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Since the first published report of experimental kidney transplantation in dogs in 1902, there were many experimental and clinical trials of organ transplantation, with many sacrifices. After the establishment of the surgical technique and the discovery of immunosuppressive drugs, transplantation became the definitive treatment strategy for patients with terminal organ failure. However, this is not a common therapy method due to the difficulty of solving the fundamental issues behind organ transplantation, including the shortage of donor graft, potential risks of transplant surgery and economic capability. The pre- and post-transplant management of recipients is another critical issue that may affect transplant outcome. Most liver transplant recipients experience post-transplant complications, including infection, acute/chronic rejection, metabolic syndrome and the recurrence of hepatocellular carcinoma. Therefore, the early prediction and diagnosis of these complications may improve overall and disease-free survival. Furthermore, how to induce operational tolerance is the key to achieving the ultimate goal of transplantation. In this review, we focus on liver transplantation, which is known to achieve operational tolerance in some circumstances, and the mechanical similarities and differences between liver transplant immunology and fetomaternal tolerance, autoimmunity or tumor immunity are discussed.

A recurrence of hepatocellular carcinoma (HCC) after living donor liver transplantation (LDLT) is one of the major concerns reflecting the higher mortality of HCC. This study aimed to explore the impact of circulating exosomes on HCC development and recurrence. One-shot transfusion of hepatoma serum to naïve rats induced liver cancer development with gradual elevation of alpha-fetoprotein (AFP), but exosome-free hepatoma serum failed to induce AFP elevation. The microarray analysis revealed miR-92b as one of the highly expressing microribonucleic acids in hepatoma serum exosomes. Overexpression of miR-92b enhanced the migration ability of liver cancer cell lines with active release of exosomal miR-92b. The hepatoma-derived exosomal miR-92b transferred to natural killer (NK) cells, resulting in the downregulation of CD69 and NK cell-mediated cytotoxicity. Furthermore, higher expression of miR-92b in serum exosomes was confirmed in HCC patients before LDLT, and its value at 1 month after LDLT was maintained at a higher level in the patients with posttransplant HCC recurrence. In summary, we demonstrated the impact of circulating exosomes on liver cancer development, partly through the suppression of CD69 on NK cells by hepatoma-derived exosomal miR-92b. The value of circulating exosomal miR-92b may predict the risk of posttransplant HCC recurrence., (© 2019 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Background & Aims: Fatty liver disease is an important complication associated with liver transplantation, and the cytochrome P-450 system of the donor liver may be involved in its pathogenesis. To explore the effects of the CYP27A1, CYP27B1, CYP2R1, and vitamin D receptor pathways on vitamin D maintenance after living donor liver transplantation, we investigated the interplay between serum 25(OH)D and common variants in 60 paired donors and recipients who underwent living donor liver transplantation., Methods: We prospectively collected 60 donor/recipient pairs from our liver transplantation programmes and extracted serum DNA to evaluate single nucleotide polymorphisms in CYP27A1 rs4674344, CYP27B1 rs10877012, CYP2R1 rs10741657, and VDR rs2228530 alleles using real-time polymerase chain reaction. We measured serum 25(OH)D concentrations of donors (D-D0) and recipients before (R-D0) and after (R-D30) living donor liver transplantation for comparison with repeated-measures analysis of variance in generalized estimating equations analysis., Results: Fatty liver disease was noted in 28.3% of the cases after living donor liver transplantation, and the graft rejection rate was 25%. There were significant differences in low serum 25(OH)D concentrations between D-D0 and R-D0 and between R-D0 and R-30 groups. Significant associations were observed for serum CYP27A1 rs4674344 in recipients and donors as well as for graft liver tissue with VDR rs2228530. There was no significant relationship with serum CYP27B1 rs10877012 in recipients and donors or with graft liver tissue with CYP2R1 rs10741657., Conclusions: Donor/recipient CYP27A1 rs4674344 and graft VDR rs2228570 may be related to low serum 25(OH)D and may play a major role in the development of fatty liver disease in recipients after living donor liver transplantation., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Acute rejection (AR) and spontaneous tolerance may occur after allograft orthotopic liver transplants (OLT) performed in certain combinations of donor and recipient rat strains, yet the underlying molecular cascades involved in these conditions remain poorly understood. Comprehensive analysis with proteomic tools revealed that ceruloplasmin was highly expressed during the tolerant period on day 63 post-OLT (POD 63) compared to the rejected samples on POD 14. Meanwhile, cytokine expression profiles implied that the inflammation was significantly stimulated in the AR subjects. Again, protein carbonylation was dramatically upregulated in the rejected subject within the tolerant group. Knockdown of ceruloplasmin would elicit more severe ROS damage, leading to cell death in the presence of H 2 O 2 , which induced Nrf2 cascade and the recovery of ceruloplasmin to mediate spontaneous tolerance. In summary, ceruloplasmin may contribute to amending the oxidative stress that eventually causes cell apoptosis and to maintaining the survival of hepatocytes in a drug-free tolerance OLT model.

Acute rejection (AR) of liver transplantation remains a formidable challenge for diagnostic medicine and biomarker discovery. We characterized AR-related microRNAs (miRNAs) and the underlying AR mechanisms in liver transplantation. Using a rat model of orthotopic liver transplantation (OLT) as well as microarrays, we compared the miRNA expression profiles between naive and AR livers on day 7 after OLT with short- (<14 days, donor Dark Agouti [DA] liver into Lewis [LEW] recipient) and long-term (>60 days, donor DA liver into Piebald Virol Glaxo [PVG] recipient) survival fates. The microarray analysis revealed that the levels of miR-301a in the lethal AR livers were significantly higher than in naive and tolerogenic AR livers. The reduced expression of miR-301a in inflamed livers suggested a difference between AR and inflammation in terms of miR-301a-mediated molecular events. Overexpression of hepatic miR-301a induced IL-6 production in rat primary hepatocytes. Hepatocytes overexpressing miR-301a were capable of transferring miR-301a to cocultured splenocytes through exosomes. These splenocytes then showed overexpression of miR-301a and downregulation of protein inhibitor of activated STAT3 (PIAS3) expression, resulting in the induction of T helper 17 cell differentiation. In conclusion, this report raises the possibility that hepatic miR-301a might potentially prove value as a biomarker of liver transplant rejection. We call for future research on this molecular target and the attendant pathways as liver transplant rejection and its early diagnosis continue to be veritable healthcare challenges.

To investigate the effect of IL28B single nucleotide polymorphisms (SNPs) (rs8099917 and rs12979860) in the donors and recipients on the outcome of Hepatitis C virus-RNA clearance after living donor liver transplantation (LDLT). The rs8099917 and rs12979860 genotypes in 50 donor and recipients pairs were explored on the pre-operative day (POD) and post-operative day 30 (POD30). There was a significant difference in HCV-RNA clearance before (12%, 6/50) and after (48%, 24/50) liver transplantation (P < 0.001). The rs8099917 genotype TT was dominant in both the recipients (82%, 41/50) and donors (86%, 43/50), but had no significant effect on HCV-RNA clearance (87.5%, 21/24) and recurrence (76.9%, 20/26) after LDLT. One recipient was detected with genotype GG on POD, which changed to genotype GT on POD30. Prevalence of rs12979860 genotype CT was 98% (49/50 recipient) and 92% (46/50 donor) and prevalence of genotype CC was 2% (1/50 recipient) and 8% (4/50 donor) on POD and POD30, respectively. Of the 4 recipients with rs12979860 genotype CC on POD30, 3 recipients (12.5%, 3/24) exhibited HCV clearance and 1 experienced recurrence (3.9%, 1/26), however, this was not statistically significant. In conclusion, alterations in IL28B SNP genotype may occur after LDLT, leading to modifications in the host genome or donor proteome by HCV. This predicted mechanism will need to be investigated further.

