Validation of the content of the prevention protocol for early sepsis caused by Streptococcus agalactiaein newborns / Validação de conteúdo do protocolo de prevenção da sepse precoce porStreptococcus agalactiae em recém-nascidos / Validación de contenido del protocolo de prevención de la sepsis precoz por Streptococcus agalactiaeen recién nacidos

AbstractObjective: to validate the content of the prevention protocol for early sepsis caused by Streptococcus agalactiaein newborns.Method: a transversal, descriptive and methodological study, with a quantitative approach. The sample was composed of 15 judges, 8 obstetricians and 7 pediatricians. The validation occurred through the assessment of the content of the protocol by the judges that received the instrument for data collection - checklist - which contained 7 items that represent the requisites to be met by the protocol. The validation of the content was achieved by applying the Content Validity Index.Result: in the judging process, all the items that represented requirements considered by the protocol obtained concordance within the established level (Content Validity Index > 0.75). Of 7 items, 6 have obtained full concordance (Content Validity Index 1.0) and the feasibility item obtained a Content Validity Index of 0.93. The global assessment of the instruments obtained a Content Validity Index of 0.99.Conclusion: the validation of content that was done was an efficient tool for the adjustment of the protocol, according to the judgment of experienced professionals, which demonstrates the importance of conducting a previous validation of the instruments. It is expected that this study will serve as an incentive for the adoption of universal tracking by other institutions through validated protocols.

ResumoObjetivo:validar o conteúdo do protocolo de prevenção da sepse precoce porStreptococcus agalactiaeem recém-nascidos.Método:estudo transversal, descritivo, do tipo metodológico, com abordagem quantitativa. A amostra foi composta por 15 juízes, oito médicos obstetras e sete pediatras. A validação ocorreu por intermédio da avaliação de conteúdo do protocolo pelos juízes, os quais receberam o instrumento de coleta de dados - checklist - contendo sete itens, que representam requisitos a serem contemplados no protocolo. A validação de conteúdo foi atingida mediante aplicação do Índice de Validade de Conteúdo.Resultado:no processo de julgamento, todos os itens que representam requisitos contemplados no protocolo obtiveram concordância dentro do nível estabelecido (Índice de Validade de Conteúdo >0,75). Dos sete itens, seis obtiveram concordância total, (Índice de Validade de Conteúdo 1.0) e o item exequibilidade obteve Índice de Validade de Conteúdo de 0,93. A avaliação global dos instrumentos obteve Índice de Validade de Conteúdo de 0,99.Conclusão:a validação de conteúdo realizada foi ferramenta eficaz para adequação do protocolo, de acordo com o julgamento de profissionais experientes, demonstrando a importância em se realizar validação prévia de instrumentos. Espera-se que, este estudo incentive a adoção do rastreio universal por outras instituições, mediante protocolos validados.

ResumenObjetivo:validar el contenido del protocolo de prevención de la sepsis precoz porStreptococcus agalactiaeen recién nacidos.Método:estudio transversal, descriptivo, del tipo metodológico, con un enfoque cuantitativo. La muestra fue conformada por 15 jueces, ocho obstetras y siete pediatras. La validación se dio a través de la evaluación de contenido del protocolo por los jueces, los cuales recibieron el instrumento de recolección de datos - checklist - conteniendo siete ítems, que representan los requisitos para ser incluidos en el protocolo. La validación de contenido se logró a través de la aplicación del Índice de Validez de Contenido.Resultado:en el proceso de evaluación, todos los ítems que representan los requisitos contemplados en el protocolo obtuvieron una concordancia dentro del nivel establecido (Índice de Validez de Contenido > 0,75). De los siete ítems, seis obtuvieron una concordancia total (Índice de Validez de Contenido 1,0), y el ítem viabilidad obtuvo un Índice de Validez de Contenido de 0,93. La evaluación global de los instrumentos obtuvo un Índice de Validez de Contenido de 0,99.Conclusión:la validación de contenido realizada fue una herramienta eficaz para la adecuación del protocolo, según la evaluación de profesionales expertos, demostrando así la importancia de realizar la validación previa de los instrumentos. Se espera que este estudio fomente la adopción del cribado (screening) universal por otras instituciones, mediante protocolos validados.

Hospitalizations for cardiovascular diseases and the coverage by the family health strategy / Internações por doenças cardiovasculares e a cobertura da estratégia saúde da família / Internaciones por enfermedades cardiovasculares y la cobertura de la estrategia salud de la familia

AbstractObjective: to verify the correlation between the rates of hospitalization for primary care-sensitive cardiovascular diseases and the coverage by the Family Health Strategy of residents of the State of Paraná, by regional health divisions, from 2000 to 2011.Method: ecological study developed from data of the Hospital Information System of the Brazilian Unified Health System (SUS) and the Department of Primary Care of the Ministry of Health. The rates of hospitalization for cardiovascular diseases were correlated with the annual coverage by the Family Health Strategy using Pearson's and Spearman's correlation coefficients.Result: there was a strong and negative correlation in the State of Paraná (r=-0.91; p <0.001) and in most regional health divisions, with the highest correlations observed in the Metropolitan and Toledo (r =-0.93; p<0.001) and Paranaguá (r=-0.92, p<0.001) regional health divisions.Conclusion: the results suggest that the increase in the coverage by the Family Health Strategy was an important factor for decrease in the hospitalizations for cardiovascular conditions among residents of the State of Paraná and in most regional health divisions. Other studies should be performed to analyze the factors and causes in regional health divisions where there was no correlation with increase in the Family Health Strategy.

