Successful Heart Transplantation After Desensitization in a Patient With Extremely High Panel-Reactive Antibody Levels and Pretransplant Donor-Specific Antibody: A Case Report.

Elevated panel-reactive antibody (PRA) levels serve as a significant risk factor for allograft survival and episodes of rejection after heart transplantation (HTX). Patients with high PRA levels tend to show expressions of donor-specific human leukocyte antigen antibodies (DSA), which can cause catastrophic hyperacute rejection after HTX. Therefore, such highly sensitized patients are required to undergo strategic perioperative desensitization therapy. We describe a successful HTX after desensitization in a patient with extremely high PRA levels and pretransplant DSA positivity.

Sulcus subarachnoid hemorrhage is a common stroke subtype in patients with implanted left ventricular assist devices.

BACKGROUND AND PURPOSE: Stroke is one of the major complications observed in patients with an implanted left ventricular assist device (LVAD). The purpose of this study was to clarify the types and characteristics of acute stroke in patients after LVAD implantation by using brain computed tomography (CT) findings. METHODS: Between 2005 and 2012, 110 consecutive patients who underwent LVAD implantation were reviewed. The most commonly used device was the pulsatile extracorporeal LVAD. Amongst them, 49 patients suffered from acute stroke at least once with a total of 115 stroke events. The clinical categories, lesion sites, laboratory data and CT findings of each acute stroke event were analyzed. RESULTS: Cerebral infarction (35 patients, 72 events), cerebral hemorrhage (25 patients, 31 events) and subarachnoid hemorrhage (SAH) (23 patients, 33 events) were identified. A mean of 2.3 stroke events occurred per person. Of the 72 infarction events, multiple infarctions were observed in 29 events. Of the cerebral hemorrhage events (n = 31), almost all were subcortical lesions (n = 27) and none were observed in the basal ganglia. Of the 23 patients with SAH events (n = 33), SAH localized within a single sulcus, sulcus SAH, was observed in 25 events. CONCLUSIONS: Computed tomography findings of acute stroke after implantation of an LVAD are characteristically multifocal cortical lesions, regardless of brain infarction and hemorrhage. Unexpectedly, sulcus SAH was a common stroke subtype in patients with implanted LVADs. Sulcus SAH should be carefully examined in patients after LVAD implantation, when they complain of non-specific neurological complaints.

Immunohistochemical expression of fibrillin-1 and fibrillin-2 during tooth development.

BACKGROUND AND OBJECTIVE: Oxytalan fibers are categorized as a microfibril assembly without elastin deposition, and are unique components in the periodontal ligament (PDL). However, little is known about their formation during PDL development. To clarify the mechanisms of oxytalan fiber formation in developing PDL, we performed immunohistochemical analysis to detect the direct expression of fibrillin-1 and fibrillin-2, which are major components of microfibrils. MATERIAL AND METHODS: Frozen sections of lower molars from mice at several stages of growth were prepared without chemical fixation and decalcification using the film transfer method. Immunostaining was performed with anti-fibrillin-1 and -2, and anticytokeratin antibodies. RESULTS: Fibrillin-1 was not expressed in the dental follicle during the crown forming stage. At postneonatal day 9, fibrillin-1 expression started with meshwork appearance between the epithelial cells from Hertwig's epithelial root sheath at the root dentin surface. Fibirillin-2 was detected much earlier than fibrillin-1 expression. Fibrillin-2 was expressed with a liner appearance, running parallel to the root axis in PDL, and was partially co-expressed with cytokeratin 14 expression in Hertwig's epithelial root sheath. Furthermore, we detected both fibrillin-1 and fibrillin-2 expression in human PDL. Fibrillin-1 was detected in fibers with a vertically oriented root axis in PDL. Fibrillin-2 was widely expressed in PDL, including around the epithelial cell rests of Malassez. Fibrillin-1 and fibrillin-2 were clearly co-expressed in thick fiber structures in human PDL. CONCLUSION: Our results suggest that both fibrillin-1 and fibrillin-2 expression is required to form thick oxytalan fibers in PDL. Based on the expression patterns for fibrillin-1 and fibrillin-2, they have different functions during tooth root and PDL development. Early expression of fibrillin-2 may regulate dental epithelial cell behavior during root and PDL development.