Objective: Hepatocellular carcinoma (HCC) and its recurrence are major problems in living donor liver transplantation (LDLT). Several biomarkers have been used to investigate this event. We conducted a prospective controlled study to determine the activities of the basic fibroblast growth factor (FGF-2), survivin, Ki67, endostatin, and vascular endothelial growth factor (VEGF) in different conditions before, early after, and late after LDLT with and without HCC recurrence., Methods: Fifty patients with virus-related HCC who underwent LDLT were enrolled in this 2-year cross-sectional study. During the study period, recurrent HCC was identified in 9 patients (study group, n = 9) and 41 patients (control group, n = 41) had no recurrence after LDLT. The mean time to HCC recurrence was 587.11 ± 398.64 days (range, 90-1352 days). Microvascular invasion (MVI) was found in 66.7% (6/9) of the recipients, as determined on pathological examination. The serum biomarkers were investigated by using enzyme-linked immunosorbent assay at the different LDLT stages., Results: The serum levels of the biomarkers significantly correlated with LDLT and HCC recurrence in the repeated-measures analysis (F = 31.676, P = 0.000). Significant differences were observed in the effects of all biomarkers (F = 85.313, P = 0.000) and the time to HCC recurrence after LDLT (F = 3.178, P = 0.046). The biomarkers, ordered by the observed power of the test for HCC recurrence after LDLT, were FGF-2 (1.000) > survivin (0.999) > Ki67 (0.949) > endostatin (0.411) > VEGF (0.305)., Conclusions: Different biomarker activities may be implicated in the pathogenesis of HCC recurrence after LDLT. Oncogenes may not exist in the new graft but may still be present in the peripheral blood. The timing of HCC recurrence and impact of MVI in the explanted liver requires confirmation in larger studies with a longer follow-up.

Cytochrome P450 metabolizes many drugs in the liver. Three genotypes of CYP2C19 with extensive, intermediate, and poor metabolizing activity, respectively, have been identified in peripheral blood of transplant recipients and new liver grafts in living donor liver transplantation (LDLT). The expression of the final genotype in liver graft biopsies depends on the donor, whereas the expression in peripheral blood mononuclear cells depends on the recipient. The metabolizing isoenzyme of the major anti-rejection agents passes through CYP3A4, CYP3A5 and MDR1, which have also been identified to have similar biological characteristics as genotype of CYP2C19 in liver tissue. Recently, pyrosequencing has been used to investigate the expressions of different genotypes in liver grafts in LDLT. This review focuses on recent findings regarding the biological expressions of the CYP2C19, CYP3A4, CYP3A5 and MRD1 genotypes in liver grafts before and after LDLT. The application of pyrosequencing may be beneficial in further research on liver transplantation. Laser capture microdissection of hepatocytes in liver grafts may be a direction for future research.

Orthotopic liver transplantation (OLT) is the gold standard procedure for treating end-stage liver disease resulting from a variety of causes. Psychiatric comorbidities are common problems among patients who have undergone OLT; however, the association between psychiatric comorbidity and biological factors in OLT has not been investigated. In our previous study, we found a positive correlation between serum C-reactive protein (CRP) level after OLT and the prevalence of psychiatric comorbidities in recipients. In this retrospective cohort analysis, we enrolled 279 recipients who underwent OLT during a 3-year period (from 2008 to 2011) at a single center. Our retrospective study showed that the recipients with a higher serum CRP level at 1 month after OLT had higher psychiatric comorbidities compared with the recipients with a normal serum CRP level. Additionally, an in vitro study demonstrated that the down-regulation of brain-derived neurotrophic factor (BDNF) gene expression by CRP treatment in retinoic acid (RA) differentiated SH-SY5Y neuroblastoma cells. These clinical and experimental results indicated that the overexpression of CRP may induce psychiatric comorbidities through suppressed expression of the BDNF, suggesting that OLT recipients who developed psychiatric comorbidities might be accompanied by an immunological or acute-phase protein response. In conclusion, an activation of systemic inflammatory processes may be one of the predictable signatures for psychiatric comorbidities in OLT recipients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

This study used pyrosequencing to determine the proportional distribution of CYP3A5*3 genotypes to further confirm the homogeneous phenomenon that is observed when recipients and donors in living donor liver transplantation (LDLT) have a different single nucleotide polymorphism (SNP) genotype. We enrolled 42 recipient/living donor pairs and the SNPs of CYP3A5*3 were identified by polymerase chain reaction-restriction fragment length polymorphism. We performed 120 liver graft biopsies as part of clinical investigations after LDLT. Pyrosequencing of the CYP3A5*3 SNPs revealed that among the 16 recipients with the G/G genotype, 94.68% had the G and 5.32% the A allele. Among the 14 recipients with the A/G genotype, 78.08% had the G and 21.92% the A allele, and among the 12 recipients with the A/A genotype, 18.45% had the G and 81.55% the A allele. Among the 12 donors with the G/G genotype, 93.85% had the G and 6.14% the A allele. Among the 26 donors with the A/G genotype, 75.73% had the G and 24.27% the A allele, and among the 4 donors with the A/A genotype, 11.09% had the G and 88.91% the A allele. There were a total of 120 liver graft biopsy samples; among the 37 recipients with the G/G genotype, 89.74% had the G and 10.26% the A allele, among the 70 recipients with the A/G genotype, 71.57% had the G and 28.43% the A allele, and among the 13 recipients with the A/A genotype, 48.25% had the G and 51.75% the A allele. The proportional distribution of G and A alleles of the CYP3A5*3 SNP between recipients/donors and liver grafts after LDLT was significantly different (p<0.001). Pyrosequencing was useful in identifying detailed proportional changes of the CYP3A5*3 SNP allele distribution, and to confirm the homogeneous phenomenon when recipients and donors in LDLT have a different genotype.

Concanavalin A (Con A) is a lectin originating from the jack-bean and well known for its ability to stimulate T cells and induce autoimmune hepatitis. We previously demonstrated the induction of immunosuppressive antinuclear autoantibody in the course of Con A-induced transient autoimmune hepatitis. This study aimed to clarify the effects of Con A-induced hepatitis on liver allograft rejection and acceptance. In this study, we observed the unique phenomenon that the induction of transient de novo autoimmune hepatitis by Con A injection paradoxically overcomes the rejection without any immunosuppressive drug and exhibits significantly prolonged survival after orthotopic liver transplantation (OLT). Significantly increased titers of anti-nuclear Abs against histone H1 and high-mobility group box 1 (HMGB1) and reduced donor specific alloantibody response were observed in Con A-injected recipients. Induction of Foxp3 and IL-10 in OLT livers of Con A-injected recipients suggested the involvement of regulatory T cells in this unique phenomenon. Our present data suggest the significance of autoimmune responses against nuclear histone H1 and HMGB1 for competing allogeneic immune responses, resulting in the acceptance of liver allografts in experimental liver transplantation.