ResumoObjetivo:verificar a correlação entre taxas de internação por doenças cardiovasculares sensíveis à atenção primária e a cobertura da Estratégia Saúde da Família de residentes no estado do Paraná, por regionais de saúde, no período de 2000 a 2011.Método:estudo ecológico, desenvolvido a partir de dados do Sistema de Informações Hospitalares do Sistema Único de Saúde e do Departamento de Atenção Básica do Ministério da Saúde. Correlacionaram-se as taxas de internação por doenças cardiovasculares com as coberturas anuais da Estratégia Saúde da Família, utilizando-se os coeficientes de correlação de Pearson e Spearman.Resultado:houve correlação negativa e forte no estado do Paraná (r=-0,91; p<0,001) e na maioria das regionais de saúde, sendo maior na Metropolitana e Toledo (r=-0,93; p<0,001) e Paranaguá (r=-0,92; p<0,001).Conclusão:os resultados sugerem que o aumento da cobertura da Estratégia Saúde da Família foi fator importante para a diminuição das internações por condições cardiovasculares em residentes no estado do Paraná e na maioria das regionais de saúde. Outros estudos devem ser realizados para analisar fatores e causas nas regiões do estado onde não houve correlação com incremento da Estratégia Saúde da Família.

ResumenObjetivo:verificar la correlación entre tasas de internación por enfermedades cardiovasculares sensibles a la atención primaria y la cobertura de la Estrategia Salud de la Familia de residentes en el estado de Paraná, por regionales de salud, en el período de 2000 a 2011.Método:estudio ecológico, desarrollado a partir de datos del Sistema de Informaciones Hospitalarias del Sistema Único de Salud y del Departamento de Atención Básica del Ministerio de la Salud. Se correlacionaron las tasas de internación por enfermedades cardiovasculares con las coberturas anuales de la Estrategia Salud de la Familia, utilizando los coeficientes de correlación de Pearson y Spearman.Resultado:hubo correlación negativa y fuerte en el estado de Paraná (r=-0,91; p<0,001) y en la mayoría de las regionales de salud, siendo mayor en la Metropolitana y Toledo (r=-0,93; p<0,001) y Paranaguá (r=-0,92; p<0,001).Conclusión:los resultados sugieren que el aumento de la cobertura de la Estrategia Salud de la Familia fue un factor importante para la disminución de las internaciones por condiciones cardiovasculares en residentes en el estado de Paraná y en la mayoría de las regionales de salud. Otros estudios deben ser realizados para analizar factores y causas en las regiones del estado en donde no hubo correlación con incremento de la Estrategia Salud de la Familia.

Risk behaviors for sexually transmitted diseases among crack users / Comportamentos de risco para doenças sexualmente transmissíveis em usuários de crack / Conductas de riesgo para enfermedades de transmisión sexual entre usuarios de crack

AbstractObjectives: to investigate the prevalence and risk behaviors by means of reporting of sexually transmitted diseases among crack users.Method: cross-sectional study carried out with 588 crack users in a referral care unit for the treatment of chemical dependency. Data were collected by means of face-to-face interview and analyzed using Stata statistical software, version 8.0.Results: of the total participants, 154 (26.2%; 95% CI: 22.8-29.9) reported antecedents of sexually transmitted diseases. Ages between 25 and 30 years (RP: 2.1; 95% CI: 1.0-4.0) and over 30 years (RP: 3.8; 95% CI: 2.1-6.8), alcohol consumption (RP: 1.9; 95% CI: 1.1-3.3), antecedents of prostitution (RP: 1.9; 95% CI: 1.3-2.9) and sexual intercourse with person living with human immunodeficiency virus/AIDS (RP: 2.7; 95% CI: 1.8-4.2) were independently associated with reporting of sexually transmitted diseases.Conclusion: the results of this study suggest high risk and vulnerability of crack users for sexually transmitted diseases.

ResumoObjetivos:investigar a prevalência e comportamentos de risco através do relato de doenças sexualmente transmissíveis em usuários de crack.Método:estudo transversal, realizado com 588 usuários de crack, de uma unidade de referência para tratamento de dependência química. Os dados foram obtidos por meio de entrevista face a face e analisados em programa estatístico Stata, versão 8.0.Resultados:do total de participantes, 154 (26,2%; IC 95%: 22,8-29,9) referiram antecedentes de doenças sexualmente transmissíveis. Idade entre 25 e 30 anos (RP: 2,1; IC 95%: 1,0-4,0) e superior a 30 anos (RP: 3,8; IC 95%: 2,1-6,8), consumo de álcool (RP: 1,9; IC 95%: 1,1-3,3), antecedentes de prostituição (RP: 1,9; IC 95%: 1,3-2,9) e relação sexual com pessoa vivendo com o vírus da imunodeficiência humana/aids (RP: 2,7; IC 95%: 1,84,2) foram independentemente associados ao relato de doenças sexualmente transmissíveis.Conclusão:os resultados deste estudo sugerem elevado risco e vulnerabilidade dos usuários de crackpara as doenças sexualmente transmissíveis.