A case of everolimus-associated chylothorax in a cardiac transplant recipient.

We herein report a case of putative everolimus-associated chylothorax in a cardiac transplant recipient. A 17-year-old Japanese boy with dilated cardiomyopathy and severe cardiac failure requiring left ventricular assist support was determined to be a cardiac transplant candidate in 1992. He underwent overseas heart transplantation in Houston, Texas in October 1992. He was subsequently treated with immunosuppression therapy: Cyclosporine (CSA), azathioprine, and prednisolone (PRD). After several acute rejection episodes requiring steroid therapy, intravascular ultrasonography revealed a moderate degree of transplant coronary arterial vasculopathy (TCAV) with 50% stenosis in 2003. He underwent coronary stenting twice; the immunosuppressive regimen was converted to CSA, mycophenolate mofetil, everolimus (EVL), and PRD in 2006. TCAV has not progressed since then. In October 2008, chest x-ray showed bilateral pleural effusion. As we thought that the pleural effusion was caused by cardiac dysfunction due to moderate mitral regurgitation and TCAV as well as renal impairment, he was treated with diuretics and digoxin. However, the pleural effusion progressed gradually associated with exertional dyspnea and moderate edema of his lower legs. Chest computed tomography showed massive bilateral pleural effusions without evidence of malignancy in 2011. A pleural tap in 2011 revealed chylothorax. Although mammalian target of rapamycin inhibitors were major drugs for lymphoangioleimyomatosis, we believed that the chylothorax was associated with EVL. EVL was discontinued in March 2011: the chylothorax spontaneously resolved in November 2011.

Risk factors to cause tooth formation anomalies in chemotherapy of paediatric cancers.

This study aimed to investigate the risk factors of tooth formation anomalies in anti-cancer chemotherapies. Long-term survivors treated by conventional chemotherapy (n = 26), conventional chemotherapy with high-dose chemotherapy (HDC) (n = 14), and HDC with total body irradiation (TBI) (n = 6) were analysed for the incidence of tooth agenesis, microdonts, and short-rooted teeth. The tooth agenesis and/or microdonts were found in second premolars and second molars, but not in first molars or central incisors. The ratio of subjects with tooth agenesis and/or microdonts was 66.7% and 18.2% in subjects administered conventional chemotherapy at <4 years and ≥ 4 years of age, respectively, while it was 100% and 25% in subjects administered HDC at <4 years and ≥ 4 years of age. The incidence of tooth formation anomalies did not related with the duration of conventional chemotherapy but increased by HDC. The incidence of tooth formation anomalies did not show significantly differences between the HDC with and without TBI groups, and was higher in busulfan-administered subjects than in subjects given cyclophosphamide. It may be concluded that the high-risk group of tooth agenesis is the subjects with HDC under 4 years of age. However, protocols of conventional chemotherapy are not an important risk factor to cause the tooth formation anomalies.

A newly developed container for safe, easy, and cost-effective overnight transportation of tissues and organs by electrically keeping tissue or organ temperature at 3 to 6°C.