In addition to cellular immune responses, humoral immune responses, mediated by natural antibodies, autoantibodies, and alloantibodies, have increasingly been recognized as causes of organ transplant rejection. In our previous studies, we have demonstrated the induction of antinuclear antibodies against histone H1 and high-mobility group box 1 (HMGB1), in both experimental and clinical liver transplant tolerance. The active induction of antinuclear antibodies is usually an undesirable phenomenon, but it is often observed after liver transplantation. However, the release of nuclear antigens and its suppression by neutralizing antibodies are proposed to be important in the initiation and regulation of immune responses. In this review article, we summarize the current understanding of nuclear antigens and corresponding antinuclear regulatory antibodies (Abregs) on infection, injury, inflammation, transplant rejection, and tolerance induction and discuss the significance of nuclear antigens as diagnostic and therapeutic targets.

Background: The cytochrome P450 (CYP) drug-metabolizing enzymes play an important role in cellular metabolism. Therapeutic failure or drug toxicity in the period after liver transplantation (LT) is influenced by the drug metabolizing capacity of the graft. The expression levels of CYP2C19 enzyme are often used as an indicator of the functioning of the CYP system. The aim of the present study was to assess the CYP2C19 protein expression in the setting of living donor liver transplantation (LDLT) by using western blotting analysis., Methodology: We performed CYP2C19 genotyping of liver biopsy samples obtained from 24 donors and 8 recipients each in the pre- and post-LT periods, after which we analyzed the CYP enzyme activity by using western blotting analysis., Results: The CYP2C19/β-actin ratio, which was an indicator of CYP expression, was 61.75% (23-100%) in donors, 59.13% (15-100%) in pre-LT recipients and 46.71% (12-67%) in post-LT recipients (p>0.05). The CYP2C19 expression levels associated with different genotypes were as follows: homozygous extensive metabolizers (HomEMs; n=24), 56.63±24.74%; heterozygous extensive metabolizers (HetEMs; n=15), 63.0±25.14% and poor metabolizers (PMs; n=1), 82.0% (p>0.05)., Conclusions: Western blotting analysis showed low CYP2C19 protein expression not only in samples from the pre- and post-LT recipients but also from the donors.

Background: The donor liver grafts with different allelic patterns do not affect CYP2C19 genotypes in the peripheral blood of living donor liver transplantation (LDLT) recipients., Aim: This study investigated the influence of graft liver CYP2C19 genotypes on recipients who received the same or different CYP2C19 genotypes from donors after LDLT., Methods: There were 30 donors and 30 recipients with the same CYP2C19 genotypes and 47 donors and 47 recipients with different CYP2C19 genotypes. Genomic DNA was isolated from the liver tissue of recipients. The CYP2C19 haplotypes were determined by polymerase chain reaction., Results: A homogenous phenomenon in the sequences of graft liver CYP2C19 genotypes was indicated because the recipients showed mixed patterns that were similar to that of the original donor after LDLT. A significant decrease in homozygous extensive metabolizer (HomEM) and an increase in poor metabolizer (PM) distribution were observed in recipients with different CYP2C19 genotypes from their donors compared with recipients with the same CYP2C19 genotype as their donors (P < 0·05)., Conclusions: Homogenous phenomenon of sequence changes in graft liver CYP2C19 from the different genotypes between the donors and the recipients may play a role in graft stability by causing decreased HomEM and increased PM after LDLT., (© 2011 The Authors. European Journal of Clinical Investigation © 2011 Stichting European Society for Clinical Investigation Journal Foundation.)

The precise roles of mast cells in liver allograft rejection and tolerance are still unknown. This study aimed to explore the roles of mast cells in immune regulation and liver regeneration for tolerance induction by using rat models of orthotopic liver transplantation (OLT). Stem cell factor (SCF) and its receptor c-Kit, which are critical to the migration and development of not only stem cells but also mast cells, significantly increased in the tolerogenic livers as compared with rejected livers. The significant elevation of mast cell tryptase, high-affinity IgE receptor, and histamine suggested the activation of mast cells in liver allografts at the tolerogenic phase after OLT. Immunohistochemical analysis using confocal microscope clearly showed colocalization of mast cells, Foxp3+ Tregs, γδ T cells, and recipient-derived hepatic progenitor cells with higher expression of SCF, IL-9, IL-10, TGF-β1, and IL-17 related to immunoregulation and liver regeneration in the donor grafts of a tolerogenic OLT model. Cross-talk among mast cells and other cells was evaluated by in vitro studies demonstrating that syngeneic bone marrow-derived mast cells (BMMCs) co-cultured with naïve splenocytes or primary hepatocytes significantly increased the population of splenic γδ T cells by mitogen stimulation or by mast cell degranulation, and also significantly induced the hepatocyte proliferation, respectively. Our results suggested that mast cells in the donor grafts may play important roles in the induction/maintenance of immune tolerance and liver regeneration resulting in the replacement of hepatic cells from donor to recipient.

Background: We examined the effects and the mechanisms of serum glycoproteins on spontaneous tolerance after orthotopic liver transplantation (OLT) between DA (RT-1(a)) and PVG (RT-1(c)) rats., Methods: A functional proteome analysis was introduced to investigate differently expressed proteins involved in overcoming major histocompatibility complex (MHC) barriers and lectin blotting was applied to survey the levels of fucosylated proteins., Results: Two-dimensional difference gel electrophoresis (2D-DIGE) coupled with mass spectrometry revealed statistically significant changes in the intensity of 19 proteins at 14 and 60 post-OLT days which respectively corresponded to rejection and tolerance. An interaction network analysis of the identified proteins indicated that the interleukin (IL)-6 signaling pathway might be correlated with the immune events in this model. The peak of IL-6 expression occurred during the recovery period might play a role in the remarkable shifts in the immune response towards spontaneous tolerance. Furthermore, increased levels of IL-6-modulated fucosylation of Igh-6 were also observed during the rejection response while fucosylated hemopexin and haptoglobin were obviously upregulated in the tolerogenic period., Conclusions: These findings suggest that IL-6 and glycoproteins may play critical roles in this spontaneous tolerogenic DA/PVG OLT model and shed light on prolonging hepatic allograft survival in the future., (Copyright © 2010 Elsevier B.V. All rights reserved.)

The function of cytochrome P450 2C19 (CYP2C19) is altered in patients with end-stage liver disease (ESLD) that require liver transplantation (LT). The status of CYP2C19 is of considerable interest because the transplanted healthy donor livers are perfused with the blood of the recipient with ESLD. This study aims to clarify the changes in CYP2C19 in the peripheral blood before and after LT. Thirty pairs of living donors and recipients were enrolled in this study. The CYP2C19 genotype in peripheral blood mononuclear cells (PBMCs) was studied immediately before operation in donors, on the day preceding the operation in the unstable recipients, and one month after LT in stable recipients. Limited data suggest that the post-LT genotype in liver biopsy is the same as donor's original genotype in most cases (80.0%) and that only 2 patients in the study cohort had the same liver tissue genotype as the respective recipient PBMCs. However, expression of the CYP2C19 genotype after living donor LT (LDLT) was identical to pre-transplant expression in 100% (30/30) of recipients, i.e., CYP2C19 genotypes in recipient PBMCs did not change after LDLT, suggesting that the donor liver did not render any mutations to the CYP2C19 genotypes after LT., (© 2010 John Wiley & Sons A/S.)