ResumenObjetivos:investigar la prevalencia y las conductas de riesgo a través del informe de las enfermedades de transmisión sexual entre los usuarios de crack.Método:estudio transversal con 588 usuarios de crack, de una unidad de referencia para el tratamiento de la dependencia química. Los datos fueron obtenidos a través de entrevista cara a cara y se analizaron utilizando el programa estadístico Stata, versión 8.0.Resultados:del total de participantes, 154 (26,2%; IC 95%: 22,8-29,9) informaron antecedentes de enfermedades de transmisión sexual. Edad entre 25 y 30 años (RP: 2,1; IC9 5%: 1,0-4,0) y superior a 30 años (RP: 3,8; IC 95%: 2,1-6,8), consumo de alcohol (OR: 1,9; IC 95%: 1,1-3,3), antecedentes de prostitución (RP: 1,9; IC 95%: 1,3-2,9) y relaciones sexuales con persona viviendo con el virus de inmunodeficiencia humana/ SIDA (RP: 2,7; IC 95%: 1,8-4,2) se asociaron de forma independiente con la notificación de las enfermedades de transmisión sexual.Conclusión:los resultados de este estudio sugieren alto riesgo y la vulnerabilidad de los usuarios de crackpara las enfermedades de transmisión sexual.

Foot reflexology in feet impairment of people with type 2 diabetes mellitus: randomized trial / Reflexologia podal no comprometimento dos pés de pessoas com diabetes mellitus tipo 2: ensaio randomizado / Reflexología podal en el comprometimiento de los pies de personas con diabetes mellitus tipo 2: ensayo aleatorio

AbstractObjective: to evaluate the effect of foot reflexology on feet impairment of people with type 2 diabetes mellitus.Method: this is a randomized, controlled and blind clinical trial. The sample was comprised by people with type 2 diabetes mellitus who, after being randomized into Treated group (n = 21) and Control group (n = 24), received guidelines on foot self-care. To the Treated Group it was also provided 12 sessions of foot reflexology. The scores of impairment indicators related to skin and hair, blood circulation, tissue sensitivity and temperature were measured by means of the instrument for assessing tissue integrity of the feet of people with diabetes mellitus. Chi-square test, Fisher exact test, Mann-Whitney test and regression analyzes were applied to the data, considering a significance level of 5% (P value <0.05).Results: participants who received the therapy showed better scores in some impairment indicators related to skin and hair (hair growth, elasticity/turgor, hydration, perspiration, texture and integrity of the skin/ skin peeling).Conclusion: the foot reflexology had a beneficial effect on feet impairment of people with type 2 diabetes mellitus, which makes it a viable therapy, deserving investment. This study was registered in the Brazilian Registry of Clinical Trials - RBR-8zk8sz.

ResumoObjetivo:avaliar o efeito da reflexologia podal no comprometimento dos pés de pessoas com diabetes mellitus tipo 2.Método:trata-se de um ensaio clínico, randomizado, controlado e mascarado. A amostra foi composta por pessoas com diabetes mellitus tipo 2 que, após serem randomizadas em grupo Tratado (n=21) e Controle (n=24), receberam orientações de autocuidado com os pés. Ao Grupo Tratado também foram fornecidas 12 sessões de reflexologia podal. Foram mensurados os escores de comprometimento de indicadores relacionados à pele e pelos, circulação sanguínea, sensibilidade e temperatura tissular por meio do Instrumento para avaliação da integridade tissular dos pés de pessoas com diabetes mellitus. Aos dados foram aplicados os testes Qui-Quadrado, Exato de Fisher, Mann-Whitney e Análises de regressão, considerando-se nível de significância de 5% (Valor P<0,05).Resultados:os participantes que receberam a terapia apresentaram melhores escores de comprometimento em alguns indicadores relacionados à pele e pelos (crescimento de pelos, elasticidade/tugor, hidratação, transpiração, textura e integridade da pele/descamação cutânea).Conclusão:a reflexologia podal apresentou efeito benéfico sobre o comprometimento dos pés de pessoas com diabetes mellitus tipo 2, o que a torna uma terapia viável e que merece investimento. Este estudo foi registrado no Registro Brasileiro de Ensaios Clínicos - RBR-8zk8sz.

