EAONIKH 2008

2008ON O OB

EAONIKH 2008

2008ON O O O

I

. OY, . OOY, . O

H ' , - , , .

O 2008

:

UNIVERSITY STUDIO PRESS A.E.A 32, 546 35 OIT. 2310 208731, 2310 209837 Fax 2310-216647E-mail: info@universitystudiopress.grH : www.universitystudiopress.grTOA TOY BIBIOY 5, 105 64 AHNAT. & Fax 210 3211097

POOO ...................................................................................................................................................................................................................................................... 7

EKOTE ........................................................................................................................................................................................................................................................... 9

YPAEI ............................................................................................................................................................................................................................................... 11

OOEO H OA

O O O

: CTS ....................................................... 15.

............................................................................................................................................ 17.

....................................................................................................................................................................... 25.

Dendritic cells (DCs) and regulatory T cells (Tregs) in renal transplantation ........................................................ 29Daniel V.

O O

...................... 31.

.................... 35.

O ...................................................................................................... 43. , ..

Kidney Transplantation in Highly sensitized recipients .................................................................................................................. 45G. Tsoulfas, T. Kawai

OO O O

................................................................................................................................... 51. , .

O ( ) ................................................................................. 67.

5

EPIEXOMENA

............................................................................................................................. 73..

O ......................................................................................................................................................................................................................... 77..

.................................................. 81. , .

.................................................................................................................................................................................. 91

..

O O

O O

............................................................................................................................... 99..

................................................................................. 100.

VII ...................... 106.

........................................................................................................................................................................................... 115.

... O O

....................... 119..

................................................................................................................................................................................ 126

.

. .......... 136.

................................................................... 144.

Infections in liver transplant patients: A short Overview and two case reports .................................................. 147F.H. Saner, I. Fouzas, G. Sotiropoulos, A. Radtke, S. Nadalin, A. Paul

6

, -

.

. O -

, -

.

-

,

-

.

o o

POOO

7

9EKOTE

T, , o o A oo

B , ,o o A oo

o, ,o o A oo

:

1. Daniel Volker MD, Professor, Department of Transplantation Immunology, Institute of Immunology, University

of Heidelberg

2. Kawai Tatsuo, Associate Professor of Surgery, Transplant Unit, Massachusetts General Hospital, Harvard Medical

School

3. Saner Fuat Hakan, PD Dr. med., Intensive Care Unit, Department of General, Visceral and Transplant Surgery,

University Hospital, Essen

4. Sotiropoulos Georgios PD Dr. med., Department of General and Abdominal Surgery, Johannes Gutenberg

University Hospital, Mainz, Germany

:

1. , , ,

2. , , Adj. Professor of Surgery, HepatoPancreatoBiliary and Transplant

Department, McGill University, Montreal, , -

,

3. , , ,

4. , , ,

5. , -, , ,

6. , ,

7. , , ,

8. , , ,

9. , -, ,

10. , -, , ,

11. , , ,

12. , ,

13. , , - ,

14. , , ,

15. , -, ,

16. , ,

17. , , , ,

18. , , , Solid Organ

Transplantation, University of Rochester, Medical Center, New York,

,

19. , , ,

20. , ,

21. , , -

,

11

YPAEI

13

YEEYAOOEO EE OEYA

CTS (Collaborative TransplantStudy) 1982 , Gerhard Opelz - , - NeuenHeimerfeld, 162 28 .

- , - , - . -, CTS 24 , - - , . - 3 , 1990 Transplant International. - HLA -, - , - -, -, , . , - - (Panel Reactive Antibodies, PAR) 50%, . O - HLA -

10%. CTS - - , - , .

-, CTS - - , - . , . . -: - .

CTS , , - - -, - - , - - .

, ( ).

O CTS , .

15

A :H CTS

.

CTS - -, - , , - , ..

.

, CTS -

295.708 - 225 - . , - 51.163 - , 32.128 , 9.076 ,8.444 1.746 -.

, CTS.

16 .

-, , - in vitro in vivo - . , - , - - .O - , :

DNA sequencing mRNA DNA DNA arrays DNA cDNA -

-

-

, - ,

, / - .

To DNA RNA - . (genomics) - omics. O - - transcriptonics (mRNAtranscripts ), proteomics (),metabolonics ( ), glycomics( -), phenomics ( - ), ... omics - - , , .. - , - . - - -.

DNAarrays

(genomics) - - , - . O - --, - . O / -

17

.

, - . - . - , - , . - -.

- - - : .. TNF-a (tumor necrosis factoralpha), PDGF (platelet-derived growth factor) ,bFGF (basic fibroblast growth factor) - 1, IFN- (interferon-gamma),ICAM-1 (intercellular adhesion molecule) - 2, cytotoxic T-cell, .. granzyme A B, -, -3. -10, -2 - -4 TGF-1 (transforming growthfactor) . - - . - real time PCR ( 100% , 100%), perforin, granzymeB, fas ligant 4.

ELIS ELISPOT (L) IFN-, -5,-7,-10,-15,-4, -6 - -5. -, perforin, granzyne granulysin6,7,8 - . - - , , , Lunimex (beads). -

PCR - .

DNA micro-arrays - - : AffymetrixGeneChips (Affymetrix inc, Santa ClaraCalifornia) arrays (25 mers) arrays PCR cDNA - (200-1000 base pairs). spottedarrays (30-70 bases). - 60-mer arrays inkjet print Agilent, GeneralElectric Healthcare covalent linking 3D gel matrix, 30 mer arrays. - .

DNA arrays, - - .

- 7 , -, 3 -, Affymetix Gene ChipsFL6800 6,800 probe sets 9. 4 - (human monokine induced byinterferon-, T cell receptor active chain protein,interleukin 2 stimulated phosphoprotein transporter associated with antigen presentationTADI) 7 - . (interferon-stimulated growth factor3, complement factor 3, nicotinamide N-methyl-tranferase, macrophage inflammatory protein3,myeloid differatiation protein CD18) - - . , cytoxine T-cell effectror perforin

18 .

granzyme - PCR - .

AffymetrixGene Chips (Hu95Av2) 12,625, - 6 10. - 12 . , 12 . 10 - 12 . - - 15 17 (88%). - 12 follow-up .

O Stegall 11 - ,, . RNA - 3, 5, 7 - Affymetrix U34A rat micro arrays - probe sets 8,800 . 2,864 - 3 , 1,418 5 2,745 7 . micro arrays 13 real time-PCR. -, 19 decotin ( ).

Lymphochip(Stanford University, National Cancer Institute), spotted cDNA array 12,440 Stanford12. 67 -

. RNA 18 , 1 2 in vitro chips: - , . - - granzyme PRF - . - PCR. - . array - - .

, , , (PBL). arrays .

13 AffymetrixHG-U95Av2 Genes Chips - - : -, - , - - . - , PBLs -. - real timePCR 15 . - - - PBL . - PBLs - .

METAMOXEYE 2008 19

- DNA microarrays PBLs .

14 - . - PBL - Affymetrix HU1331A microarrays probe sets 22,283 . 91 - -. 98% - - . PCR - - caspase 8, Fadd-like apoptosis regulator, superoxide dismutase 2. - PBL - .

O Flechner 15 - ( ) calcineurininhibitor-free sirolimus (Rapamycin, Wyeth, Collegeville, Pen-nsylvania) mycophenolate mofetil (CellCept,Roche, Nutley, New Jersey) calcineurin inhibitor (Neoral, Novartis, East Hanover, New Jersey). O - -. - - / / - . O - , , / - - -.

cDNA microarrays - - - . -

16 . O - . , - . - 113 , 62 . . , 9 - - . - - DNA microarrays .

Proteomics

O - - . - , (chips, arrays) - - . - , - - - .

- , . - -.

20 .

(.. -). - .

proteomics , - 100,000 , transcri-ptome mRNA 30,000 . - - (.. ), - splicing, , -. , , - , , - - , - , .

- -, - , N-terminal C-terminal sequencing -/ . -, - . - (2D PAGE), , , (Mass Spectrometry MS), .1. - -. , - . , S .

. 1. .

(.. , )

2D PAGE

(.. AgNO3)

()

HPLC capillary

Nanospray LC-MS (

)

MS/MS (m/q)

( )

- - , - -. O - - .

H - Yamani 17 - . O ( ) 12 kDa - , - . , , - , - S, . 1. -, . O -

METAMOXEYE 2008 21

eart Science Center-2-Dimen-sional Polyacrylamide Gel Electrophoresis (HSC-2DPAGE), HEART-2PAGE, High HeartPerformance 2D PAGE (HP-2DPAGE).

18

-. O , 2DPAGE, - -. , , (ubiquijnol cytochrome c reductase - NADH ubiquinone oxido-reductasecomplex I), - .

19, - - : (1) , (2) , (3) - de-novo - (4) control - [34]. control (4) - (1) - . - 3 /: - 5270-5550 (5 ), 7050-7360 (3 ) 10530-11100 (5). O , -. , , - , test .

20 - 17 - 15 (controls). - - -

. O - - : -. O 91% 34 ( 83% 100%).

O - , . - - .

- , -21. - - - .

2D PAGE - -. spots - - . 2D PAGE . 2D PAGE - , .

Kurian,Yates 22 - tandem - - . - MuDPIT (multi dimensional proteinidentification tool). - -

22 .

. (- ion exchange). - /. - - Swiss-Prot translations - , .

(MuDPIT) - 10,000 - . O - , - , - - , , .

O , - , - , - - proteogenomics. O - - -. O - . - - . - , - . , 23. 10,000 , - , 100,000. -

Fourier-transformed tandem - uDPIT -. - 50,000 .

- - .O - - . - .

- RNA (siRNA small interferma) . siRNA - - - .

- - - - - -. , .

1. De Groot-Kruseman HA, Mol WM, Niesters HG, et al.

Differential intragraft cytocine messenger RNA profilesduring rejection and repair of clinical heart transplants:a longitudinal study. Transpl Int 2003; 16:9-14.

2. Moudgil A, Bagga A, Toyoda M, et al. Expression ofgamma-IFN mRNA in bronchoalveolar lavage fluidcorrelates with early acute allograft rejection in lungtransplant recipients. Clin Transplant 1999; 13:20-207.

METAMOXEYE 2008 23

3. Sabek O, Dorak MT, Kotb M, et al. Quantitative detectionof T-cell activation markers by real-time PCR in renaltransplant rejection and correlation with histopathologicevaluation. Transplantation 2002; 74:701-707.