Background: New graft cytochrome P450 2C19 (CYP2C19) should have different characteristics after living-donor liver transplantation (LDLT). We prospectively investigated the influence of genotypes of CYP2C19 in liver graft pathological finding (GPF) and postoperative liver function (POLF) of recipients after LDLT., Material/methods: Among 60 consecutive patients who underwent LDLT, 36 recipients developed sudden-onset abnormal liver function and required liver biopsy, while the remaining 24 recipients did not require biopsy. LDLT recipient blood samples were genotyped for CYP2C19 variants, and recipients were categorized as homozygous extensive metabolizers (HomEM), heterozygous extensive metabolizers (HetEM), and poor metabolizers (PM)., Results: The acute rejection rate was 15.0% (9/60). There were 4 characteristics of GPF when abnormal POLF occurred. Logistic regression analysis showed that the risk estimate of abnormal POLF was 26.7 times higher for LDLT recipients with the CYP2C19 HomEM genotype as compared to the PM genotype, and 5.0 times higher for LDLT recipients with the HomEM genotype as compared to the HetEM genotype. A linear trend relationship was found between the incidence of abnormal POLF and the CYP2C19 genotype., Conclusions: These results suggest that the speed of drug metabolism as characterized by the CYP2C19 genotype (HomEM > HetEM > PM) may affect the outcome after LDLT; thus, CYP2C19 genotyping may be valuable for predicting abnormal POLF with different GPF after LDLT.

Although magnolol is cytoprotective against warm ischemia/reperfusion injury, its effect on cold preservation has not been fully investigated. This study aimed at examining whether magnolol maintains the liver graft integrity after cold preservation and elucidating the underlying mechanisms in terms of apoptotic signaling under both normothermic and hypothermic conditions. After being preserved in Ringer's lactate (RL) at 4 degrees C for 6h ex vivo, the magnolol-treated grafts demonstrated significantly higher AST, ALT, and LDH levels in perfusates than those from negative controls. TUNEL staining showed no difference in the number of apoptotic nuclei in both groups, whereas a more intense apoptotic signal in magnolol-treated grafts was shown as compared with the controls. In vitro data showed no significant difference in viability of RL-preserved clone-9 hepatocytes between the magnolol-treated and control groups, while magnolol pretreatment at 30min before cold preservation prominently induced hepatocyte cell death. RT-PCR and Western blotting analyses revealed a suppression in Bcl-2, but an up-regulation in Bax expression in clone-9 cells after magnolol treatment. Magnolol suppressed the ratios of NF-kappaB to I-kappaBalpha protein contents and I-kappaBalpha phosphorylation induced by TNF-alpha, and potentiated mitochondrial cytochrome c release and subsequent caspase-3 cleavage. Conversely, caspase-3 inhibitor attenuated magnolol-induced hepatotoxicity. We concluded that magnolol could not protect liver grafts from cold ischemia/reperfusion injury. High concentration of magnolol under serum-reduced conditions attenuates NF-kappaB-mediated signaling and induces intrinsic apoptotic pathway, thereby inducing in vitro hepatotoxicity., (Copyright 2009 Elsevier GmbH. All rights reserved.)

Aims: Distal splenorenal shunt effectively controls bleeding from esophageal and gastric varices but has a different effect on liver transplantation. This study sought to develop an animal model in rats to mimic the recipient with a portosystemic shunt and to investigate its hemodynamic consequences on liver transplantation., Methods: We prepared 5 groups of allogeneic or syngeneic rat liver transplantation models with versus without portosystemic shunt, to investigate its effects on graft survival and portal flow. To explore the effects of excessive portal flow on graft survival in small-for-size liver transplantation, we transplanted partial liver grafts into syngeneic recipients., Results: In allogeneic combinations, graft survival among the shunt group was shortened compared with their control counterparts. The graft survival of the large shunt group was significantly lower than that of a small shunt or without shunt group in a syngeneic liver transplantation model. Portal blood pressure of the large shunt group was significantly lower than that of the small shunt group. In contrast, excessive portal flow resulted in dysfunction of liver graft in small-for-size liver transplantation., Conclusions: These results suggested that reduction in portal flow by portosystemic shunt lead to an acceleration of acute rejection and subsequent liver graft dysfunction, but it may be applicable to regulate the excessive portal flow in small-for-size transplantations. This study showed a valuable model mimicking the recipient with a portosystemic shunt.

Objective: The aims of the study were to determine the effects of denervation on the function of the liver transplantation as a blood reservoir and to define its vulnerability to ischemic-reperfusion (I/R) injury after hemorrhagic shock., Materials and Methods: Hemorrhagic shock with a mean arterial blood pressure (MAP) of 40 to 50 mm Hg was induced by withdrawing blood at a rate of approximately 1 mL/min among 10 posttransplant denervated rats and 10 sham rats for 1 hour. The rats were then resuscitated by retransfusing the drawn blood with sacrifice under deep anesthesia at 1 hour after resuscitation. The total amount of blood required to achieve hemorrhagic shock was compared between groups as well as the vulnerability and reactions of the posttransplant denervated liver to I/R injury after hemorrhagic shock as assessed by gene expressions of c-jun, c-fos, tumor necrosis factor (TNF)-alpha, interleukin (IL)6, IL-10, and heat-shock protein 70 (HSP70)., Results: The volume of blood that had to be drawn to reach a MAP of 40 to 50 mm Hg was not significantly different between the groups. One hour of hemorrhagic shock followed by resuscitation resulted in significant increases in the genes expression of c-fos, TNF-alpha, IL-6, IL-10, and HSP70 in comparison to the control values, but no difference was observed between experimental and sham groups., Conclusion: We suggest that the function of the liver as a blood reservoir and the gene expressions of c-fos and pro- and anti-inflammatory cytokines, as well as the protective protein HSP70 in response to I/R injury, were not altered by liver transplantation.

Background and Aim: Indoleamine 2,3-dioxygenase (IDO) is expressed in the placenta and plays an essential role in maternal tolerance. Recent data showed that giving IDO inhibitor blocked liver allograft tolerance. However, the immunological role of IDO in rat liver allograft models has not been characterized. In the present study, the time-course of IDO expression and the localization of IDO were analyzed to address the role of IDO in the induction of tolerance., Methods: Rat orthotopic liver transplantations (OLT) were performed and IDO gene expression of OLT livers was analyzed. Immunohistochemistry was used to evaluate the localization of IDO-expressed cells in the liver., Results: The IDO gene was detected in the allogeneic liver graft at the acute phase but the signal could not be detected when these OLT rats were treated with cyclosporinee A. The time-course of IDO gene expression in liver grafts of the spontaneous tolerant OLT model revealed that the IDO mRNA was expressed in both the rejection phase and the induction phase of tolerance, but the signal was gradually lowered during the maintenance phase of tolerance. Immunohistochemistry confirmed that the IDO protein was detected in antigen-presenting cells but not in hepatocytes., Conclusion: Our results demonstrated that IDO is induced in antigen-presenting cells of rat liver allografts under drug-free status, suggesting that indirect or direct recognition of donor antigen and further T-cell activation may be inhibited. IDO may act as a local immunosuppressive molecule to protect transplanted cells, tissues and organs from immune attack.