ResumenObjetivo:evaluar el efecto de la reflexología podal en el comprometimiento de los pies de personas con diabetes mellitus tipo 2.Método:se trata de un ensayo clínico, aleatorio, controlado y enmascarado. La muestra estuvo compuesta por personas con diabetes mellitus tipo 2 que, después de ser tratadas aleatoriamente en los grupos Tratado (n=21) y Control (n=24), recibieron orientaciones de autocuidado de los pies. También, al Grupo Tratado se le suministraron 12 sesiones de reflexología podal. Fueron medidos los puntajes de comprometimiento de indicadores relacionados a la piel y pelos, circulación sanguínea, sensibilidad y temperatura tisular por medio de instrumento para evaluación de la integridad del tejido de los pies de personas con diabetes mellitus. Los datos fueron sometidos a las pruebas Chi-cuadrado, Exacta de Fisher, Mann-Whitney y Análisis de regresión, considerando un nivel de significación de 5% (Valor p<0,05).Resultados:los participantes que recibieron la terapia presentaron mejores puntajes de comprometimiento en algunos indicadores relacionados a la piel y pelos (crecimiento de pelos, elasticidad/turgencia, hidratación, transpiración, textura e integridad de la piel/descamación cutánea).Conclusión:la reflexología podal presentó efecto benéfico sobre el comprometimiento de los pies de personas con diabetes mellitus tipo 2, lo que la torna una terapia viable y que merece inversiones. Este estudio fue registrado en el Registro Brasileño de Ensayos Clínicos - RBR-8zk8sz.

Preoperative Selective Desensitization of Live Donor Liver Transplant Recipients Considering the Degree of T Lymphocyte Cross-Match Titer, Model for End-Stage Liver Disease Score, and Graft Liver Volume

Several studies have suggested that a positive lymphocyte cross-matching (XM) is associated with low graft survival rates and a high prevalence of acute rejection after adult living donor liver transplantations (ALDLTs) using a small-for-size graft. However, there is still no consensus on preoperative desensitization. We adopted the desensitization protocol from ABO-incompatible LDLT. We performed desensitization for the selected patients according to the degree of T lymphocyte cross-match titer, model for end-stage liver disease (MELD) score, and graft liver volume. We retrospectively evaluated 230 consecutive ALDLT recipients for 5 yr. Eleven recipients (4.8%) showed a positive XM. Among them, five patients with the high titer (> 1:16) by antihuman globulin-augmented method (T-AHG) and one with a low titer but a high MELD score of 36 were selected for desensitization: rituximab injection and plasmapheresis before the transplantation. There were no major side effects of desensitization. Four of the patients showed successful depletion of the T-AHG titer. There was no mortality and hyperacute rejection in lymphocyte XM-positive patients, showing no significant difference in survival outcome between two groups (P=1.000). In conclusion, this desensitization protocol for the selected recipients considering the degree of T lymphocyte cross-match titer, MELD score, and graft liver volume is feasible and safe.

Strategies for local gene therapy of corneal allograft rejection

Penetrating keratoplasty is the most common type of tissue transplant in humans. Irreversible immune rejection leads to loss of vision and graft failure. This complex immune response further predisposes future corneal transplants to rejection and failure. A diverse armamentarium of surgical and pharmacologic tools is available to improve graft survival. In this review, we will discuss the various gene therapeutic strategies aimed at potentiating the anterior chamber-associated immune deviation to extend graft survival

The imbalance between Treg and Th17 cells caused by FTY720 treatment in skin allograft rejection

OBJECTIVES: FTY720 modulates CD4+T cells by the augmentation of regulatory T cell activity, secretion of suppressive cytokines and suppression of IL-17 secretion by Th17 cells. To further understand the process of graft rejection/acceptance, we evaluated skin allograft survival and associated events after FTY720 treatment. METHODS: F1 mice (C57BL/6xBALB/c) and C57BL/6 mice were used as donors for and recipients of skin transplantation, respectively. The recipients were transplanted and either not treated or treated with FTY720 by gavage for 21 days to evaluate the allograft survival. In another set of experiments, the immunological evaluation was performed five days post-transplantation. The spleens, axillary lymph nodes and skin allografts of the recipient mice were harvested for phenotyping (flow cytometry), gene expression (real-time PCR) and cytokine (Bio-Plex) analysis. RESULTS: The FTY720 treatment significantly increased skin allograft survival, reduced the number of cells in the lymph nodes and decreased the percentage of Tregs at this site in the C57BL/6 recipients. Moreover, the treatment reduced the number of graft-infiltrating cells and the percentage of CD4+ graft-infiltrating cells. The cytokine analysis (splenocytes) showed decreased levels of IL-10, IL-6 and IL-17 in the FTY720-treated mice. We also observed a decrease in the IL-10, IL-6 and IL-23 mRNA levels, as well as an increase in the IL-27 mRNA levels, in the splenocytes of the treated group. The FTY720-treated mice exhibited increased mRNA levels of IL-10, IL-27 and IL-23 in the skin graft. CONCLUSIONS: Our results demonstrated prolonged but not indefinite skin allograft survival by FTY720 treatment. This finding indicates that the drug did not prevent the imbalance between Tr1 and Th17 cells in the graft that led to rejection.