4. Strehlau J, Pavlakis M, Lipman M, et al. Quantitativedetection of immune activation transcripts as adiagnostic tool in kidney transplantation. Proc NatlAcad Sci U S A 1997; 94:695-700.

5. Nickel P, Presber F, Bold G, et al. Enzyme-linkedimmunosorbent spot assay for donor-reactive inter-feron-gamma-producing cells identifies T-cellpresensitization and correlates with graft function at 6and 12 months in renal-transplant recipients.Transplantation 2004; 78:1640-1646.

6. Li B, Hartono C, Ding R, et al. Noninvasive diagnosis ofrenal-allograft rejection by measurement of messengerRNA for perforin and granzyme B in urine. N Engl JMed 2001; 344:947-954.

7. Dadhania D, Muthukumar T, Ding R, et al. Molecularsignatures of urinary cells distinguish acute rejection ofrenal allografts from urinary tract infection.Transplantation 2003; 75:1752-1754.

8. Kotsch K, Mashreghi MF, Bold G, et al. Enhancedgranulysin mRNA expression in urinary sediment inearly and delayed acute renal allograft rejection.Transplantation 2004; 77:1866-1875.

9. Akalin E, Hendrix RC, Polavarapu RG, et al. Geneexpression analysis in human renal allograft biopsysamples using high-density oligoarray technology.Transplantation 2001; 72:948-953.

10 Scherer A, Krause A, Walker JR, et al. Early prognosis ofthe development of renal chronic allograft rejection bygene expression profiling of human protocol biopsies.Transplantation 2003; 75:1323-1330.

11. Stegall M, Park W, Kim D, Kremers W. Gene expressionduring acute allograft rejection: novel statistical analysisof microarray data. Am J Transplant 2002; 2:913-925.

12. Alizadeh A, Eisen M, Davis RE, et al. The lymphochip :a specialized cDNA microarray for the genomic-scaleanalysis of gene expression in normal and malignant

lymphocytes. Cold Spring Harb Symp Quant Biol 1999;64:71-78.

13. Flechner SM,Kurian SM, Head SR, et al. Kidneytransplant rejection and tissue injury by gene profilingof biopsies and peripheral blood lymphocytes. Am JTransplant 2004; 4:1475-1489.

14. Horwitz PA, Tsai EJ, Putt ME, et al. Detection ofcardiac allograft rejection and response to immuno-suppressive therapy with peripheral blood geneexpression. Circulaton 2004; 110:3815-3821.

15. Flechner SM, Kurian SM, Solez K, et al. De novo kidneytransplantation without use of calcineurin inhibitorspreserves renal structure and function at two years. AmJ Transplant 2004; 4:1776-1785.

16. Kainz A, Mitter Bauer C, Hauser P, et al. Alterations ingene expression in cadaveric vs. live donor kidneys suggestimpaired tubular counter balance of oxidative stress atimplantation. Am J Transplant 2004; 10:1595-1604.

17. Yamani MH, Kinter MT, Starling RC, et al. Increasedbeta-myosin heavy chain in acute cellular rejectionfollowing human heart transplantation. Am J Trans-plant 2002; 2:386-388.

18. Sarto C, Marocchi A, Sanchez JC, et al. Renal cellcarcinoma and normal kidney protein expression.Electrophoresis 1997; 18:599-604.

19. Schaub S, Rush D, Wilkins J, et al. Proteomic-baseddetection of urine proteins associated with acute renalallograft rejection. J Am Soc Nephrol 2004; 15:219-227.

20. Clarke W, Silverman BC, Zhang Z, et al. Characteriza-tion of renal allograft rejection by urinary proteomicanalysis. Ann Surg 2004; 237:660-665.

21. Traun AZ, Schachter AD. Transplantation proteomics.Pediatr Transplantation 2005; 9:700-711.

22. Figeys D. Functional proteomics: mapping protein-protein interactions and pathways. Curr Opin MolTher 2002; 4:210-215.

23. Liu H, Sadygov RG, Yates JR 3rd. Amodel for randomsampling and estimation of relative protein abundancein shotgun proteomics. Anal Chem 2004; 76:4193-4201.

24 .

, -. - - -. O - . - -. , - - , 1,2.

Matzinger , 3. / (ischemia/reperfusion injury-IRI) -, - , - -, [4]. , IRI -, - [4]. toll-like receptors(TLRs) - IRI

4.

, Toll-like receptors (TLRs) , (APC) [DCs], , , ). , (pathogen-associatedmolecular patterns-PAMPs) -, - IRI (damage associated molecularpatterns-DAMPs) 4. - , TLRs - , - NFB,AP-1, IRF3, - , - , - (iDCs)5. DCs - , - -, - -. 1, . , 2002, 6, - - stress -- , - () TLR . , LR , -

25

.

, . NK-, NKT-, T , - PAMPs DAMPs)7.

- (reactive oxygenspecies-ROS), - - , - - TLR DCs . - - (MHC) DCs - DCs, TLRs, - . - TLRs, TLR4

TLR2 DAMPs HSP70 (high mobility group box 1) HMGB-1, - PAMPs TLRs. , ROS, -. - ( 1)4.O , DAMPs TLRs , - , - 1,8-11.

, - IgM . IgM - -

26 .

TLR

7TLR

5

TLR

9

TLR

10

Gram-negativebacterialinfection:

Allograftrepesfusion

injury

PAMPse.g. LPS

DAMPs e.g. HSPs, HMGB-1

ROS

TLR

1 TLR

2 TLR

3 TLR

4

TLR

8TIRAP TRAM

TRIFMyD88

IRAK TBK1

TRAF6 IKKsIKKs-Complex

NF-kB

NF-kB IRF-3

AP-1

AP-1

>500 genes

rejection,inflammation,???? defense

cytokines, chemikines,type I-interferons

adhesive andcostimulatory molecules

transcroptional gene activatione.g. innate

dendritic cell

IRF-3

MAPks

1. TLR (Land WG. Innate immunity-mediatedallograft rejection and strategies to prevent it. Transplant Proc. 2007 Apr; 39(3):667-72).

mannanbinding lectin (MBL). BL, - -, . 12,13.

O IRI . - - -, IL-6, TNF- IFN-. - , . - mannose-binding lectin (MBL) , , C3, C6 C9 . , MBL-A -C C6, MBL -. MBL - 14,15.

, C3. -, ( ) CD55 . - - knockout - C3 C3 C3 . - . 10% C - 16. - IRI - ( TLRs) - 17.

- - , / - . - IRI, -, , . (instant blood-mediated inflammatory reaction-IBMIR) - - () . , - , - , - 18,19.

(- ) - . DCs . - /, TLR, - - . - IRI - . - 8 (IL-8/CXCL8), growth-relatedoncogene (GRO/CXCL1), monocyte chemoat-tractant protein 1 (MCP-1/CCL2), MCP- 2 (CCL8),MCP-3 (CCL7), MCP-4 (CCL13), macrophageinflammatory protein, (MIP-1/CCL3-), CCL4- RANTES (CCL5)20,21.

- - - - , ,

METAMOXEYE 2008 27

- . - a priori - (time restricted therapeuticwindow). O : (1) stress, (2) - MBL, (3) - TLR4 NF-gene (4) - , - 22-25.

1. Land, W.G. The role of postischemic reperfusion injury and

other nonantigen-dependent inflammatory pathways intransplantation. Transplantation, 2005. 79(5): p. 505-14.

2. Land, W.G. Injury to allografts: innate immune pathwaysto acute and chronic rejection. Saudi J Kidney DisTranspl, 2005. 16(4): p. 520-39.

3. Matzinger, P. The danger model: a renewed sense of self.Science, 2002. 296(5566): p. 301-5.

4. Land, W.G. Innate immunity-mediated allograft rejectionand strategies to prevent it. Transplant Proc, 2007. 39(3):p. 667-72.

5. Takeda, K. and S. Akira. Toll-like receptors in innateimmunity. Int Immunol, 2005. 17(1): p. 1-14.

6. Thimmulappa, R.K., et al. Nrf2 is a critical regulator of theinnate immune response and survival during experimentalsepsis. J Clin Invest, 2006. 116(4): p. 984-95.

7. Munz, C., R.M. Steinman, and S. Fujii. Dendritic cellmaturation by innate lymphocytes: coordinated stimulationof innate and adaptive immunity. J Exp Med, 2005.202(2): p. 203-7.

8. Andrade, C.F., et al. Innate immunity and organ trans-plantation: the potential role of toll-like receptors. Am JTransplant, 2005. 5(5): p. 969-75.

9. Boros, P. and J.S. Bromberg. New cellular and molecularimmune pathways in ischemia/reperfusion injury. Am JTransplant, 2006. 6(4): p. 652-8.

10. Goldstein, D.R. Toll like receptors and acute allograftrejection. Transpl Immunol, 2006. 17(1): p. 11-5.

11. Obhrai, J. and D.R. Goldstein. The role of toll-likereceptors in solid organ transplantation. Transplantation,2006. 81(4): p. 497-502.

12. Walsh, M.C., et al. Mannose-binding lectin is a regulator ofinflammation that accompanies myocardial ischemia andreperfusion injury. J Immunol, 2005. 175(1): p. 541-6.

13. Zhang, M., et al. Identification of a specific self-reactive IgMantibody that initiates intestinal ischemia/reperfusion injury.Proc Natl Acad Sci U S A, 2004. 101(11): p. 3886-91.

14. Collard, C.D., et al. Complement activation after oxidativestress: role of the lectin complement pathway. Am JPathol, 2000. 156(5): p. 1549-56.

15. de Vries, B., et al. The mannose-binding lectin-pathway isinvolved in complement activation in the course of renalischemia-reperfusion injury. Am J Pathol, 2004. 165(5): p.1677-88.

16. Pratt, J.R., S.A. Basheer, and S.H. Sacks. Local synthesisof complement component C3 regulates acute renaltransplant rejection. Nat Med, 2002. 8(6): p. 582-7.

17. Lin, T., W. Zhou, and S.H. Sacks. The role of complementand Toll-like receptors in organ transplantation. TransplInt, 2007. 20(6): p. 481-9.

18. Johansson, U., et al. Composite islet-endothelial cell grafts:a novel approach to counteract innate immunity in islettransplantation. Am J Transplant, 2005. 5(11): p. 2632-9.