Background: Our recent studies suggested that anti-histone H1 autoantibody (auto-Ab) plays an important role in experimental and clinical liver allograft tolerance as a natural immunosuppressive factor. The present study aimed to explore how the autoimmune response against histone H1 is involved in tolerance induction., Methods: The measurement of anti-histone H1 auto-Ab and immunohistochemical analysis were performed in serum and liver allografts after orthotopic liver transplantation (OLT). To compare the auto-Ab response against histone H1 between the recipients of rejector (DA-LEW) and tolerogenic (DA-PVG) OLT models, naïve recipients were immunized with calf thymus histone H1. The immunosuppressive state of histone H1-immunized rats was assayed by mixed lymphocyte reaction (MLR)., Results: Anti-histone H1 Ab titer was transiently increased during the rejection phase after OLT (days 7-21) in the DA-PVG combination, while no such response was confirmed in the DA-LEW acute rejection model. Nuclear histone H1 antigens were found in the cytoplasm and the extracellular environment in liver allografts at the rejection phase in the tolerogenic model but not in the rejector model, resulting from the transient induction of anti-histone H1 auto-Ab in recipient PVG rats after OLT. Low dose and short-term immunization with histone H1 upregulated the anti-histone H1 Ab titer in naïve PVG rats, which exhibited a low allogeneic immune response, while no such response was found in naïve LEW rats., Conclusions: These results suggest that the sensitivity to nuclear antigens such as histone H1 may be a key factor determining the acceptance or rejection of donor liver grafts, at least in DA-PVG and DA-LEW combinations.

Histone H1 and high-mobility group box 1 (HMGB1) proteins are known to initiate an immune reaction, and the corresponding antibodies (Abs) possess immunosuppressive activity. In the present study, we aimed to evaluate the immunological role of antinuclear Abs in experimental and clinical liver transplantation. In a rat tolerogenic orthotopic liver transplantation (OLT) model, antihistone H1 and HMGB1 titers were induced during the rejection and tolerance induction phases, respectively. Those Ab responses also were confirmed in a drug-induced tolerance model (acute rejection model + cyclosporin A [0 to 14 days after OLT]). We also found a similar tendency in our clinical drug-free patient (who experienced complete cessation of any immunosuppressive treatments) and that antinuclear Abs induced in the serum after cessation of immunosuppressants play a part of immune privilege in this patient. These results suggest that antinuclear Abs are important factors for overcoming rejection and the subsequent tolerance induction in liver transplantation.

In orthotopic liver transplantation (OLT), tolerance is induced in a certain combination of donors and a recipient in rats and, in some clinical cases, rejection has not occurred in OLT patients after weaning off immunosuppression. However, this mechanism has not yet been elucidated. Among our cases of liver transplantation (LTx), one OLT patient (Patient A) has not required immunosuppressive drugs for the last 5 years, following post-transplant lymphoproliferative disease (PTLD). This patient's serum interleukin-2 levels were undetectable following withdrawal of immunosuppressants. The same serum taken after discontinuing the immunosuppressants inhibited concanavalin A blast cultured cells and up-regulated the IL-4/IFN-gamma gene expression ratio. These results suggested that other proteins were induced following withdrawal of immunosuppressants. Proteomic assay demonstrated 12 differentiated spots exclusive to this patient where immunosuppressants have been discontinued. Haptoglobin, found to have immunosuppressive activity in vitro, may play an important role in the maintenance of drug-free tolerance as a natural immunological suppressor after cessation of immunosuppression. Proteomic analysis will allow us to develop a novel weaning protocol for patients on long-term immunosuppression to avoid major immunosuppressant-related complications.

Background: In a rat tolerogenic orthotopic liver transplantation (OLT) model, recipient serum after OLT (post-OLT serum) has been reported to prevent allograft rejection. A previous proteomic study indicated that apolipoprotein E (apo-E), which is an important factor for cholesterol transportation, is expressed at the latter tolerogenic phase after OLT. It has also been known that adipose tissue-derived adipokine, adiponectin, is an essential factor for fatty acid catabolism. This study aimed to characterize the role of lipid transfer/metabolic proteins in liver transplantation tolerance., Methods: To identify the apo-E and adiponectin in post-OLT serum, Western analyses and enzyme-linked immunosorbent assay (ELISA) were performed, respectively. The immunosuppressive activities of those factors were evaluated by inhibition of the mixed lymphocyte reaction (MLR)., Results: Western analyses showed that the mobility of apo-E was shifted at the latter tolerogenic phase after OLT in a natural tolerance model, and a similar phenomenon was confirmed in the serum of a drug-induced tolerance model (rejection model+cyclosporin A (CsA); 0 to 14 days) after cessation of CsA. Further study revealed that neutralization of modified apo-E in post-OLT serum reduced the immunosuppressive activity. Additionally, plasma adiponectin was significantly elevated at the latter phase after OLT, and possessed MLR-inhibitory activity., Conclusions: These results suggest that the mobility shift of apo-E and/or the up-regulation of adiponectin may be necessary for overcoming the rejection, recovering the liver allograft function, and following tolerance induction in experimental OLT models, and may be useful as one indicator to surmise the prognosis after liver transplantation.

Objective: In a rat tolerogenic orthotopic liver transplantation (OLT) model, the recipient serum (post-OLT serum) shows strong immunosuppressive activity. In our previous reports, we suggested that autoreactive antibody (Ab) against histone H1 is a major immunosuppressive factor in this serum. The present study sought to determine whether up-regulation of anti-histone H1 Ab by histone H1 vaccination led to tolerance., Materials and Methods: Using mixed lymphocyte reactions (MLR) and heterotopic heart transplantations (HHT), the alloreactive T-cell responses and allograft survivals of histone H1-immunized rats were compared with those of control rats. Cytokine and cellular profiles were determined by enzyme-linked immunosorbent assay (ELISA) and flow cytometry., Results: The alloreactive T-cell response of histone H1-immunized rats was significantly lower than that of control rats, although there was no difference in nonspecific T-cell activation between the 2 groups. The allograft survival of histone H1-immunized rats was significantly prolonged after HHT. The major histocompatibility complex (MHC) class II and CD25 molecules of histone H1-immunized rats were significantly down-regulated compared with those of control rats. Moreover, the serum cytokine profile was modified by the immunization with histone H1., Conclusions: These results suggest that histone H1 vaccination of transplant recipients leads to the production of immunosuppressive factors and the modification of cytokine/cellular profiles.