Synergistic suppression of pre-perfusion of donor livers with recipient serum and cobra venom factor treatment on hyperacute rejection following liver xenotransplantation / Supressão sinérgica da rejeição hiperaguda no xenotransplante hepático com uso da pre-perfusão dos fígados doadores tratados com soro do receptor e com fator veneno de cobra

PURPOSE: To investigate synergistic suppression of donor liver pre-perfusion with recipient serum (RS) and cobra venom factor (CVF) treatment on hyperacute rejection (HAR) following liver xenotransplantation. METHODS: Guinea-pigs (GP, n=24) and Sprague-Dawley rats (SD, n=24) were recruited. Before transplantation, serum was collected from SD rats and used for preparation of inactivated complements. GP and SD rats were randomly assigned into four groups (n=6), respectively: RS group, CVF group, RS+CVF group and control group. Orthotopic liver xenotransplantation was performed with modified two-cuff technique. The survival time and liver function of recipients, morphological and pathological changes in rat livers were investigated. RESULTS: There was no piebald like change in the recipient livers in all experiment groups. The survival time of recipients in all experiment groups was longer than that in control group (p<0.05). Moreover, the survival time in the RS+CVF group was markedly longer than that in the RS group (p<0.01) and CVF group (p<0.05). The serum ALT level in all experiment groups were lower than that in the control group (p<0.05). Furthermore, the ALT level in the RS+CVF group was significantly lower than that in the CVF group (p<0.05) and RS group (p<0.01). The histological damages were significantly improved when compared with the control group, and the histological damages in the RS+CVF group were milder than those in the remaining groups (p<0.05) CONCLUSION: Pre-perfusion of donor liver with recipient serum and cobra venom factor treatment can exert synergistic suppressive effects on the hyperacute rejection following liver xenotransplantation.

OBJETIVO: Investigar a supressão sinérgica da pré-perfusão do doador de fígado com soro do receptor (SR) e tratamento com fator veneno de cobra (FVC) na rejeição hiperaguda (RHA) após o xenotransplante de fígado. MÉTODOS: Foram utilizados Cobaias (GP, n=24) e ratos Sprague-Dawley (SD, n=24). Antes do transplante foram coletadas amostras de soro dos ratos SD e usados para a preparação dos complementos inativados. Cobaias GP e ratos SD foram randomicamente distribuídos em quatro grupos (n=6), respectivamente: grupo RS, grupo FVC, grupo SR+FVC e grupo controle. Xenotransplante ortotópico do fígado foi realizado com a técnica de dois cuffs modificados. Foram investigados o de tempo de sobrevida, a função hepática dos receptores e alterações morfopatológicas em fígados de ratos. RESULTADOS: Não houve alteração na coloração do parênquima dos fígados nos receptores. O tempo de sobrevida dos receptores em todos os grupos experimentais foi mais longo do que o grupo controle (p<0,05). Além disso, o tempo de sobrevida do grupo SR+ FVC foi marcadamente maior do que o grupo SR (p<0,01) e o grupo FVC (p<0,05). O nível sérico ALT foi menor em todos os grupos experimentais do que o grupo controle (p<0,05). O nível de ALT no grupo SR+ FVC foi significantemente menor do que no grupo FVC (p<0,05) e o grupo SR (p<0,01). As alterações histológicas foram significantemente melhoradas quando comparado com o grupo controle, e os danos histológicos no grupo SR+ FVC foram mais moderados do que nos grupos restantes (p<0,05). CONCLUSÃO: Pré-perfusão do fígado doador com soro do receptor e fator veneno de cobra pode exercer efeito supressor sinérgico da rejeição hiperaguda após xenotransplante de fígado.

The impact of pretransplant donor-specific antibodies on graft outcome in renal transplantation: a six-year follow-up study

OBJECTIVE: The significance of pretransplant, donor-specific antibodies on long-term patient outcomes is a subject of debate. This study evaluated the impact and the presence or absence of donor-specific antibodies after kidney transplantation on short- and long-term graft outcomes. METHODS: We analyzed the frequency and dynamics of pretransplant donor-specific antibodies following renal transplantation from a randomized trial that was conducted from 2002 to 2004 and correlated these findings with patient outcomes through 2009. Transplants were performed against a complement-dependent T- and B-negative crossmatch. Pre- and posttransplant sera were available from 94 of the 118 patients (80%). Antibodies were detected using a solid-phase (LuminexH), single-bead assay, and all tests were performed simultaneously. RESULTS: Sixteen patients exhibited pretransplant donor-specific antibodies, but only 3 of these patients (19%) developed antibody-mediated rejection and 2 of them experienced early graft losses. Excluding these 2 losses, 6 of 14 patients exhibited donor-specific antibodies at the final follow-up exam, whereas 8 of these patients (57%) exhibited complete clearance of the donor-specific antibodies. Five other patients developed ''de novo'' posttransplant donor-specific antibodies. Death-censored graft survival was similar in patients with pretransplant donor-specific and non-donor-specific antibodies after a mean follow-up period of 70 months. CONCLUSION: Pretransplant donor-specific antibodies with a negative complement-dependent cytotoxicity crossmatch are associated with a risk for the development of antibody-mediated rejection, although survival rates are similar when patients transpose the first months after receiving the graft. Our data also suggest that early posttransplant donor-specific antibody monitoring should increase knowledge of antibody dynamics and their impact on long-term graft outcome.