19. Moberg, L. The role of the innate immunity in islettransplantation. Ups J Med Sci, 2005. 110(1): p. 17-55.

20. Chen, D., et al. Viral IL-10 gene transfer inhibits theexpression of multiple chemokine and chemokine receptorgenes induced by inflammatory or adaptive immunestimuli. Am J Transplant, 2003. 3(12): p. 1538-49.

21. Moser, B., et al. Chemokines: multiple levels of leukocytemigration control. Trends Immunol, 2004. 25(2): p. 75-84.

22. Mahaffey, K.W., et al. Effect of pexelizumab on mortalityin patients with acute myocardial infarction orundergoing coronary artery bypass surgery: a systematicoverview. Am Heart J, 2006. 152(2): p. 291-6.

23. Masini, E., et al. Protective effects of M40403, a selectivesuperoxide dismutase mimetic, in myocardial ischaemiaand reperfusion injury in vivo. Br J Pharmacol, 2002.136(6): p. 905-17.

24. Saemann, M.D., et al. Hyporesponsiveness in alloreactiveT-cells by NF-kappaB inhibitor-treated dendritic cells:resistance to calcineurin inhibition. Am J Transplant,2004. 4(9): p. 1448-58.

25. Tahara, M., et al. A radical scavenger, edaravone, protectscanine kidneys from ischemia-reperfusion injury after 72hours of cold preservation and autotransplantation.Transplantation, 2005. 80(2): p. 213-21.

28 .

Dendritic cells (DCs) and regulatory T cells(Tregs) are supposed to contribute to the inductionand maintenance of graft acceptance and trans-plant tolerance. Transplant recipients with fun-ctioning grafts were shown to possess increasedcirculating lineage-HLA-DR+CD11c-CD123+

plasmacytoid dendritic cells type 2 (DC2) pre-cursors, forkehead/winged helix transcriptionfactor (Foxp3)-expressing CD3+CD4+CD25+

regulatory T cells (Treg), CD3+CD8+CD28- Tsuppressor lymphocytes (Ts), TGF-2-producing Thelper lymphocytes type 3 (Th3), TCR+CD4-CD8-

T, and NK Treg cells. However, the contributionof these cell subsets to the establishment andmaintenance of graft acceptance is unclear.

DCs start out on every immune reaction. Theycan initiate or suppress an immune responseagainst antigen. Their diagnostic and therapeuticutilization are major research topics in trans-plantation medicine. One goal of studies in trans-plantation-immunology is the identification oftransplanted patients, whose immunosuppressivetreatment can be reduced or potentially discon-tinued without a subsequent impairment of graftfunction. The induction of tolerogenic DCs andtheir immunological monitoring in the patientblood would be an option for the realization ofthis goal. In experiments with cell cultures andanimals, DCs were identified as target cells ofimmunosuppressive drugs. Clinical studies withtransplant recipients showed alterations of DCsubpopulations in the patient blood depending onthe immunosuppressive drugs and their dosage.Up to now, no DC subpopulation could be identi-fied in the blood of transplant recipients thatwould allow prospectively a discontinuation of theimmunosuppressive protocol. Further studies invitro and in vivo are necessary to define the DCsubsets that are relevant for the induction and

maintenance of graft acceptance and transplanttolerance.

Treg and Ts were shown to produce IL-10 butnot IFN- and it was suggested that IL-10 might inpart account for the immunosuppressive effect ofTreg and Ts. Recently, we described in long-termstable kidney transplant recipients a domination ofmyeloid IL-10-producing DC1. In contrast to ourexpectation, the patients showed abnormally highIFN- and IL-2, and low IL-10 plasma levels. Morethan 10 years posttransplant, some patients showedIFN- plasma levels three-times higher than healthycontrols. We confirmed these data in another studyand speculated that the abnormally increased IFN-plasma levels might be associated with IFN--producing Treg and might contribute to graft ac-ceptance2. In a further study we showed that renaltransplant recipients with good long-term graftfunction had more often detectable CD3+CD4+

CD25+Foxp3+IFN-+ peripheral blood lymp-hocytes (PBL) late posttransplant than patients withimpaired graft function3. Apparently, CD3+CD4+

CD25+Foxp3+IFN-+ PBL may contribute to themaintenance of immunological quiescence andabsence of CD3+CD4+CD25+Foxp3+IFN-+ PBLpromotes chronic graft dysfunction. In a currentstudy we show that high IFN- plasma levels areassociated with low numbers of B lymphocytes andactivated CD8+ T lymphocytes in the blood ofpatients with good long-term graft function. Theselow B and T cell counts might be involved in preven-ting the development of an immunological allores-ponse against the graft and support the maintenanceof graft acceptance.

An immunosuppressive capacity of CD3+

CD4+CD25+IFN-+ Treg in mice was describedby Sawitzki et al. and Wood et al.4,5. As proposedby Wood et al., IFN- might indirectly preventfurther T-cell activation by creating a microenvi-

29

Dendritic cells (DCs) and regulatoryT cells (Tregs) in renal transplantation

V. Daniel

ronment that influences the function of antigen-presenting cells as a result of IFN--induced nitricoxide synthase, indoleamine-2,3-dioxygenase andheme oxygenase-1 expression5.

Obviously, IFN- mediated immune mecha-nisms orchestrate interactions of DCs, Tregs, IFN-producing Tregs, IFN- plasma levels, B cells andcytotoxic T lymphocytes late posttransplant thatmight contribute to the establishment and mainte-nance of graft acceptance.

References:1. Daniel V, Naujokat C, Sadeghi M, Wiesel M, Hergesell O,

Opelz G. Association of circulating IL-12- and IL-10-producing dendritic cells with time posttransplant, doseof immunosuppression, and plasma cytokines in renaltransplant recipients. Transplantation 2005; 79: 1498.

2. Sadeghi M, Daniel V, Naujokat C, Schmidt J, Mehrabi A,Zeier M, Opelz G. Evidence for IFN-g Up- and IL-4Down-Regulation Late Posttransplant in Patients WithGood Kidney Graft Outcome. Clin Transplant. 2007;21: 449.

3. Daniel V, Naujokat C, Sadeghi M, Weimer R, Renner F,Yildiz S, Opelz G. Observational support for an im-munoregulatory role of CD3(+)CD4(+)CD25(+)IFN-gamma(+) blood lymphocytes in kidney transplantrecipients with good long-term graft outcome. TransplInt. 2008 (in press).

4. Sawitzki B, Kingsley CI, Oliveira V, Karim M, Herber M,Wood KJ. IFN-gamma production by alloantigen-re-active regulatory T cells is important for theirregulatory function in vivo. J Exp Med 2005; 201: 1925.

5. Wood KJ, Sawitzki B. Interferon gamma: a crucial rolein the function of induced regulatory T cells in vivo.Trends Immunol 2006; 27: 183.

30 V. DANIEL

-: ) (intravenous immunoglobulin,IVIg) ) - - (plasma-pheresis, PP). , - - -CD20 rituximab, - HLA- .

- (IVIg)

O - - - 901,2. , - , Glotz .3 Jordan .4.

3, 15 -HLA >50% crossmatch , IVIg, 2g/ Kg , 3 . - ( -HLA 50% crossmatch ) (11 2 ). IVIg 0 1 - , , 20 21 40 41.

- (thymoglo-bulin), 1mg/Kg , - 10 , - MMF, tacrolimus. - . , - , - 1 .

4, 45 - (15 28 2 ) - . - crossmatch . - 2g/ Kg ( 140 g). , crossmatch , - 24 72 . IVIg - 1 . 26 28 , crossmatch - -, 2 , - - -. - daclizumab, - MMF, - tacrolimus. - , 13 42 (31%) - ( 2 ) 3 -

31

A

.

. 2 , - 1,4mg/dl - 98%. , , 89% - .

O (,, , - ..) - 5.

(/IVIg)

- - - , -. - , - (donor-specific antibodies, DSA) . -, - (CMV-Ig) . - , 100mg/ Kg , . O - - --HLA . - crossmatch, - .

Montgomery .6, - crossmatch . - daclizumab MMF, tacrolimus. -

-HLA - . 7, - DSA 89% , - , - 13 .

- Schweitzer .8, 11 15 crossmatch - - , -. , O3 . 13,3 , - 1,6mg/dl.

, Mayo Clinic - - IVIg . -9, - :

1 IVIg (2g/ Kg x 1) (1-3 )

2 + IVIg (100mg/ Kg )Rituximab (375mg/m2 x 1) (4-7 )

3 + IVIg (100mg/ Kg )Rituximab (375mg/m2 x 1) (4-7 ) (1,5mg/ Kg ) (5-7 ) DSA - ( /IVIg, , - ).

, crossmatch (38%, 84% 88% -

32 . OOO

1,2 3 ) - - (80%, 37% 29% 1,2 3 ).

Rituximab ( -CD20 )

rituximab - CD20 --. rituximab 2 - Mayo Clinic9. Gloor .10, 14 crossmatch 6 ( 4, 3 1 , 1 3 ). - IVIg, 100mg/ Kg , - , rituximab, 375mg/m2 , 4 . - , . - , - MMF, tacrolimus. crossmatch . - 448172 , - 87% 79% 1,4mg/dl. 86% -, crossmatch - . -, - -HLA . , - , - 11.

()

1995, Reisaeter .12 - 100 -

. , 90 10 , - -. PRA HLA-- - 50% , , PRA - 6 10 . 83 - , 17 . - crossmatch . - - , - 1 4 77% 64% , - - .

, - O -13 14. -, Goodyear Silverman15,16 - - , - -. O - , , 15.

, - - , - . , - - . , - , .

METAMOXEYE 2008 33

1. Glotz D, Haymann JP, Sansonetti N, et al. Suppression

of HLA-specific alloantibodies by high-dose intra-venous immunoglobulins (IVIg). A potential tool fortransplantation of immunized patients. Trans-plantation 1993; 56:335.

2. Tyan DB, Li VA, Czer L, et al. Intravenous immunoglo-bulin suppresion of HLA alloantibody in highlysensitized transplant candidates and transplantation witha histoincompatible organ. Transplantation 1994; 57:553.

3. Glotz D, Antoine C, Julia P, et al. Desensitization andsubsequent kidney transplantation of patients usingintravenous immunoglobulins (IVIg).Am J Transplant2002; 2:758.

4. Jordan SC, Vo A , Bunnapradist S, et al. Intravenousimmunoglobulin treatment inhibits crossmatchpositivity and allows for successful transplantation ofincompatible organs in living-donor and cadaverrecipients. Transplantation 2003; 76:331.