Objective: We recently reported that autoreactive antibodies (Abs) against nuclear histone H1 was transiently induced at an early phase after orthotopic liver transplantation (OLT) in a tolerogenic rat OLT model and possessed immunosuppressive activity. It was also reported that nuclear antigen, high-mobility group box 1 (HMGB1) protein was one of the initiators of the immune reaction. The present study sought to evaluate the role of antinuclear Abs in experimental and clinical liver transplantation., Materials and Methods: We prepared 3 animal models: natural tolerance model (DA liver into PVG); acute rejection model (DA liver into LEW); and drug-induced tolerance model (acute rejection model + cyclosporine [CsA]). In addition, we examined clinical samples, including 1 drug-free patient, to measure the antihistone H1/HMGB1 titers at various times after OLT., Results: In a natural tolerance model, antihistone H1 and HMGB1 Ab was induced during the rejection and the tolerance induction phases, respectively. Those Ab responses were also confirmed in a drug-induced tolerance model, whereas no such responses were shown in an acute rejection model. In our clinical drug-free patient, antihistone H1/HMGB1 titer was significantly higher after cessation of CsA than that in healthy volunteers., Conclusions: Antinuclear Ab is actively expressed in accordance with overcoming rejection episodes with subsequent tolerance induction in both a natural tolerance model and a drug-induced tolerance model. We also observed a similar tendency in our clinical drug-free patient. These results suggested that antinuclear Abs may be useful markers to determine the timing to withdraw immunosuppressants.

Background: In a rat tolerogenic model of orthotopic liver transplantation (OLT), recipient serum after OLT (post-OLT serum) possesses strong immunosuppressive activity. This study aimed to identify immunosuppressive factors present in early post-OLT serum., Methods: Immunosuppressive activity was evaluated in vitro by inhibition of the mixed-lymphocyte reaction (MLR). Autoantigens recognized by MLR-inhibitory IgG were identified by the internal protein sequencing., Results: Recipient post-OLT serum inhibited MLR, and OLT-inducible IgG was the major immunosuppressive factor. IgG from post-OLT sera (2 to 3 weeks) specifically reacted to 31; 34; and 73-kd autoantigens on spleen cells. The internal sequences of the 31- and 34-kd antigens coincided completely with those of histone H1 molecules. Immunodepletion of anti-histone H1 antibodies (Abs) from early post-OLT serum abolished the MLR-inhibitory activity. Furthermore, rabbit polyclonal Ab-directed histone H1 not only significantly suppressed rat and human MLR but also prolonged survival of heart allografts. Flow-cytometric analysis revealed that some live PVG splenocytes were stained with antihistone H1 Abs, and that these positive cells increased on Con A stimulation. Western blot analysis indicated that several cross-reactive antigens against anti-histone H1 Abs were found in their membrane fraction., Conclusions: In this study we provide evidence that autoreactive Abs, against histone H1 are a major OLT-induced graft survival factor, and may play at least a part in overcoming the acute rejection phase to establish solid allograft tolerance.

Orthotopic liver transplants (OLT) performed in certain combinations of donor and recipient rat strains, such as DA (RT1a) to PVG (RT1c), without immunosuppressive drugs could completely overcome major histocompatibility complex barriers. Although other organs transplanted in a similar fashion within the same combination have been promptly rejected, 60 day post-OLT serum (POD 60) has been proven competent in rapidly reversing the established rejection in animal models. In order to understand the functional role of tolerogenic serum proteins and their involvement with immune response regulation, a comprehensive analysis surveying global changes in complex OLT systems by proteomic techniques was applied. The results display the varying protein expressions in sera extracted from naïve and transplanted animals on POD 60 with regard to immunosuppression. Among these proteins, haptoglobin (Hp) which is related to inhibition of T-cell proliferation was found to be up-regulated following OLT. In addition, the transcriptional expression level and intracellular localization of Hp correlated with the immune events. Hp also exhibited a strong in vitro immunosuppressive effect on the mixed lymphocyte reaction. In conclusion, the presence of Hp may play an important role in modulating the spontaneous tolerance of liver transplantation. Furthermore, the serum proteome map could provide guidance with respect to discovering potential protein targets in OLT tolerance and eventually prolong hepatic allograft survival in the future.

Background: In a rat model of orthotopic liver transplantation (OLT), recipient serum after OLT (post-OLT serum) has been reported to prevent allograft rejection. However, the molecular identities of immunosuppressive factors, which are in the early stage of post-OLT, remain elusive. This study was aimed to identify immunodominant suppressive factors present in early post-OLT serum., Methods: The immunosuppressive activities of post-OLT serum, immunoglobulin (Ig) G-depleted serum, and purified IgG were evaluated in vitro by inhibition of the mixed lymphocyte reaction (MLR). Autoantigens recognized by the MLR-inhibitory IgG in early post-OLT serum were identified by the internal protein sequencing., Results: Recipient post-OLT serum inhibited MLR, and its immunosuppressive activity vanished by means of the elimination of OLT-inducible IgG. IgG from post-OLT sera (2-3 weeks) specifically reacted to 31-, 34-, and 73-kDa autoantigens on splenic cells. The internal sequences of the doublet 31- and 34-kDa antigens coincided completely with those of histone H1 molecules. The levels of histone H1-specific antibodies were transiently increased to a plateau around 2 to 3 weeks after OLT but decreased in the later tolerogenic phase. Immunodepletion of antihistone H1 autoantibodies from early post-OLT serum abolished the MLR-inhibitory activity. Furthermore, rabbit polyclonal antibody-directed histone H1 not only suppressed MLR but also prolonged allograft survival., Conclusions: In this article, the authors provide evidence that autoreactive antibodies against histone H1, which are transiently induced at the early stage by liver transplantation, are a major OLT-induced graft survival factor.

Background: Preoperative delineation of any vascular anomalies offers planning for possible alteration of surgical procedures, especially in pediatric recipients undergoing living-related liver transplantation., Purpose: We assess the efficacy of three-dimensional (3D) multislice computed tomography (CT) angiography in the hope of replacing conventional angiography as the pretransplant evaluation of the hepatic vascular system for potential recipients of liver transplantation., Methods: 3D CT angiography was performed in 38 children with biliary atresia. Conventional angiography was also performed in the first 15 patients. Twelve patients underwent living-related liver transplantation. The findings on 3D CT angiography were compared with conventional angiography and operative findings., Results: 3D CT angiography was successfully performed in 37 pediatric patients. All findings of 3D CT angiography on hepatic artery, portal vein, and inferior vena cava paralleled those of catheter angiography and operative findings. Four patients were unsuitable to receive living grafts because of pathologic insults of the hepatic artery (one patient) and the portal vein (three patients). Three patients were advised to undergo a venous graft for portal anastomoses. Eight patients demonstrated portosystemic shunts that may require closure., Conclusion: 3D CT angiography proves to be a better tool in the demonstration of the vascular system and identification of pathologic insults in pediatric patients. It is superior to conventional angiography because it is less invasive, more convenient, and more efficient in providing thorough preoperative information that would have a major impact on patient selection and surgical planning.

Partial hepatectomy is a major upper abdominal operation associated with certain stress to the patient. Successful adaptation to such stress is a prerequisite for survival. Donor hepatectomy with maximal safety is a principal concern during living donor liver transplantation. The purpose of the study was to compare the stress response by assessing cytokines and the acute-phase response induced by hepatectomy in patients with a healthy liver and those with a diseased liver. Fourteen patients undergoing partial right hepatectomy were enrolled in this study. Seven of them were donors for living related liver transplantation (group 1, or GI); the other seven were patients with hepatocellular carcinoma due to chronic hepatitis B (Child's class A) (GII). Blood samples for interleukin-6 (IL-6), tumor necrosis factor-alpha (TNFalpha), and C-reactive protein (CRP) assays were collected before the operation, at the beginning and end of the operation, and 24 and 48 hours after the operation. The data were analyzed and compared in the same group using the Friedman test and between groups using the Mann-Whitney U-test. A value of p < 0.05 was regarded as significant. Results showed that resection of the liver in patients with both healthy and disease livers leads to significant increases in IL-6 and CPR but not TNFalpha. Significantly lower levels of IL-6 before and after operation in GI patients compared to those in GII patients suggests that GI patients adapted to surgical stress more easily than did the GII patients.