BACKGROUND: As there is only one skin procurement organization in Japan the Japan Skin Bank Network (JSBN), all skin grafts procured in Japan are sent by a commercialized delivery system. Preliminarily, bottles containing saline were transported in a cardboard box using a so-called "cooled home delivery service" using a truck with a refrigerated cargo container. During transportation the temperature in the cardboard box increased to 18°C in summer and decreased to -5°C in winter. For these reasons, we investigated whether a newly developed container "Medi Cube" would be useful to transport skin grafts. OBJECTIVES: Four bottles with a capacity of 300 mL containing 150 mL of saline in a Medi Cube container were transported from Osaka to the JSBN in Tokyo between 4 PM and 10 AM using a commercialized cooled home delivery service. Two bottles were transported in a Medi Cube container without phase change materials (PCM) in winter and summer, respectively. Another two bottles were transported in the Medi Cube with PCMs in winter. The temperatures inside saline, inside a transportation container, and outside the container, and air temperature were monitored continuously with a recordable thermometer. RESULTS: The temperatures inside saline and inside a Medi Cube container were maintained between 3 and 6°C, even when the temperature outside the container increased during parking. The temperature inside a Medi Cube container without PCM decreased to -3°C when the inside of the cargo container was overcooled in winter. However, the temperatures inside saline and inside a Medi Cube container with PCM were between 3 and 6°C, even when the temperature outside the container decreased to below 0°C in winter. CONCLUSION: A Medi Cube container with PCM provided a safe, easy, and cost-effective method for overnight transportation of skin grafts.

Hybrid endovascular stent-grafting technique for patent ductus arteriosus in an adult.

A 51-year-old man was referred to our institution for patent ductus arteriosus (PDA) complicated by left ventricular dysfunction and pulmonary hypertension. Surgical closure of a PDA is usually carried out via a small posterior thoracotomy. However, thoracoscopic procedures are probably not appropriate in adults because of the frequency of calcification and the greater risk of rupture while ligating the ductus. To minimize surgical trauma, we used hybrid endovascular stent grafting combined with revascularization of the left subclavian artery, which enabled us to eliminate shunt flow to the pulmonary artery. At 11-month follow-up, the patient was asymptomatic and showed no complications.

Tissue procurement system in Japan: the role of a tissue bank in medical center for translational research, Osaka University Hospital.

Although organ procurement has been regulated by The Organ Transplantation Law (brain-dead donors since 1997, donors after cardiac death since 1979), there has been no law or governmental procurement network (except for cornea) in Japan. Since the late 1980s, some university hospitals have developed original banks. Finally, in 2001 guidelines for tissue procurement were established by The Japanese Society of Tissue Transplantation and Japan Tissue Transplant Network (JTTN) to coordinate tissue harvesting. Five tissue banks were joined to the tissue transplant network (skin in one, heart valves in two, and bone in two). As the number of tissue banks is small, each bank cooperates on procurement, but cannot cover the entire country. With regard to skin transplantation, only one skin bank-The Japan Skin Bank Network (JSBN), which is located in Tokyo-has organized skin procurement. Therefore, it has been difficult to procure skin in areas distant from Tokyo, especially around Osaka. In order to improve such a situation, a tissue bank collaborating with the JSBN was established at The Medical Center for Translational Research (MTR), Osaka University Hospital in April 2008. The bank has played a role in skin procurement center in western Japan and supported procurement and preservation at the time of the skin procurement. Between April 2008 and September 2009, the bank participated in eight tissue procurements in the western area. In the future, the bank is planning to procure and preserve pancreatic islets and bones. Moreover, there is a plan to set up an induced pluripotent stem cells center and stem cell bank in MTR. This tissue bank may play a role to increase tissue procurement in Japan, especially in the western area.

Adenovirus-mediated gene expression of the human c-FLIP(L) gene protects pig islets against human CD8(+) cytotoxic T lymphocyte-mediated cytotoxicity.

Cell-mediated immunity, especially of human CD8+ cytotoxic T lymphocytes (CTLs) is believed to have an important role in the long-term survival of pig islet xenografts. Protection against human CD8+ CTL cytotoxicity may reduce the direct damage to pig islets and enable long-term xenograft survival in pig-to-human islet xenotransplantation. We have previously reported that c-FLIP(S/L) genes, which are potent inhibitors of death receptor-mediated proapoptotic signals through binding competition with caspase-8 for recruitment to the Fas-associated via death domain (FADD), markedly suppress human CD8+ CTL-mediated xenocytotoxicity. In addition, the cytoprotective effects of c-FLIP(L) seem to be significantly stronger than those of c-FLIP(S). Accordingly, in the present study, expression of c-FLIP(L) was induced in intact pig islets by adenoviral transduction. Consequently, the cytoprotective capacity of the transgene in pig islets was examined in in vitro and in vivo exposure to human CD8+ CTLs. Cells from untransduced islets or mock islets were sensitive to CD8+ CTL-mediated lysis (59.3% +/- 15.9% and 64.0% +/- 8.9% cytotoxicity, respectively). In contrast, cells from pig islets transduced with the c-FLIP(L) gene were markedly protected from lysis (30.5% +/- 3.5%). Furthermore, prolonged xenograft survival was elicited from pig islets transduced with this molecule as assessed using an islet transplant model using the rat kidney capsule. Thus, these data indicate that intact pig islets can be transduced to express c-FLIP(L) with adenovirus. Pig islets expressing c-FLIP(L) are significantly resistant to human CTL killing and further exhibit beneficial effects to prolong xenograft survival.