5. Jordan S, Cunningham-Rundles C, McEwan R. Utilityof intravenous immune globulin in kidney transplanta-tion: efficacy, safety, and cost implications. Am JTransplant 2003; 3:653.

6. Montgomery RA, Zachary AA, Racusen LC, et al.Plasmapheresis and intravenous immune globulinprovides effective rescue therapy for refractoryhumoral rejection and allows kidneys to be successfullytransplanted into cross-match-positive recipients.Transplantation 2000; 70:887.

7. Zachary AA, Montgomery RA, Ratner LE, et al. Specificand durable elimination of antibody to donor HLAantigens in renal-transplant patients. Transplantation2003; 76:1519.

8. Schweitzer EJ, Wilson JS, Fernandez-Vina M, et al. Ahigh panel-reactive antibody rescue protocol for cross-match-positive live donor kidney transplants. Transpla-ntation 2000; 70:1531.

9. Stegall MD, Gloor J,Winters JL, et al. A comparison ofplasmapheresis versus high-dose IVIg desensitizationin renal allograft recipients with high levels of donorspecific alloantibody. Am J Tranplant 2006; 6:346.

10. Gloor JM, DeGoey SR, Pineda AA, et al. Overcoming apositive crossmatch in living-donor kidney transplanta-tion. Am J Transplant 2003; 3:1017.

11. Gloor JM, DeGoey SR, Griffin MD, et al. Living donorkidney transplantation with and without splenectomyin positive crossmatch patients. American TransplantCongress, Boston, 2004 (abstract 364).

12. Reisaeter AV, Leivestad T, Albrechtsen D, et al.Pretranplant plasma exchange or immunoadsorptionfacilitates renal transplantation in immunized patients.Transplantation 1995; 60(3):242.

13. Squifflet JP, De Meyer M, Malaise J, et al. Lessons learnedfrom ABO-incompatible living donor kidney transplanta-tion: 20 years later. Exp Clin Transplant 2004; 2:208.

14. Lorenz M, Regele H, Schillinger M, et al. Peritransplantimmunoadsorption: A strategy enabling transplantationin highly sensitized crossmatch-positive cadaveric kidneyallograft recipients. Transplantation 2005; 79:696.

15. Goodyear CS, Silverman GJ. B cell superantigens: Amicrobes answer to innate-like B cells and naturalantibodies. Springer Semin Immunopathol 2005; 26:463.

16. Goodyear CS, Silverman GJ. Staphylococcal toxininduced preferential and prolonged in vivo deletion ofinnate-like B lymphocytes. Proc Natl Acad Sci 2004;101:11392.

34 . OOO

(cross-match) Patel Terasaki1 - cross-match .

, crossmatch - - - , - - crossmatch. , - crossmatch - IgG HLA - - .

, -HLA IgG , 2-7:

) ) ( ))

10% . - ( ) - - .

- 5-10%8.

- -

, HLA (mis-matches)7,8. HLA: 20% (0-1 mis-matches) 46-52% (5-6 mismatches)7,8.

- - 8: 50%, - - - 80%!

- - :

(

HLA, 28% 3.

. - - , PRA.

- PRA>50%, - (urotranspant Registry> 85%)7. - - > 70% panel.

OO O

1994-2003 - 12800 17814 -. 2003 32% - HLA - 13,7% PRA>80%2.

6,3% - - , 14% -. - - , - - . O - - - - . 7-10.

O (O 2007) 819 ,79 (9%) PRA>70% . - , -

.

O O OO

- - , - - - -.

O :) , -

- crossmatch, - - .

) , / anti-HLA - .

OO O

Eurotransplant Acceptable Mismatching Program

Acceptable Mismatching Program (AMP) Eurotransplant HLA - - - crossmatch HLA mis-matches7. - - (HLA Match-maker) - . - , cros-smatch , - . - , 450 - - . - 45 3100

36 . OO

Eurotransplant. O 43% 58% 21 . AMP 87%, 7.

(UK)

( mis-matching)9. O - - . - anti-HLA (HLAmismatches , ). - - - 9. .

Emory ()- crossmatch

Emory - - (PRA>30%)10. - Eurotransplant - . - -HLA (flow cytometry-based solid phase assay). HLA - ( cros-smatch), crossmatch.O - -

(30% PRA>30% 15% PRA>80%.

OO O

(IVIG)

- ( 2gr/ ) IgG -, - . - - ( ) - , - . O Clark 22 7 - , PRA crossmatch11.

2: ) - - - -, ) -, ) -, ) -- Fc , )anti-CD4 , ) - , ) . - Fc - (C3b, C4b), C5b-C9 MAC12.

O Glotz 15 PRA>50% cros-smatch , - 2 mg/ IVIG 4 PRA - crossmatch 3 IVIG13. (13) - PRA (2 ).

METAMOXEYE 2008 37

O thymoglobulin tacrolimus, MMF -. IVIG - (2 mg/kg) 3 6. ( IVIG ), , BK - .

O Jordan 48 - 1-4 - IVIG14. VIG -. PRA IgG - IVIG. - -. - (42) crossmatch IgG . O - 31% (3 -) 89% .

G02 - (placebo) IVIG - (PRA >50%) - 15. 98 2 mg/kg IVIG/ 4 - 4 . - PRA - . 35% IVIG 17% - -. - 9/17 IVIG 1/10 . - 80% 75% . PRA Glotz 13 - (20% ) 15.

IVIG - . , 70 kg 4 2 gr/kg 30000 USD15. , 300.000 USD 2.

IVIG . O Jordan - IG02 300 IVIG 300 placebo2,15. 24 - IVIG 23 . IVIG , . , - IgA, ( - ) ( ) - 16.

- -17-20. - - - crossmatch. - - anti-HLA IgG - IVIG - -. - , - , -HLA (rebound) -

38 . OO

. - - 2,8.

-, IgG, - .

O Lorenz - crossmatch - 21. - crossmatch , . - - -. O - . (9/14) 78% -. crossmatch, .

Silverman - -22. O o !

Rituximab

To rituximab - CD20, -. - - non-Hodgkin (- - - , PTLD),

2.

- rituximab - anti-HLA . - CD20 - , : ) - (precursor) -- ) - - - .

rituximab I 9 - -, - -23. - PRA . - (off-label) - John Hopkins, O - ( ) . rituximab - - - 2,3.

- , - crossmatch, - .

O Gutierrez - crossmatch, - ( )24. O Olausson 7 PRA (50-99%) - (

METAMOXEYE 2008 39

- - split liver) - crossmatch, 25. - ( ) 20-60 , crossmatch , . - (primary non function) - (C4d+) -. - (- , - ).

OO OOO O

, - - - (thymoglobulin) - tacrolimus, MMF . - - rituximab. thy-moglobulin - --2 (basiliximab, daclizumab) . thymoglobulin - anti-HLA - - basiliximab dacli-zumab. CD52 alemtuzu-mab (Campath 1H) - - - 3 -. O Vo alemtuzumab - , 26.

OO - OO

O :

IG02, .O - (historical controls), - (tacrolimus, MMF, sirolimus, everolimus).

. IG02 - IVIG - / , .

/ - - , - - (, - ), - - . - , , - , .

-, , - , - CMV . , .

- . O - - - anti-HLA

40 . OO

- - .

. - - - - . -, -, -, - .

O - - , - PRA 27.

HLA anti-HLA . - , - , - . , . ( solidphase assays) - - 28, - 29.

- G02 , - - ( ) - ( IVIG) - - . - Eurotransplant, - .

- ( LA, ) . - ( - C4d ) - , - crossmatch - IVIG, rituximab .

Rother , C5 - eculizumab ( - ) - , - 30. -- .

O1. Patel R, Terasaki PI. Significance of the positive cros-

smatch test in kidney transplantation. N Engl J Med1969; 280: 735-739.

2. Jordan SC, Pescovitz MD. Presensitization: the problemand its management. Clin J Am Soc Nephrol 2006; 1:421-432.

3. Magee CC. Transplantation across previously incom-patible immunological barriers. Transplant Int 2006;19: 87-97.

4. Zachary AA, Montgomery RA, Leffell MS. Desensitizationprotocols improving access and outcome in transplan-tation. Clin Appl Immunol Reviews 2005; 5: 373-395.

5. Beimler JHM, Susal C, Zeier M. Desensitization stra-tegies enabling successful renal transplantation in highlysensitized patients. Clin Transplant 2006; 20(Suppl 17):7-12.

6. Crew RJ, Ratner LE. Overcoming immunologic incom-patibility: Transplanting the difficult to transplantpatient. Sem Dial 2005; 18: 474-481.

7. Doxiadis IIN, Duquesnoy RJ, Claas FHJ. Extendingoptions for highly sensitized patients to receive a suitablekidney graft. Curr Opin Immunol 2005; 17: 536-540.

METAMOXEYE 2008 41

8. Glotz D, Antoine C, Julia P, ET AL. Intravenous im-munoglobulins and transplantation for patients withanti-HLA antibodies. Transplant Int 2004; 17: 1-8.

9. Fuggle SV, Martin S. Towards performing transplan-tation in highly sensitized patients. Transplantation2004; 78;186-189.

10. Bray RA, Nolen JDL, Larsen C et al. Transplanting thehighly sensitized patient: The Emory algorithm. Am JTransplant 2006; 6: 2307-2315.

11. Clark B, Cole JY, Wortley A et al. Intravenous immuno-globulin-induced panel reactive antibody reduction:not all preparations are created equal. Transplantation2003; 75: 242-245.

12. Watanabe J, Scornik JC. IVIG and HLA antibodies:Evidence for inhibition of complement activation butnot for anti-idiotypic activity. Am J Transplant 2005; 5:2786-2790.

13. Glotz D, Antoine C, Julia P et al. Desensitization andsubsequent kidney transplantation of patients usingintravenous immunoglobulins. Am J Transplant 2002;2; 758-760.

14. Jordan SC, Cunnigham-Rundles C, McEwan R. Utilityof intravenous immune globulin in kidney transplan-tation: efficacy, safety and cost implications. Am JTransplant 2003;3: 653-664.

15. Jordan SC, Tyan D, Stablein D et al. Evaluation of intra-venous immunoglobulin as an agent to lower allo-sen-sitization and improve transplantation in highly sen-sitized adult patients with end-stage renal disease:Report of the NIH IG02 trial. J Am Soc Nephrol 2004;15: 3256-3262.