Unlabelled: Hypernatremia in the donor organ is one of the most dangerous risk factors that may cause primary graft loss after orthotopic liver transplantation (OLT). However, the viability of donor grafts from acute hypernatremic donors, which is likely to occur during resuscitation of trauma patients with hypertonic saline solution, has not been studied precisely. In the present study, we sought to evaluate whether the hypernatremia, per se, induced by hypertonic saline solution, affects the outcome of liver transplantation in the normal rat. Thirty minutes after the induction of hypernatremia (>160 mEq/L), the livers of nine Wistar rats were removed under ether anesthesia. Six livers were immediately transplanted into normal Wistar rats, whereas the other three were preserved in 4 degrees C University of Wisconsin solution for 6 h before transplantation in the recipients. Liver function variables of the donor rats at graft procurement and of the recipients at Day 7 after OLT were compared with a control group. The water content of the graft at procurement and the survival of the recipients at 7 days after OLT were, likewise, compared with the untreated control group. Results showed that there were no significant differences in the liver function tests of the donors and recipients, as well as in the water content of the grafts, between groups. All the rats survived the observation period of 7 days. This study showed that acute hypernatremia induced by the infusion of 10% saline solution before graft procurement in a nonbrain-dead donor rat model did not lead to a deterioration of liver graft viability after OLT., Implications: Hypernatremia in cadaveric donors may be detrimental to the graft in clinical liver transplantation, but acute donor hypernatremia induced by an IV infusion of 10% saline solution before graft procurement in nonbrain-dead rats did not affect the survival of the recipient rats in an experimental liver transplantation model.

Liver suppressor factor one (LSF-1) is a 40-kDa immunosuppressive protein in the serum of rats 60 days after orthotopic liver transplantation (OLT) between the non-rejector combination of DA donors into PVG recipients. In the present study, a polyclonal anti-LSF-1 antibody was used to detect the lymphoid cell populations expressing LSF-1 epitopes in several transplant models. In this study we examined cell samples acquired from rats that had undergone OLT in syngeneic, rejecting or non-rejecting combinations. Flow cytometry indicated that the polyclonal antibody reacts specifically with an epitope present on a CD4 CD11b positive cell of recipient origin. In the first 3 weeks after transplant there is a large increase in the number of these cells isolated from the spleens and livers of rats in tolerogenic OLT model, which correlates with prolongation of allograft survival. In the rejector and isograft models of OLT there is a minimal change in the expression of the LSF-1 N-terminal pep epitope. These results suggest that these recipient CD4 CD11b cells may have a critical role in the formation of transplant tolerance by interfering with the indirect pathway of allorecognition via as yet undetermined mechanisms. The increased expression of the LSF-1 N-terminal pep epitope on liver leukocytes 14 days after partial hepatectomy indicates a natural role for LSF-1 in the process of liver regeneration after insult or injury.

Background: Liver graft size, anatomy of the bile duct and the vascular inflow and outflow are essential for living related liver transplantation (LRLT). Preoperative delineation of those variations that would change the operative procedure to achieve a successful result especially in an emergency condition., Purpose: Our aim was to develop a rapid and noninvasive imaging diagnostic method for the detection of anatomical variants that is mandatory for a safe operation when selecting potential liver transplant living donors. We used a different magnetic resonance (MR) imaging technique, which enabled to us to exploit the anatomical landmark of the liver, signal enhancement of blood flow in the abdomen, and the intrahepatic biliary routes inside the liver. Then, with the help of Advantage Window workstation reconstruction, the reconstructed single vascular or biliary systems were displaced in a three-dimensional fashion and the whole examination finished within 30 min., Methods: Modification of the standard MR technique was performed on a superconductive 1.5T whole body image scanner, MR arteriogaphy, venography, and cholangiography with three-dimensional reconstruction in evaluating the anatomy of the hepatic arteries, hepatic veins, portal venous system, bile ducts, and liver size in potential liver transplant living donors. These anatomical structures were compared with traditional imaging methods., Results: In all 38 cases, as well as delineation of the portal vein detail to the segmental level was satisfactorily obtained in this MR study. The images were well displayed in a three-dimensional fashion, which had good correlation with images from traditional imaging modalities and operative findings. In 86.8% cases, the MR arteriography was well matched with the celiac angiography. Of those 17 operative cases, estimation of liver volume was well correlated with the liver graft within 3.9-12.5% variation. In the major hepatic vein, we obtained 100% accuracy and 88.2% in the minor branches. Of 12 donors received intraoperative cholangiography during liver donation, good correlation of biliary anatomy was achieved. One donor was excluded from graft donation due to the complicated arterial supply to the left liver. According to the anatomical variation, surgical procedures in graft harvesting and anastomosis were readjusted and no major complications were found in those donors and all recipients survived after liver transplantation., Conclusion: MR volumetry, venography, angiography, and cholangiography with three-dimensional reconstruction is sufficient for all major imaging evaluation. It may replace the traditional conventional catheter angiography, computed tomography, sonography and endoscopic retrograde cholangiography as a single investigation in the evaluation of the potential liver transplant donors. Angiography is only valuable in suboptimal cases and intraoperative cholangiography is only performed in biliary ductile variants.

Postoperative biliary and vascular complications contribute significantly to morbidity and mortality in liver transplantation. Interventional radiologists are an integral part of the multidisciplinary team necessary for optimizing the management of these complications. During a 15-year period, 39 cadaveric and 25 living related liver transplantations were performed at the Chang Gung Memorial hospital, Taiwan. Of 64 liver transplant recipients, 9 (3 adult and 6 pediatric) underwent 13 interventional radiological procedures for the treatment of biliary sludge-casts (n = 2), bile duct occlusion or stenosis (n = 2), hepatic veins thrombosis (n = 1), hepatic veins stenosis (n = 1), portal vein stenosis with splenorenal shunting (n = 1), biloma (n = 1), and infected fluid collection or ascites (n = 4). Antegrade or retrograde interventional approach was used to successfully treat all biliary complications, and all percutaneous drainage procedures were effective in the control of intra-abdominal fluid collections. Portal vein stenosis was treated by balloon dilatation, and the associated splenorenal shunt was closed by metallic coil embolization via transhepatic catheterization of the portal vein. Hepatic vein stenosis was effectively treated by balloon dilatation and expandable metallic stent deployment via transfemoral and jugular venous approaches, respectively. Hepatic vein thrombosis was only partially lysed by transvenous streptokinase administration, and surgical thrombectomy was needed to achieve complete recanalization. The total success rate of the interventional procedures was 92 % with no procedure-related complications. The overall survival rate in this series is 89 %, and all patients who underwent living related liver transplantation maintain to date a 100 % survival rate. We can conclude that interventional radiological procedures are very useful for managing biliary and vascular complications after liver transplantation. These techniques provide a cure in most situations, thus obviating the need for further surgical intervention or re-transplantation.