Complement-dependent lymphocytotoxicity crossmatch in deceased donor renal transplant: A single institutional experience.

Complement-dependent lymphocytotoxicity crossmatches (n=217) between 47 deceased donors and 150 potential renal recipients were retrospectively studied. A negative cross match was reported in 48 (22.1%), doubtful positive in 126 (58.1%), weakly positive in 32 (14.7%) and positive in 11 (5.1%). No autoantibodies were detected. Renal transplantation was performed in 35.5% of the potential recipients. There was no incidence of hyperacute rejection. The graft survival rate was 88% at 15 months of follow up. The study concludes that a negative pretransplant lympocytotoxicity crossmatch using the basic National Institute of Health technique eliminates hyperacute rejection, but carries drawbacks, which require modification and supplementation with more sensitive and specific assays.

B-cell Complement Dependent Cytotoxic Crossmatch Positivity is an Independent Risk Factor for Long-term Renal Allograft Survival

The clinical significance of positive B-cell complement-dependent cytotoxicity crossmatching (B-CDC) in renal transplant recipients remains unclear. We reviewed 20 recipients with isolated B-CDC positivity at the time of transplantation. We compared the clinical characteristics, acute rejection and long-term graft survival between positive and negative B-CDC patients (n = 602). The number of retransplant recipients and positivity for T- and B-flowcytometric crossmatch was greater in positive B-CDC patients than in negative B-CDC patients. The overall acute rejection rate of positive B-CDC patients was significantly higher (P < 0.001), and Banff grade II or III cellular rejection was more frequently observed in positive B-CDC patients (P = 0.037). Compared with negative B-CDC patients, acute cellular rejection as a cause of graft loss was more prevalent (P = 0.020) and rescue rejection therapy was more frequently needed in positive B-CDC patients (P = 0.007). The allograft survival rate of positive B-CDC patients was significantly lower than that of negative B-CDC patients (P < 0.001), and B-CDC positivity independently increased the risk of allograft failure 2.31-fold (95% CI 1.15-4.67; P = 0.019) according to multivariate analysis. In conclusion, isolated B-CDC positivity is an independent long-term prognostic factor for allograft survival.

The Decellularized Vascular Allograft as an Experimental Platform for Developing a Biocompatible Small-Diameter Graft Conduit in a Rat Surgical Model

PURPOSE: The present study was aimed to assess the feasibility of using decellularized aortic allograft in a rat small animal surgical model for conducting small diameter vascular tissue engineering research. MATERIALS AND METHODS: Decellularized aortic allografts were infra-renally implanted in 12 Sprague-Dawley (SD) adult rats. The conduits were harvested at 2 (n = 6) and 8 weeks (n = 6), and assessed by hematoxylin and eosin (H&E), van Gieson, Masson Trichrome staining, and immunohistochemistry for von Willebrand factor, CD 31+, and actin. RESULTS: Consistent, predictable, and reproducible results were produced by means of a standardized surgical procedure. All animals survived without major complications. Inflammatory immune reaction was minimal, and there was no evidence of aneurysmal degeneration or rupture of the decellularized vascular implants. However, the aortic wall appeared thinner and the elastic fibers in the medial layer showed decreased undulation compared to the normal aorta. There was also minimal cellular repopulation of the vascular media. The remodeling appeared progressive from 2 to 8 weeks with increased intimal thickening and accumulation of both collagen and cells staining for actin. Although the endothelial like cells appeared largely confluent at 8 weeks, they were not as concentrated in appearance as in the normal aorta. CONCLUSION: The results showed the present rat animal model using decellularized vascular allograft implants to be a potentially durable and effective experimental platform for conducting further research on small diameter vascular tissue engineering.

Inmunidad humoral y trasplante renal posibilidades terapéuticas / Humoral inmunity and renal trasplant: therapeutic possibilities