16. Vo AA, Cam V, Toyoda M et al. Safety and adverseevents profiles of intravenous immunoglobulin pro-ducts used for immunomodulation: A single center ex-perience. Clin J Am Soc Nephrol 2006; 1: 844-852.

17. Schweitzer EJ, Wilson JS, Fernandez-Vina M et al. Ahigh panel reactive antibody rescue protocol for cros-smatch positive live donor kidney transplants Trans-plantation 2000; 70: 1531-1536.

18. Gloor JM, DeGoey SR, Pineda AA et al. Overcoming apositive crossmatch in living donor kidney transplan-tation. Am J Transplant 2003; 3;1017-1021.

19. Montgomery RA, Zachary AA. Transplanting patientswith a positive donor specific crossmatch: a singlecenters perspective Pediatr Transplant 2004; 8:535

20. Stegall MD, Gloor J, Winters JL, Moore SB, DeGoey S.A comparison of plasmapheresis versus high doseIVIG desensitization in renal allograft recipients withhigh levels of donor specific alloantibody. Am J Trans-plant 2006; 6: 346-351.

21. Lorenz M, Regele H, Schillinger M et al. Peritransplantimmunoabsorption: a strategy enabling transplantationin highly sensitized crossmatch positive cadaverickidney allograft recipients. Transplantation 2005; 79:696-701.

22. Silverman GJ, Goodyear CS, Siegel DL. On themechanism of staphylococcal protein A immunomo-dulation. Transfusion 2005; 45: 274-280.

23. Viera CA, Agarwal A, Book BK et al. Rituximab forreduction of anti-HLA antibodies in patients awaitingrenal transplantation: safety, pharmacodynamics andpharmacokinetics. Transplantation 2004; 77: 542-548.

24. Gutierrez A, Crespo M, Mila J, Torregrosa JV, Martorel J,Oppenheimer F. Outcome of simultaneous liver-kidneytransplantation in highly sensitized crossmatch positivepatients. Transpl Proc 2003; 35: 1861-1862.

25. Olausson M, Mjornstedt L, Norden G et al. Successfulcombined partial auxilliary liver and kidney transplan-tation in highly sensitized cross-match positive reci-pients. Am J Transplant 2007; 7; 130-136.

26. Vo AA, Wechsler EA, Wang J et al. Analysis of subcuta-neous alemtuzumab induction therapy in highly sen-sitized patients desensitized with IVIG and rituximab.Am J Transpl 2008;8: 144-149.

27. Johnston O, Rose C, Landsberg D, Gourlay WA, Gill JS.Nephrectomy after transplant failure: current practiceand outcomes. Am J Transpl 2007; 7: 1961-1967

28. Gupta A, Iverson V, Varagunam M et al. Pre-transplantdonor-specific antibodies in cytotoxic negative cros-smatch kidney transplants: Are they relevant? Trans-plantation 2008; 85: 1200-1204.

29. Vaughan R, Shaw O. How much donor human leuko-cyte antigen-specific antibody is too much for a renaltransplant? Transplantation 2008; 85: 1081-1082.

30. Rother RP, Arp J, Jaing J et al. C5 blockade with con-ventional immunosuppresion induces long-term graftsurvival in presensitized recipients. Am J Transpl 2008;doi:10.1111/j.1600-6143.2008.02222.x (in press).

42 . OO

- - -HLA , (PRA > 20%). , HLA -, , 1,2.

- PRA>80%. O - , 3.

- 1989, - , - - - 4. , - - 5.

O , - , - HLA, - 6.O HLA , -HLA -. , -

, HLA . - - HLA , - HLA -7. , - , - - 8.

-, - - HLA . O - - (panel) . - (%) panel(panel reactive antibodies-PRA). crossmatch . O CDC (complement dependent cytotoxi-city), PRA HLA .PRA - . ELISA, CDC, HLA - Luminex, (flow cytometry).

43

O

. , ..

crossmatch, - , . IgG , - HLA, IgM -HLA .

T- - -HLA - I . , B (+) cros-smatch HLA II -, . I T . , - IgG I II, invitro , - , IgM - 6 .

O - . o 1985 Eurotransplant - acceptablemissmatch PRA >85%. - - LA - , -9.

HLA .

O - - -, - HLA I ( ) - HLA II (DR), (acceptable mismatch), CDC T- B-flow crossmatch .

1. Zachary AA, Montgomery RA, et al. 14th International

HLA and Imunogenetics Workshop: Report onunderstanding andibodies in transplantation.TissueAntigens 2007; 69: 160-173.

2. Cecka JM, Zhang Q et al. Performed cytotoxic anti-bodies in potential allograft recipients:recent data.Hum Immunol 2005; 66: 343-349.

3. Zachary AA and Hart JM. Relevance of antibodyscreening and crossmatch tests for organ transplan-tation. In: Handbook of Human Immunology.

4. Vella JP,ONeill D et al. Sensitization to human leucocyteantigen before and after the introduction of erythro-poietin.Nephrol Dial Transplant 1998; 13: 2027-2032.

5. Brand A. Immunological aspects of blood transfusions.Transpl Immunol 2002; 10: 183-190.

6. Young CJ and Gaston RS. Renal transplantation inblack Americans.N Engl J Med 2000; 343: 1545-1552.

7. Massa MF Mazzoli P et al. Proinflammatory responses toself HLA epitopes are triggered by molecular mimicry toEpstein-Barr virus proteins in oligoarticular juvenileidiopathic arthritis.Arthritis Rheum 2002; 46: 2721-2729.

8. Bernasconi NL, Traggiai E et al. Maintenance of sero-logical memory by polyclonal activation of humanmemory B cells. Science 2002; 298: 2199-2202.

9. Fuggle SV and Martin S. Toward performing transplan-tation in highly sensitized patient. Transplantation2004; 78: 186-189.

44 . , .. O

Introduction

The goal of this brief review is to introduce thetopic of recipient sensitization in kidney trans-plantation, assess the risk it poses and discusssome of the different protocols used to addressthis most vexing problem in transplantation.Finally, some of the alternatives, such as ABOincompatible transplantation and a paired kidneyexchange protocol1.

Sensitization is defined as the presence ofantibodies against Class I and/or Class II HLAmolecules, specifically, HLA-A, HLA-B, HLA-DR, DQ. It may include sensitization against asingle or multiple donors, leading to a positivedonor-specific cross match. It represents asignificant obstacle to transplantation, as itincreases the waiting time. In the US nearly 30%of the 67,070 patients in the deceased donorwaiting list are sensitized, with these patientshaving to wait three times longer than thenonsensitized ones for suitable match2.

Ways that a patient can become sensitizedinclude exposure to non-self HLA molecules (pre-vious pregnancies, previous transplant or bloodtransfusions, or use of tissue allografts or homo-grafts for vascular reconstruction in congenitalheart surgery), viral infections (CMV), or non-infectious immune stimulation (vaccination, use ofleft ventricular assist devices). There are differentlevels of sensitization and these can be assessed bymeasuring the antibody level with differenthistocompatibility techniques. The combination ofa high PRA (50-80%) and a positive crossmatchindicate a high level of donor-specific antibodyresulting in a high risk of antibody mediatedrejection (AMR). Even when a classic cytotoxicitycrossmatch is negative, a low level of donor-specific antibody with a high-moderate risk of

AMR can be detectable by more sensitive assaysusing flow cytometry or Luminex.

Basic concepts in the management of HLA-sensitized patients

These include a) suppression of the T-cellresponse, b) elimination of pre-formed antibodies,c) inhibition of residual antibody and thecomplement system cascade, and d) depletion ofantibody producing cells or their precursors(Nave, memory and plasma B-cells).

Efforts to suppress the T-cell response includethe use of induction therapy with depleting and non-depleting antibodies, such as Thymoglobulin or IL-2receptor blockers. These are effective in T-celldependent B-cell responses, but ineffective inmemory B-cell responses. Elimination of preformedantibody is done with plasma exchange (plasma-pheresis, double filtration plasmapheresis, andimmunoabsorption plasmapheresis), whereasinhibition of residual antibody and complementsystem is done with IVIG or CMV-Ig. Its methods ofaction include anti-idiotypic activity, inhibition of thecomplement system, FcRII -mediated inhibitionof antibody production, and enhanced catabolism ofendogenous IgG3-5. Finally, depletion of B cells thateventually differentiate to antibody producingplasma cells is achieved primarily with Rituximab6.Rituximab is a genetically engineered chimericmurine/human monoclonal anti-CD20 antibody, thefirst of its type to be approved by the FDA fortreatment of cancer (lymphoma). Its actions includeantibody-dependent cell-mediated cytotoxicity,complement-dependent cytotoxicity and apoptosis.

All of the above are part of the transplantphysicians armamentarium in bringing highly-sensitized renal patients successfully to trans-plantation. The main modalities to achieve thatinclude:

45

Kidney Transplantation in Highly sensitizedrecipients

G. Tsoulfas, Tatsuo Kawai

desensitization protocolsABO-incompatible transplantationtransplantation across a positive donor

specific crossmatchPaired-kidney exchange program

In this review we will discuss desensitizationprotocols in some more detail.

Desensitization protocols

One of the more successful desensitizationprotocols is the one by the transplant team fromthe University of California Los Angeles Cedars-Sinai Medical Center (7). In the 1990s theydeveloped the IVIg-PRA/CMX test to determinewhether IVIg could inhibit PRA (Panel ReactiveAntigen) or CMX (crossmatch) positivity ofpatients sera in vitro. Briefly, if the IVIg in vitrotest shows any inhibition of the crossmatch test,then the highly-sensitized patients are treated withIVIg monthly x4 until a negative or acceptableCMX (living-donor) or deceased-donor transplantbecomes available. Modification of antibodyscreens and antibody specificity by IVIg treatmentcan be monitored as usual and used to guidefuture therapy. If no inhibition is seen then thework-up stops and the patient is referred forplasma exchange therapy. These patients who failin vitro IVIg inhibition or who have very high-titeranti-HLA antibody enter a protocol that includesfive plasma exchange treatments followed by IVIg2 g/kg x1 and Rituximab 375 mg/m2 x1. Thesepatients are usually awaiting living-donor renaltransplantation, although this has also been usedin patients with prolonged (more than 5 years)time on the deceased-donor waiting list. At thetime of the transplant the patients receive IVIG2gm/kg and Campath 30mg SQ, as well as steroids,Tacrolimus and MMF. Finally, a month post-transplant they receive another dose of IVIG.

