-14 days in ascitic form). These animals were killed when showing signs of debilitation by tumor growth (1 mo.). The recipients' own thoracic and abdominal organs (lung, liver, spleen, and kidney plus peritoneal fluid) as well as the solid tumor were removed to obtain imprints and smears fixed and stained for cytology (May Grünwald Giemsa). Tumor-free mice were used as a control and i.p. transplanted mice were sacrificed on day 8. Disseminated tumor cells were seen in recipient organ imprints and peritoneal fluid smears scattered among local normal cells. Host defense cells with prevalence of neutrophils were observed infiltrating the solid tumor or adjacent to disseminated tumor cells. According to previous findings, organ imprints of i.p. transplanted mice showed disseminated tumor cells and host defense cells. Surprisingly, in liver imprints of ectopically transplanted BALB/c mice, numerous megakaryocytes were detected. This tumor and host organ imprint assay offers the possibility to monitor in vivo the phenomenon of metastatic tumor spread.     

Influence of the CNS Environment on Chromaffin Cell Survival and Catecholamine Secretion Patterns

Abstract: Chromaffin cells implanted into the CNS have been used as a potential source of sustained catecholamine delivery, although their survival and continued catecholamine secretion are controversial. In addition, chromaffin cells exhibit a high degree of neurochemical plasticity in response to environmental factors. The present aims were to determine whether the CNS provides a supportive environment for sustained catecholamine production in transplanted chromaffin cells and to assess whether this novel environment alters patterns of catecholamine secretion. Catecholamine release from bovine chromaffin cells implanted into the rat midbrain was determined in brain slices. In addition, alterations in catecholamine secretion patterns, particularly adrenaline/noradrenaline ratios, were compared in vitro versus in transplants. Results indicated that brain slices containing chromaffin cell implants released high basal and nicotine-stimulated levels of adrenaline and noradrenaline. It is surprising that although adrenaline/noradrenaline ratios steadily declined in culture, this did not occur when cells were transplanted to the CNS in the early postharvesting phases. However, if cells were transplanted following longer periods in culture, adrenaline/noradrenaline ratios remained low. Together, these results suggest that the CNS can provide a supportive environment for chromaffin cell survival and that the pattern of catecholamine secretion can be optimized by prior in vitro manipulation.     

Immunohistochemical detection of nicotinic acetylcholine receptor subunits alpha9 and alpha10 in rat lung isografts and allografts

The success of clinical lung transplantation is poor in comparison to other solid organ transplants and novel therapeutic approaches are badly needed. In the view of the recent discovery of anti-inflammatory pathways mediated via nicotinic acetylcholine receptors, we investigated changes in this system in pulmonary isografts and allografts by immunohistochemistry. Lung transplantation was performed in the isogeneic Lewis to Lewis rat strain combination. For allogeneic transplantation Dark Agouti rats were used as donors. Nicotinic alpha9 and alpha10 acetylcholine receptor subunits were detected on alveolar macrophages as well as in the lung parenchyma of native and transplanted lungs. The expression of both receptor subunits was up-regulated in the parenchyma of day 4 allografts. These allografts were characterized by accumulations of alveolar macrophages strongly expressing the alpha9 and the alpha10 receptor subunit. Therapeutic application of nicotinic agonists might down-modulate pro-inflammatory functions of alveolar macrophages and protect pulmonary transplants.