In vivo controlling of cellular response to pig islet xenografts by adenovirus-mediated expression of either membrane-bound human FasL or human decoy Fas.

The critical problem with clinical islet transplantation for patients with type 1 diabetes is the severe shortage of human donors. Pig islet xenotransplantation has the potential to provide a virtually unlimited source of donor pancreata. However, our previous studies demonstrated that cell-mediated rejection, especially human CD8(+) cytotoxic T lymphocyte (CTL)-mediated cytotoxicity, remains a major obstacle for long-term islet xenograft survival. Moreover, we have demonstrated that the overexpression of either membrane-bound human FasL (mFasL) or human decoy Fas antigen (decoy Fas) in pig islets not only prevented CTL xenocytotoxicity in vitro, but also prolonged histological survival of pig islet xenografts in vivo. Therefore, the aim of the present study was to determine whether adenoviral transfer of these genes into pig islets ex vivo prior to transplantation had a beneficial effect on posttransplantation glycemic control of diabetic recipients. Isolated pig islets were transfected with adenovirus vector carrying complementary DNA (cDNA) of either mFasL or decoy Fas. The transfected islets were transplanted under the kidney capsule of diabetic recipient rats. Rats transplanted with either mFasL- or decoy Fas-transfected pig islet grafts showed significantly suppressed blood glucose levels from 12 hours to 18 hours posttransplantation compared with control groups transplanted with empty vector-transfected pig islets. Unfortunately, blood glucose levels of these groups were increased, with no significant difference observed at 24 hours posttransplantation. However, transgenic expression of these molecules with clinically tolerable amount of immunosuppressants may be more effective to achieve islet xenograft survival in the future.

Rapamycin induces autophagy in islets: relevance in islet transplantation.

Islet transplantation can provide insulin independence in patients with type 1 diabetes mellitus. However, islet allograft recipients exhibit a gradual decline in insulin independence, and only 10% do not require insulin at 5 years. This decline may reflect drug toxicity to islet beta cells. Rapamycin, a central immunosuppressant in islet transplantation, is a mammalian target of rampamycin inhibitor that induces autophagy. The relative contributions of autophagy in transplanted islets are poorly understood. Therefore, in the present study we sought to evaluate the effects of rapamycin on islet beta cells. Rapamycin treatment of islets resulted in accumulation of membrane-bound light chain 3 (LC3-II) protein, an early marker of autophagy. In addition, rapamycin treatment of isolated islets elicited not only reduction of viability but also downregulation of in vitro potency. To further examine the occurrence of autophagy in rapamycin-treated islets, we used GFP (green fluorescent protein)-LC3 transgenic mice that express a fluorescent autophagosome marker. The GFP-LC3 signals were markedly increased in rapamycin treated islets compared with control islets. In addition, to show improvement by blockade of autophagic signaling, islets were treated with rapamycin in the presence of 3-methyladenine, which inhibits autophagy. Thereafter, both islet viability and islet potency were dramatically improved. The number of GFP-LC3 dots clearly increased after 3-MA treatment. Thus, rapamycin treatment of islets induces autophagy in vitro. This phenomenon may contribute to the progressive graft dysfunction of transplanted islets. Therapeutically targeting this novel signaling may yield significant benefits for long-term islet survival.