Of the 89 patients who were evaluated andtreated with this protocol from July 2002 toOctober 2005, only 2 (2.2%) failed to respond toIVIg sufficiently to allow transplantation to beperformed. The mean PRA for these recipientswas 83%, and nearly all patients had antibodiesspecific to their donors that were eliminated orreduced b IVIg therapy. The incidence of allograftrejection is 28% with a 3year patient and graft

survival of 97.5% and 87.1% respectively. Fivegrafts were lost to rejection and the mean serumcreatinine overall at 3 years was 1.4 mg/dl.

Other protocols include the one from JohnsHopkins University where they used a combinationof plasma exchange and CMV-Ig in 90 patientswith patient and graft survivals at 3 years of 95%and 80.9% respectively. However, the rejectionrate was higher at 62%, but the overall creatinineremained excellent at 1.2 mg/dl at 3 years8. Finally,the Mayo Clinic using a protocol of high dose IVIgand plasma exchange achieved patient and graftsurvival rates at 5 years of 97% and 80%respectively, with a rejection rate of 35%9.

Costs and Complications

The complications of IVIg treatment werestudied from 1997 to 2000 in the ICOG2 study ofthe National Institutes of Health, a controlled,clinical, multicenter, double-blinded trial of IVIgversus placebo in highly sensitized patientsawaiting kidney transplantation10. Adverse eventswere similar in both arms of the study (24 IVIgversus 23placebo), with the most common adverseevent in the IVIg arm being headache. Thisusually abated with reduction in the infusion rateand acetaminophen. Ten serious adverse eventswere noted, nine of these in the placebo group.

Regarding cost, a four dose course of IVIg fora 70-kg person at 2 g/kg would cost $30,000.However, in the ICOG2 study the cost savings wasapproximately $300,000 per patient who received akidney transplant versus those who remained ondialysis for the 5 years of the study. Thus aconsiderable cost savings are realized by beingable to successfully bring these patients totransplantation.

Future perspectives

Although Rituximab has been used as part ofdesensitization protocol, it does not delete plasmacells that actually produce antibodies. Therefore,there has been no clear evidence of antibodyreduction reported by Rituximab alone. Toimprove the results of desensitization, treatmentsto block B cell maturation have been extensivelystudied. BAFF (B cell activation factor from thetumor necrosis factor family) and APRIL (AProlifeRation Inducing Ligand) are members of

46 G. TSOULFAS, TATSUO KAWAI

the TNF family and interaction with their threeligands (BAFF-R, TACI and BCMA) is essentialfor B cell/Plasma cell survival, germinal centermaintenance, T-dependent and independentantibody responses and T cell co-stimulation (11).BAFF and APRIL are secreted from various cells,such as T cell, dendritic cells and granulocytes, as asoluble form. BAFF binds to three receptors,BAFF-R, TACI (transmembrane activator andcalcium-modulator and cyclophilin ligandinteractor) and BCMA (B cell maturationantigens), whereas APRIL interacts with TACI,BCMA and proteoglycans.

Three reagents (Belimumab, BR3 Fc andTACI-Ig) to block BAFF/APRIL are now underactive investigation (12, 13). While Belimumab(anti-soluble BAFF mAb) and BR3-Fc only blockBAFF, TACI-Ig is soluble receptor that block bothBAFF and APRIL. In our preliminary studies inmonkeys, TACI-Ig reduced splenic plasma cellsand significantly decreased alloantibody titerswithout plasma exchange. With these reagentsdirectly affect antibody production, bettertherapeutic interventions will be available forsensitized patients in near future.

References1. Kaplan I, Houp JA, Leffell MS, Hart JM, Zachary AA. A

computer match program for paired and unconven-tional kidney exchanges. Am J Transplant 2005; 5:2306-2308.

2. Organ Procurement Transplantation Network/ ScientificRegistry of Transplant Recipients: 2004 Annual Report:Transplant Data 1994-2003, Department of Health andHuman Services, Health Resources and ServicesAdministration, Healthcare Systems Bureau, Divisionof Transplantation; United Network of Organ Sharing;University Renal Research and Education Association,2004.

3. US Renal Data System: USRDS 2003 Annual DataReport; Atlas of End-Stage Renal Diseases in theUnited States, Bethesda, National Institutes of Health,National Institute of Diabetes and Digestive andKidney Diseases, 2003.

4. Tyan D, Li VA, Czer L. Trento A, Jordan SC. Intra-venous immunoglobulin suppression of HLA alloanti-body in highly sensitized transplant candidates andtransplantation with a histocompatible organ.Transplantation, 1994; 57: 553-562.

5. Kazatchkine MD, Kaveri SV. Immunomodulation ofautoimmune and inflammatory diseases withintravenous immune globulin. N Engl J Med, 2001;345: 747-755.

6. Pescovitz MD. The use of Rituximab, antiCD20monoclonal antibody, in pediatric transplantation.Pediatr Transplant, 2005; 45: 274-280.

7. Vo AA, Toyoda M, Peng A, Bunnapradist S, LukovskyM, Jordan SC. Effect of induction therapy protocols ontransplant outcomes in crossmatch positive renalallograft recipients desensitized with IVIG. Am JTransplant, 2006; 6: 2384-2390.

8. Montgomery RA, Zachary AA, Racusen LC, et al.Plasmapheresis and intravenous immunoglobulinprovides effective rescue therapy for refractoryhumoral rejection and allows kidneys to be successfullytransplanted into crossmatch positive recipients.Transplantation, 2000; 70: 887-895.

9. Stegall MD, Gloor J, Winters JL, Moore SB, DeGoey S. Acomparison of plasmapheresis versus high-dose IVIGdesensitization in renal allograft recipients with highlevels of donor specific antibody. AM J Transplant,2006; 6: 346-351.

10. Jordan SC, Tyan D, Stablein D, et al. Evaluation ofintravenous immunoglobulin as an agent to lowerallosensitization and improve transplantation in highlysensitized adult patients with end stage renal disease:Report of the NIH ICOG2 trial. J Am Soc Nephrol,2004; 15: 3256-3262.

11. Ye Q, Wang L, Wells AD. BAFF binding to T cellexpressed BAFF-R costimulates T cell proliferationand alloresponses. Eur J of Immunology, 2004; 34:2750-2759.

12. Bhat P, Rhadhakrishnan J. B lymphocytes and lupusnephritis: new insights into pathogenesis and targetedtherapies. Kidney Intern, 2008; 73: 261-268.

13. Morimoto S, Nakano S, Watanabe T. Expression of theB-cell activating factor of the tumor necrosis factorfamily (BAFF) in T cells in active systemic lupuserythematosus: the role of BAFF in T-cell dependent Bcell pathogenic autoantibody production. Rheuma-tology (Oxford), 2007; 46: 1083-1086.

METAMOXEYE 2008 47

OAO OE A EA OEYA

OO O O

H - ( )1. B - - , - , - - - , - 2,3.

H , 4,5., - - , - - 25%, - 6. - , , - (reduced-size livertransplantation, RLTx, Bismuth, 1984),7 ex vivo(Pichlmayr, 1988) in situ (Rogiers Broelsch, 1995) - (split liver transplantation, SLTx),8-10

(adult-to-pediatricliving donor liver transplantation, pLDLTx, Strong1990 Broelsch 1991)11,12 -

(adult to adult living donor livertransplantation, aLDLTx, Hashikura 1994)13,14.

O O O - O

- 14000 -, 1989 200715. - LDLTx, - , - - , , , - 16. , 200% (100% ) - , .

O O O

2737/27.8.1999 - , , (). -, - , -, . - - .

51

Z

. , .

- , . -, , 18 60 . O - - . , - -, 17. - . , - - 18,19. , - 20.

O - - , - . O , -, - ( 1)21.

O - - , ( >30 Kg/m2) ( 2)15. O - - - 15.O ,

52 . O, . O

1. / 22.

1

, ,

: , , , : HAV, HBV, HCV, EBV,CMV, HSV, HIV.

1

2

: , , , .

, 23.

1

3

(, , test ), , (TSH, FT3, FT4, IgA, IgG, IgM, Fe, , 1-, , (V, VII, VIII, C, S, APC), (CEA, AFP, Ca 19-9), 24.

1

4

2

meeting

2

5

[HLAs, (cross match)]

22. - Vancouver Forum,23 - - , ( >30 Kg/m2), , - , - . , - : ) , ) , ) > 20% ( ) ) 23.

O

, - .

, , : . (standard liver volume, SLV), 24-27

(BSA m2) (Du Bois)24 = 0.007184

(cm)0.725 (Kg)0.425

(mL) (Urata)25 = 706.2 BSA (m2) + 2.4

METAMOXEYE 2008 53

2. 15.

> 60

> 30-35 Kg/m2

,

,

C S

C

HBV HBsAg+

HCV Anti-HCV+

EBV, CMV, HSV IgM+

HIV

,

Crohn

> 10%

,

,

. 1

- /

(mL) (Heinemann)26 = 1072.8 BSA (m2) 345.7

(Vauthey)27 = 794.41 + 1,267.28 BSA (m2)

. (Graft Weight/Recipient BodyWeight Ratio, GW/RBW)28.

O GW/RBW 1% -, , 50% SLV29. A, , , - - ,30 ( 1 2). , , 10%, 31. - . 30% - , 0.8% GW/RBW23.

O - : 1. T ( V-VIII, 800-1000 ml, 80 Kgr), 2. T ( II-IV),

I, 400 ml 60 Kgr),3. O - ( II III, 250 ml, ),4. O ( I, IV, V-VIII, 1100 ml, - 80 Kgr) 5. O ( VI VII, ) - 33-35.

-, -. , , -, -38. , -, - (Multi-detector computer tomography,MDCT) 30,40.

O , - , -

54 . O, . O

E 1. : (Graft Weight/Recipient Body Weight Ratio, GW/RBW), - (standardliver volume, SLV). : 29.

METAMOXEYE 2008 55

E 2. O . A. A 30. B. M (- T1, ), () ( ). T (Rt), (Med) (Lat) , (C), 30. . M (MPV) ( T1, ). T - (Rt), (Med) (Lat) , 30. . . . T . E. T - 14 . H - (110% ). T. 30 ,, (101% )32.

31. , - . - . - - , - . -, - -- (ERCP),

, . (MDCT) - , - 96% , -28,40. -- (MRCP) - MDCT, - 41.

O (Allin one procedures), -, - . MDCT - , , , , - , (- 4)42. - 42,43. - , MDCT .