El trasplante renal es el tratamiento de elección para los pacientes con falla renal terminal. Las principales causas de pérdida de injertos son la muerte del paciente con injerto funcionante, especialmente de causa cardiovascular y la nefropatía crónica del injerto, con una pérdida crónica de injertos que resulta en un problema relevante. Dentro de las causas de nefropatía crónica destaca la causa inmunológica. Una de las causas de pérdida de injertos de origen inmunológico son los rechazos agudos, los que pueden ser de origen celular y humoral. Por otra parte, y a pesar de los avances en la comprensión de los mecanismos responsables de la inmunidad celular y el desarrollo de nuevas drogas inmunosupresoras (DIS), el rechazo mediado por anticuerpos o humoral aparece hoy como un peligro para la sobrevida del injertos a corto y a largo plazo. Afortunadamente el tratamiento del rechazo agudo humoral con drogas específicas ha resultado exitoso, sin embargo no ha ocurrido lo mismo con el rechazo mediado por anticuerpos de presentación más tardía, posiblemente por su comportamiento subclínico y un diagnóstico tardío, permaneciendo como un nuevo desafío recientemente reconocido. Por otra parte y basado en el exitoso tratamiento del RAH, se ha planteado mejorar las expectativas de llegar a realizar un trasplante a los pacientes sensibilizados. Esto es posible conseguir aplicando protocolos de desensibilización que se basan en la utilización de las mismas drogas para tratar RAH, consiguiendo ampliar las posibilidades de trasplante. El éxito de éstas es relativo al tipo de protocolos y a la intensidad de la sensibilización. La sobrevida del injerto en esta situación es plausible en la gran mayoría de los casos, sin embargo existe riesgo de presentar rechazo agudo humoral, y más complejo aún es el hecho que la sobrevida a largo plazo de los injertos sigue siendo todavía desconocida.

Renal Transplantation is the therapy of choice for patients with end-stage renal failure. The main causes for graft losses are patient death with functioning graft, mainly of cardiovascular etiology and chronic allograft nephropathy. Among the causes of chronic allograft nephropathy, the immunological ones are among the most important; one of them are the acute rejection episodes, which can be of cellular or humoral etiology; in addition, and despite the understanding of the mechanisms responsible for the cell immunity and the development of new immunosuppressive drugs (DIS) the antibody mediated rejection o humoral rejection has become today a danger for the short and long term allograft survival. Fortunately, the treatment of acute humoral rejection with specific drugs has become successful, however, the situation is different with late occurring antibody mediated rejection episodes, probably due to its subclinical behavior and a late diagnosis, remaining as a new challenge recently recognized. On the other hand based on the successful treatment of the RAH, expectations of performing a transplant in sensitized patients have been improved. This is possible to achieve using desensitizing protocols base don the same drugs used to treat RAH, thus increasing transplant possibilities. The success is related to the type of protocols and the intensity of the desensitizing. Graft survival in this situation is possible in the large majority of cases, however, the risk of acute humoral rejection is present, but even more complex is the fact thatlong-term survival is still unknown.

Fenómeno de acomodación inmunológica: Trasplante hepático ABO incompatible. Caso clínico / Accomodation process: ABO-incompatible liver transplantation. Report of one case

We report a 33 year-old female with a diagnosis of halothane-induce fulminant hepatic failure who was subjected to a liver transplant with an ABO-incompatible graft. The patient received a therapeutic protocol that included total plasma exchange, splenectomy and quadruple immunosuppression. After 5 years, the patient remains asymptomatic and with normal liver enzymes, while she has been treated with low dose of immunosuppressive drugs. This case demonstrates an example of how the immunological process of accomodation opens the possibility of using ABO-incompatible organs as a definitive grafts.

Cotransplantation of Cord Blood Hematopoietic Stem Cells and Culture-Expanded and GM-CSF-/SCF-Transfected Mesenchymal Stem Cells in SCID Mice

Mesenchymal stem cells (MSC) are multipotent in nature and believed to facilitate the engraftment of hematopoietic stem cells (HSC) when transplanted simultaneously in animal studies and even in human trials. In this study, we transfected culture-expanded MSC with granulocyte macrophage-colony stimulating factor (GMCSF) and stem cell factor (SCF) cytokine genes and then cotransplanted with mononuclear cells (MNC) to further promote HSC engraftment. MNC were harvested from cord blood and seeded in long-term culture for ex vivo MSC expansion. A total of 1 x 10(7) MNC plus MSC/microliter were introduced to the tail vein of nonobese diabetic/severe combined immunodeficiency mice. After 6-8 weeks later, homing and engraftment of human cells were determined by flow cytometry and fluorescence in situ hybridization studies. The total nucleated cell count and the engraftment of CD45+/CD34+ cells and XX or XY positive human cells were significantly increased in cotransplanted mice and even higher with the cytokine gene-transfected MSC (GM-CSF>SCF, p<0.05) than in transplantation of MNC alone. These results suggest that MSC transfected with hematopoietic growth factor genes are capable of enhancing the hematopoietic engraftment. Delivering genes involved in homing and cell adhesions, CXCR4 or VLA, would further increase the efficiency of stem cell transplantation in the future.

Role of Complement Regulatory Proteins in the Survival of Murine Allo-transplanted Sertoli Cells

Sertoli cells (SC) are known to contain immunoprotective properties, which allow them to survive as allografts without the use of immunosuppressive drugs. Experiments were designed to determine which factors are related to prolonged survival of allogeneic SC. Balb/c derived Sertoli (TM4) and colon cancer (CT-26) cell lines were implanted beneath the kidney capsule of non-immunosuppressed C57BL/6 mice and compared their survival as allografts. Compared to TM4 graft, which survived more than 7 days after transplantation, CT-26 showed massive infiltration of polymorphonuclear cells, necrosis and enlargement of draining lymph nodes. Cultured cell lines showed no differences in their expression patterns of FasL, TGF beta1, clusterin and two complement regulatory proteins (CRP, i.e., membrane cofactor protein, MCP; decay accelerating factor, DAF), but protectin (CD59), another member of CRP was expressed only on TM4. These results suggest that CD59 and unknown factors may contribute to the prolonged survival of SC in non-immunoprivileged sites.