- (MeVisLiver-Analyzer and Liver-Viewer, Bremen, Ger-many). , - HepaVision (MeVis,Bremen, Germany) : . -, -, . -

56 . O, . O

(Couinaud)

V, VI, VII, VII

II, III, IVI

II, III

I, IV, V, VI, VII, VIII

E 3. . O .H - . O Healey Schroy, Goldsmith Woodburne,36,37 , Couinaud Bismuth2,3,37

.

, . -, . - (risk analysis) - , (hepatic vein dominance)44-47.

- - -

- 48. H - - - , . - .

METAMOXEYE 2008 57

4. (all in one) - , . . ( ). . () (). . - () , - (* ). . (O) ()42.

H - . A - . , - - .

, , -, - ( 6).

, - - , - 48 (- 7). , - , -, , - 49.

A - , ,

. , O - , , - . H 50. , - - 51. - , , -, . O - , , - , .

I IV 40% - . A - IV , () IV HA (E- 8). A

58 . O, . O

5. HepaVision - MeVis43-47.

IV AHA, AHA HA, HA - . M - (E 8)52,53.

, -, , - . (KK). O -

(H), , . H , - KK, - . K , KK - - .(E 9 -).

10% - , -

METAMOXEYE 2008 59

E 6.. - (MH), . . 1 cm MH Argon laser . . A (-), Doppler, (middle hepaticvein, MHV) . ( ), Gray-scale US scan ().

5 mm, - - KK. (E 9). T -. O -

5 mm KK .

- ( 3). - , -

60 . O, . O

E 7. . : O VII ( ) , : (), VII ( ). . : .. .

48. ( + ), - - . - 55. - IV - , ( 9).

Cantlie, - -. . -

, . Hong Kong - - - 56,57. - 58,59. O de Villa et al.,60 , - , - (standard liver volume,SLV) , , - . - Essen deVilla et al.,60 - MeVis HepaVision,45-47 61. -, (carving ) 62.

H - - . - . H - - . A -, -. O CUSA (Cavitron Ultrasonic Aspirator,Valley Lab, Boulder, CO). H - - - . T, - - . T . (E- 10 ) T

METAMOXEYE 2008 61

E 8. IV . T - - (b) . T - IV (2).

- - (clips). M - Argon laser (Argonbeam coagulator, Conmed, Utica, NY)51. O - , - . , - , , . T, , , . M -

, - 1 2 -, - . O - - - , , . - (E 10). O - Wisconsin. A- , Argon laser,

62 . O, . O

E 9. . O . O KK . . E KK. . K - KK , KK . . A , - .

. T .

OE

- LDLTx. LDLTx

, . - 20%, 67% 63. - - 64. ,

METAMOXEYE 2008 63

E 10 . CUSA (Cavitron Ultrasonic Aspirator, Valley Lab,Boulder, CO). A . . O (HA) (), - (EH) (H).

-. - -, - 65.

O LDLTx 2007 - 12 - 66. , 21 - 66. O , 8 , 10 2 66. - 0.1-0.3% 14000 2007 0.5% - 66. , - 80% 160 67.

O1. Renz JF, Busuttil RW. Adult-to-adult living-donor liver

transplantation: a critical analysis. Semin Liver Dis2000; 20, 4 : 411.

2. Couinaud C. Le Foie, Etudes Anatomiques et Chirur-gicales. Paris: Masson & Cie, 1957.

3. Couinaud C. Controlled hepatectomies and exposureof the intrahepatic bile ducts. Anatomical and technicalstudies. Paris: C Couinaud, 1981.

4. 2000 Annual Report of the U.S. Scientific Registry forTransplant Recipients and the Organ Procurement andTransplantation Network: Transplant Data: 1990-1999.U.S. Department of Health and Human Services,Health Resources and Services Administration, Officeof Special Programs, Division of Transplantation,Rockville, MD; United Network for Organ Sharing,Richmond, VA.

5. Keeffe EB. Liver transplantation: current status andnovel approaches to liver replacement. Gastro-enterology 2001; 120:749.

6. Emond JC, Whitington PF, Thistlethwaite JR, et al.Reduced-size orthotopic liver transplantation: use inthe management of children with chronic liver disease.Hepatology 1989; 10: 867.

7. Bismuth H, Houssin D. Reduced-sized orthotopic livergraft in hepatic transplantation in children. Surgery1984; 95: 367.

8. Pichlmayr R, Ringe B, Gubernatis G, et al. Trans-plantation of a donor liver to 2 recipients (splittingtransplantation)a new method in the further deve-lopment of segmental liver transplantation.Langenbecks Arch Chir 1988; 373: 127.

9. Rogiers X, Malago M, Habib N, et al. In situ splitting ofthe liver in the heart-beating cadaveric organ donor fortransplantation in two recipients. Transplantation.1995 Apr 27; 59:1081.

10. Azoulay D, Astarcioglu I, Bismuth H, et al. Split-livertransplantation. The Paul Brousse policy. Ann Surg1996; 224: 737.

11. Strong RW, Lynch SV, Ong TH, et al. Successful livertransplantation from a living donor to her son. N EnglJ Med 1990; 322: 1505.

12. Broelsch CE, Whitington PF, Emond JC, et al. Livertransplantation in children from living related donors.Surgical techniques and results. Ann Surg 1991; 214: 428.

13. Hashikura Y, Makuuchi M, Kawasaki S, et al. Successfulliving-related partial liver transplantation to an adultpatient. Lancet 1994; 343: 1233.

14. Yamaoka Y, Washida M, Honda K, et al. Livertransplantation using a right lobe graft from a livingrelated donor. Transplantation 1994; 57: 1127.

15. Nadalin S, Malago M, Radtke A, et al. Current trends inlive liver donation. Transplant Int 2007; 20(4):312.

16. Berg CL, Gillespie BW, Merion RM, et al. A2ALL StudyGroup. Improvement in survival associated with adult-to-adult living donor liver transplantation.Gastroenterology. 2007 Dec; 133(6):1806-13.

17. Hirata M, Harihara Y, Kitamura T et al. The influenceof donor age to graft volume increase rate in livingdonor liver transplantation. Transplant Proc. 2001 Feb-Mar; 33(1-2):1416.

18. Hwang S, Lee SG, Lee YJ, et al. Lessons learned from1,000 living donor liver transplantations in a singlecenter: how to make living donations safe. Liver Transpl2006; 12: 920.

19. Heffron T, Welch D, Pillen T, et al. Successful ABOincom-patible pediatric liver transplantation utilizing standardimmunosuppression with selective postoperative plasma-pheresis. Liver Transpl 2006; 12: 972.

20. Testa G, Vidanovic V, Chejfec G, et al. Adult living-donor liver transplantation with ABO-incompatiblegrafts. Transplantation. 2008 Mar 15; 85(5):681.

21. Valentin-Gamazo C, Malago M, Karliova M, et al.Experience after the evaluation of 700 potential donorsfor living donor liver transplantation in a single center.Liver Transpl 2004; 10: 1087.

21. Brown RS Jr. Live donors in liver transplantation. Gas-troenterology. 2008 May; 134(6):1802-13.

23. Barr ML, Belghiti J, Villamil FG, et al. A report of theVancouver Forum on the care of the live organ donor:lung, liver, pancreas, and intestine data and medicalguidelines. Transplantation 2006; 81: 1373.

24. DuBois D, DuBois EF. A formula to estimate theapproximate surface area if height and weight beknown. Arch Intern Med 1916; 17: 863.

25. Urata K, Kawasaki S, Matsunami H, et al. Calculation ofchild and adult standard liver volume for livertransplantation. Hepatology 1995; 21:1317.

64 . O, . O

26. Heinemann A, Wischhusen F, Puschel K, Rogiers X.Standard liver volume in the Caucasian population.Liver Transpl Surg 1999; 5:366.

27. Vauthey JN, Abdalla EK, Doherty DA, et al. Bodysurface area and body weight predict total liver volumein Western adults. Liver Transpl 2002; 8: 233.

28. Kawasaki S, Makuuchi M, Ishizone S, et al. Liverregeneration in recipients and donors aftertransplantation. The Lancet 1992; 339 (Mar. 7) : 580.

29. Kiuchi T, Kasahara M, Uryuhara K., et al. Impact ofgraft size mismatching on graft prognosis in livertransplantation from living donors. Transplantation1999; 67: 321.

30. Bassignani MJ, Fulcher AS, Szucs RA, et al. Use ofimaging for living donor liver transplantation. Radio-Graphics 2001; 21:39.

31. Itamoto T, Emoto K, Mitsuta H, et al. Safety of donorright hepatectomy for adult-to-adult living donor livertransplantation. Transpl Int 2006; 19: 177.

32. Marcos A. Right lobe living donor liver transplantation: a review. Liver Transplantation 2000; 6: 3.

33. Sugawara Y, Makuuchi M, Takayama T, et al. Rightlateral sector graft in adult living-related liver trans-plantation. Transplantation 2002; 73: 111.

34. Kasahara M, Kaihara S, Oike F, et al. Living- donorliver transplantation with mono-segments. Trans-plantation 2003; 76: 694.

35. Kokudo N, Sugawara Y, Imamura H, et al. Tailoring theType of Donor Hepatectomy for Adult Living DonorLiver Transplantation. Am J Transplant 2005; 5(7):1694.

36. 6. Healey JE, Jr, Schroy PC. Anatomy of the biliaryducts within the human liver; analysis of the prevailingpattern of branchings and the major variations of thebiliary ducts. Arch Surg 1953; 66: 599.

37. 11. Bismuth H. Surgical anatomy and anatomicalsurgery of the liver. World J Surg 1982; 6:3.

38. Kishi Y, Sugawara Y, Kaneko J, et al. Hepatic arterialanatomy for right liver procurement from livingdonors. Liver Transpl 2004; 10: 129.

39. Coskun M, Kayahan EM, Ozbek O, et al. Imaging ofhepatic arterial anatomy for depicting vascular vari-ations in living related liver transplant donor candi-dates with multi-detector computed tomography:comparison with conventional angiography. TransplantProc 2005; 37: 1070.

39. Carr JC, Nemcek Jr AA, Abecassis M, et al. Preoperativeevaluation of the entire hepatic vasculature in livingliver donors with use of contrast-enhanced MRangiography and true fast imaging with steady-stateprecession. J Vasc Interv Radiol 2003; 14: 441.

40. Wang ZJ, Yeh BM, Roberts JP, et al. Living donorcandidates for right hepatic lobe transplantation:evaluation at CT cholangiography initial experience.Radiology 2005; 235: 899.