IL-2 Pathway Blocking in Combination with Anti-CD154 Synergistically Establishes Mixed Macrochimerism with Limited Dose of Bone Marrow Cells and Prolongs Skin Graft Survival in Mice

To facilitate the establishment of mixed chimerism with limited dose of bone marrow (BM) cells, and to achieve tolerance in skin graft model, combined blocking of costimulatory pathway and IL-2 pathway was used in minimally myeloablative model using busulfan. BM cells (2.5 x 10(7)) of BALB/c were injected into C57BL/6 mice at day 0 with full thickness skin graft after single dose injection of busulfan (25 mg/kg) on day-1. Recipients were grouped and injected the anti-CD154, CTLA4-Ig, anti-IL-2R at days 0, 2, 4, and 6 according to protocol. Mixed macrochimerism were induced in groups treated with anti-CD154+anti-CTLA4-Ig, anti-CD154+anti-IL-2R, and anti-CD154+anti-CTLA4 Ig+anti-IL-2R. Three groups having chimerism enjoyed prolonged graft survival more than 6 months. Superantigen deletion study revealed deletion of alloreactive T cells in combined blockade treated groups. In graft versus host disease model using CFSE staining, CD4+ T cell and CD8+ T cell proliferation were reduced in groups treated with CTLA4-Ig or anti-IL-2R or both in combination with anti-CD154. However, anti-IL-2R was not so strong as CTLA4-Ig in terms of inhibition of T cell proliferation. In conclusion, IL-2 pathway blocking combined with anti-CD154 can establish macrochimerism with limited dose of BM transplantation and induce specific tolerance to allograft.

IL-2 Pathway Blocking in Combination with Anti-CD154 Synergistically Establishes Mixed Macrochimerism with Limited Dose of Bone Marrow Cells and Prolongs Skin Graft Survival in Mice

To facilitate the establishment of mixed chimerism with limited dose of bone marrow (BM) cells, and to achieve tolerance in skin graft model, combined blocking of costimulatory pathway and IL-2 pathway was used in minimally myeloablative model using busulfan. BM cells (2.5 x 10(7)) of BALB/c were injected into C57BL/6 mice at day 0 with full thickness skin graft after single dose injection of busulfan (25 mg/kg) on day-1. Recipients were grouped and injected the anti-CD154, CTLA4-Ig, anti-IL-2R at days 0, 2, 4, and 6 according to protocol. Mixed macrochimerism were induced in groups treated with anti-CD154+anti-CTLA4-Ig, anti-CD154+anti-IL-2R, and anti-CD154+anti-CTLA4 Ig+anti-IL-2R. Three groups having chimerism enjoyed prolonged graft survival more than 6 months. Superantigen deletion study revealed deletion of alloreactive T cells in combined blockade treated groups. In graft versus host disease model using CFSE staining, CD4+ T cell and CD8+ T cell proliferation were reduced in groups treated with CTLA4-Ig or anti-IL-2R or both in combination with anti-CD154. However, anti-IL-2R was not so strong as CTLA4-Ig in terms of inhibition of T cell proliferation. In conclusion, IL-2 pathway blocking combined with anti-CD154 can establish macrochimerism with limited dose of BM transplantation and induce specific tolerance to allograft.

4-1BB (CD137) signals depend upon CD28 signals in alloimmune responses

Our previous study has demonstrated that there is a significant delay of Balb/c cardiac allograft rejection in the C57BL/6 4-1BB-deficient knockout recipient. In this study, we examined the effect of combined blockade of the 4-1BB and CD28 costimulatory pathways on cardiac allograft rejection in the C57BL/6-->Balb/c model. A long-term cardiac allograft survival was induced in CD28/4-1BB- deficient mice (>100 days survival in 3 of 4 mice), which was comparable with CD28-deficient mice (>100 days survival in 2 of 5 mice; P<0.2026). There was no long-term cardiac allograft survival in either wild-type (WT) or 4-1BB-deficient mice, even though 4-1BB-deficient recipients showed a significant delay of cardiac allograft rejection than WT mice. An in vitro mixed leukocyte reaction (MLR) assay showed that 4-1BB-deficient and WT mouse T cells had a similar responsiveness to allostimulation, whereas CD28- and CD28/4-1BB-deficient mouse T cells had a defective responsiveness to allostimulation. Furthermore, 4-1BB-deficient mice showed a similar CTL but an elevated Ab response against alloantigens as compared to WT mice, and the alloimmune responses of 4-1BB-deficient mice were abrogated in the CD28-deficient background. Overall, these results indicate that the CD28 costimulatory pathway plays a major role in the alloimmune response and that 4-1BB signals are dependent upon CD28 signals.