41. Kim RD, Sakamoto S, Haider MA, et al. Role of magneticresonance cholangiography in assessing biliary anatomy inright lobe living donors. Transplantation 2005; 79: 1417.

42. Schroeder T, Radtke A, Kuehl H, et al. Evaluation ofliving liver donors with an allinclusive 3D multi-detector row CT protocol. Radiology 2006; 238: 900.

43. Yeh BM, Breiman RS, Taouli B, et al. Biliary tractdepiction in living potential liver donors: comparisonof conventional MR, mangafodipir trisodium-enhancedexcretory MR, and multi-detector row CT cholangio-graphy initial experience. Radiology 2004; 230: 645.

44. Radtke A, Schroeder T, Molmenti EP, et al. Anatomicaland physiological comparison of liver volumes amongthree frequent types of parenchyma transection in livedonor liver transplantation. Hepatogastroenterology2005; 52: 333.

45. Malago M, Molmenti EP, Paul A, et al. Hepatic venousoutflow reconstruction in right live donor livertransplantation. Liver Transpl 2005; 11: 364.

46. Radtke A, Schroeder T, Molmenti EP, et al. The ter-ritorial belonging of the middle hepatic vein: atroublesome dilemma in adult live donor liver trans-plantationanatomical evidence based on virtual 3-dimensional-computed tomography-imaging recon-structions. Eur J Med Res. 2006 Feb 21; 11(2):66-72.

47. Radtke A, Nadalin S, Sotiropoulos GC, et al. Computerassisted operative planning in adult living donor livertransplantation: a new way to resolve the dilemma ofthe middle hepatic vein. World J Surg. 2007; 31: 175.

48. Fan ST. Live Donor Liver Transplantation in Adults.Transplantation 2006; 82: 723.

49. Testa G, Malago M, Porubsky M, et al. Hilar early divisionof the hepatic duct in living donor right hepatectomy: theprobe-and-clamp technique. Liver Transpl 2006; 12: 1337.

50. Imamura H, Makuuchi M, Sakamoto Y, et al. Anatomi-cal keys and pitfalls in living donor liver transplanta-tion. J Hepatobiliary Pancreat Surg 2000; 7: 380.

51. Grewal HP, M. Shokouh-Amir H, Vera S, et al. Surgicaltechnique for right lobe adult living donor liver trans-plantation without venovenous bypass or portocavalshunting and with duct-to-duct biliary reconstruction.Ann Surg 2001; 233(4): 502.

52. Marcos A, Fisher RA, Ham JM, et al. Liver regenerationand function in donor and recipient after right lobeadult to adult living donor liver transplantation.Transplantation 2000; 69: 1375.

53. Pomfret EA, Pomposelli JJ, Lewis WD, et al. Live donoradult liver transplantation using right lobe grafts.Donor evaluation and surgical outcome. Arch Surg2001; 136: 425.

54. Marcos A, Ham JM, Fisher RA, Olzinski AT, Posner MP.Surgical management of anatomical variations of theright lobe in living donor liver transplantation. AnnSurg 2000; 231 (6): 824.

55. Couinaud C. Liver anatomy: portal (and suprahepatic)or biliary segmentation. Dig Surg 1999; 16: 459.

METAMOXEYE 2008 65

56. Fan ST, Lo CM, Liu CL, Wang WX, Wong J. Safety andnecessity of including the middle hepatic vein in theright lobe graft in adult-to-adult live donor livertransplantation. Ann Surg 2003; 238: 137.

57. Liu CL, Lo CM, Fan ST. What is the best technique forright hemiliver living donor liver transplantation? Withor without the middle hepatic vein? Duct-to-duct bili-ary anastomosis or Roux-en-Y hepaticojejunostomy? JHepatol 2005; 43: 17.

58. Shah SA, Grant DR, Greig PD, et al. Analysis andoutcomes of right lobe hepatectomy in 101 consecutiveliving donors. Am J Transplant 2005; 5: 2764.

59. Scatton O, Belghiti J, Dondero F, et al. Harvesting themiddle hepatic vein with a right hepatectomy does notincrease the risk for the donor. Liver Transpl 2004; 10:71.

60. de Villa VH, Chen CL, Chen YS, et al. Right lobe livingdonor liver transplantation-addressing the middlehepatic vein controversy. Ann Surg 2003; 238: 275.

61. Broelsch CE, Frilling A, Testa G, et al. Early and latecomplications in the recipient of an adult living donorliver. Liver Transpl 2003; 9(Suppl. 2): S50.

62. Nadalin S, Boockhorn M, Malago M, et al. Living donorliver transplantation. HPB 2006; 8: 10.

63. Beavers KL, Sandler RS, Shrestha R. Donor morbidityassociated with right lobectomy for living donor livertransplantation to adult recipients: a systematic review.Liver Transpl 2002; 8: 110-117.

64. Dindo D, Demartines N, Clavien PA. Classification ofsurgical complications: a new proposal with evaluationin a cohort of 6336 patients and results of a survey.Ann Surg 2004; 240:205.

65. Chan SC, Fan ST, Lo CM, Liu CL, Wong J. Towardcurrent standards of donor right hepatectomy foradult-to-adult live donor liver transplantation throughthe experience of 200 cases. Ann Surg 2007; 245: 110.

66. Ringe B, Strong RW. The Dilemma of Living LiverDonor Death: to Report or not to Report? Transplan-tation 2008; 85: 790.

67. Chan SC, Fan ST. Historical perspective of living donorliver transplantation. World J Gastroenterol. 2008 Jan 7;14(1):15.

66 . O, . O

- - - -. O - -.1,2 - -: - .3

- . - , , - . - - -. - - .

- : > 65 , ... > 7 ( > 4 ), >30, > 40%, - > 165 mmol/l, - SGOT (AST) SGPT (ALT) > , > 3 mg/dl,

HbsAg,anti-HBc anti-HCV, - , , , -.4 - .5-7

., - , , - , - - (non heart beating donor).8-13

, - - .

, - (>50 ) - .14 - , , -, - .15,16 UNOS, . 1996, 25% 50 , 2006 34%

67

O ( )

.

50 . - 65 -: 6% 1996 10% 2006.17 , EuropeanLiver Transplant Registry, - 60 3 -, - 60 ( 2% 1991 20% 2001).18,19 - - - - .20

- - - , - - .21,22

, - - . - - .16 , .23 - .

C (HCV +), - , . - 60 , - HCV .24,25 , - HCV+ .

- . O - , .26 - 14 -, - , , - .26-29 ELTR - > 13 3 12 -.18 - 12 , - - .18 -, , - 50 -, 12 . , , - , - > 12 ( 16 ).

-

O . 3 - - .30 - - , -, - .31-34

UNOS -

68 .

. -.35 , - 10 g/kg/min 6 g/kg/min . , (. -, ) - .36

()

13%-26% .37 O , , -, . : -, . - - - . .38,39 , - (< 30% ) - , - - -.40 (> 60% ) - - .41 - (30%-60%) -. - , - - (13% 3% -).40 - - - .

C

- C. O (HBV) .42

- (HbsAg ) (anti-Hbc +) - HBV HbsAg () 33% - 78%.43 O (13%) - (anti-HBs) (anti-Hbc +).44 O - anti-Hbc(+) HBV , anti-HBs(+) HBV . - anti-HBc - , - 2,5 HBV , - - (HBIG) lamivudine.45 HBc(+) HbsAg(+) , - HBIG. , anti-HBs(+) -, - HBIG. HBc(+) HBV -, - .

- C (HCV+) - de novo - C(HCV).46 , - HCV(+) - -. HCV(+) , , - HCV() -.47-52 HCV(+)

METAMOXEYE 2008 69

( 50 ) - HCV() . , - - HCV(+) CV(+) -, - - .

- ., -, , in situ ( ) - .53,54 - , , -, , - - .

- , , - - , - . - - - 5 .55 , , .56

, UNOS - - (0,02%).56

1. Cameron A, Busuttil R. AASLD/ILTS transplant course:

is there an extended donor suitable for everyone? LiverTranspl 2005; 11(11 Suppl 1): S25.

2. Renz J, Kin C, Kinkhabwala M, et al. Utilization of ex-tended donor criteria liver allografts maximizes donoruse and patient access to liver transplantation. AnnSurg 2005; 242:55663.

3. The Organ Procurement and Transplant Network.Transplants by donor type; liver. Available at:www.optn.org. Accessed July 17, 2006.

4. Nickkholgh A, Weitz J, Encke J, Sauer P, Mehrabi A,Bchler MW, Schmidt J, Schemmer P. Utilization ofextended donor criteria in liver transplantation: a com-prehensive review of the literature. Nephrol DialTransplant. 2007 Sep; 22 Suppl 8: viii29-viii36.

5. Briceno J, Solorzano G, Pera C. A proposal for scoringmarginal liver grafts. Transpl Int 2000; 13 [Suppl 1]:S249S252.

6. Pokorny H, Langer F, Herkner H et al. Influence ofcumulative number of marginal donor criteria on pri-mary organ dysfunction in liver recipients. Clin Trans-plant 2005; 19: 532536.

7. Fischer-Fro hlich CL, Lauchart W. Expanded CriteriaLiver Donors (ECD): Effect of Cumulative Risks. AnnTransplant 2006; 2: 5256.

8. Seu P, Imagawa DK, Olthoff KM, Yersiz H, RosenthalTJ, Sellers CA, et al. A prospective study on the reliabi-lity and cost effectiveness of preoperative ultrasoundscreening of the marginal liver donor. Transplan-tation 1996; 62:129-130.

9. Alexander JW, Vaughn WK. The use of marginal donorsfor organ transplantation. The influence of donor age onoutcome. Transplantation 1991; 51:135-141.

10. Mor E, Klintmalm GB, Gonwa TA, Solomon H, HolmanMJ, Gibbs JF, et al. The use of marginal donors for livertransplantation. A retrospective study of 365 liverdonors. Transplantation 1992; 53:383-386.

11. Mirza DF, Gunson BK, Da Silva RF, Mayer AD, BuckelsJA, McMaster P. Policies in Europe on marginalquality donor livers. Lancet 1994; 344:1480-1483.

12. De Carlis L, Sansalone CV, Rondinara GF, Colella G,Slim AO, Rossetti O, et al. Is the use of marginal donorsjustified in liver transplantation? Analysis of resultsand proposal of modern criteria. Transpl Int 1996;9(supp