Total RNA differential display (DD) using random primers was performed for rat orthotopic liver transplantation (OLT) models. DA (RT1a) donor livers were transplanted into DA, PVG (RT1c), and LEW (RT1l) recipients: (1) syngeneic OLT (DA-DA): no rejection occurs; (2) allogeneic OLT (DA-PVG): rejection occurs, but is naturally overcome without immunosuppression; (3) allogeneic OLT (DA-LEW): animals die of acute rejection within 14 days. cDNA was isolated from selected bands, re-amplified for sequencing, and confirmed by Northern blots. Two down-regulated genes were observed in day-7 allogeneic OLT livers (DA-PVG, DA-LEW), while they were consistently expressed in day-7 syngeneic OLT (DA-DA) livers. These two genes were identified as alpha-glutathione sulfotransferase (alpha-GST) Ya gene and estrogen sulfotransferase (EST), respectively. Northern blots confirmed that their expression was down-regulated in OLT (DA-PVG) livers on days 7-26 and gradually restored. The mRNA expression of GST and EST may be good markers to predict rejection or induction of tolerance.

Aim: The effect of fatty liver on graft survival, especially with reference to macrovesicular and microvesicular steatosis, is still uncertain. This preliminarily study was designed to create a noninvasive method for the quantification of the hepatic fat content in vivo and to establish provisional criteria for the assessment of fatty donor livers before liver transplantation among transplant surgeons, radiologists, and pathologists., Methods and Materials: Different degrees of rat fatty liver model were established by feeding rats a diet deficient in choline and methionine for different periods of time. Computed tomography (CT) with test tubes containing variable percentages of fat equivalent substance were used to assess the severity of fatty change of the rat liver. This was then correlated with the histological classification, level of hepatic enzymes, and graft survival., Results: Linear correlation between the fat volume fraction added to the test tubes and CT density were found. The process of producing a fatty liver via diet alteration peaked at week 3. At this time hepatic enzymes, radiological fat content, and posttransplantation survival were worse (P=0.013), compared with other time points. Radiological assessment of fatty liver correlated well with survival and serum glutamic oxaloacetic transaminase and glutamic pyruvate transaminase levels., Conclusion: Severe microvesicular steatosis does not influence recipient survival, however, macrovesicular steatosis affects graft survival. Caliber CT is a practical and simple method that allows an accurate noninvasive quantitative assessment of hepatic fatty infiltration. It has potential to be a useful parameter for the assessment of donor livers for clinical liver transplantation.

Spontaneous orthotopic liver transplant (OLT) tolerance occurs uniformly between the inbred rat strains of DA (MHC haplotype RT1(a)) into PVG (RT1(c)) despite a fully allogeneic barrier. Animals transplanted in this combination do, however, undergo a rejection episode which appears to be self-limiting. In order to clarify this further we under took in situ measurements of the cytokines IL-2, IFN-gamma and TNF-alpha prior to, during and post rejection episode. The cytokine protein product was examined via immunoblotting assays and mRNA levels by RT-PCR. Comparisons were also made for syngeneic transplant combinations over the same time period. Peak protein expression of IL-2 and, to a lesser extent, IFN-gamma, occurred during the rejection episode between days 10 and 14. IFN-gamma was still present in syngeneic OLT on day 10 but was only present in allogeneic OLT on day 14. IL-2 was only detectable in allogeneic OLT on days 10 and 14. Transient increases in TNF-alpha occurred in allogeneic and syngeneic OLT with TNF-alpha levels falling by the peak rejection episode. Immunoblotting also confirmed the ability of hepatocytes to produce each of the cytokines studied. mRNA levels, by contrast, were maximal at days 1 and 10 for IL-2 and day 3 for IFN-gamma in allogeneic OLT when compared with syngeneic and non-transplanted controls. Earlier increases in IL-2 and IFN-gamma mRNA and time of peak protein expression do not correlate in this model. We therefore conclude that the measurement of peak mRNA levels alone are not enough to evaluate the rejection process especially since it is the cytokine protein products which have potential biological activity., (Copyright 2001 Academic Press.)

A tryptophan catabolizer, indoleamine 2,3-dioxygenase (IDO) is highly expressed in the placenta and plays an essential role in maternal tolerance. Recent data have shown that the administration of an IDO inhibitor blocked not only maternal tolerance but also liver allograft tolerance. However, little is known about the induction of IDO in liver allografts, although a gene specific for tryptophan 2,3-dioxygenase (TDO) is believed to be expressed in the liver. In the present study, we investigated whether IDO is induced in liver allografts. Synthetic oligonucleotide primers based on the mouse IDO cDNA sequence were used to amplify RNA derived from livers of donor, syngeneic or allogeneic OLT rats. RNA encoding IDO was induced in the rat allogeneic liver after orthotopic liver transplantation (OLT), but not in syngeneic OLT. The rat nucleotide sequence of the RT-PCR products obtained from OLT livers revealed identities of 89% homology to the mouse IDO and of 68% to the human IDO. This study demonstrated the presence of RNA encoding IDO in allogeneic OLT livers, which may be involved in the immune response after liver transplantation.

Background: Donor hepatectomy with maximal safety while preserving graft viability is of principal concern in living donor liver transplantation. There are compelling reasons for avoiding blood transfusion, even with autologous blood, to avoid the potential risks it imposes on healthy donors. This study aims to describe the surgical technique and clinical outcomes of living donor hepatectomy with minimal blood loss requiring no blood transfusion., Methods: Donor hepatectomy was performed in 30 living donors according to a detailed preoperative imaging study of the vascular and biliary anatomy. Liver parenchymal transection was carried out with strict adherence to a meticulous surgical technique without vascular inflow occlusion to either side of the liver. Pre-, intra-, and postoperative data were gathered, and factors related to blood loss were analyzed retrospectively., Results: The intraoperative blood loss ranged from 20 to 300 ml with a mean of 72.0+/-58.9 ml (median, 55 ml), and neither homologous nor autologous blood transfusion was required in any of the donors intra- and postoperatively. All 30 donors were discharged with minimal complications, and remain well at a mean follow-up of 24 months after donation. Excellent graft viability was verified by the fact that all 30 recipients are alive and well with a few manageable complications. The actual graft and patient survival are both 100% at the time of writing., Conclusions: Regardless of the extent of donor hepatectomy, blood loss can and should be kept to a minimum, and living donor hepatectomy without blood transfusion is a realistic objective.

Little is known about the possible role of complement inhibitors on tolerance induced by liver allografts. Clusterin, which is a plasma glycoprotein, inhibits cytolytic membrane attack complex (MAC) of complement by binding to soluble C5b-7 complex. The role of clusterin in relation to the naturally achieved tolerance in a rat orthotopic liver transplantation (OLT) has not been investigated before. Here we determined the kinetics of clusterin expression at different post-transplantation time points in a tolerogenic model (DA-PVG) where rejection was naturally overcome without any immunosuppressive drugs in comparison with the syngenic OLT model (DA-DA). Peripheral blood and liver tissues were taken from OLT at various post-operative time points. A strong expression of soluble clusterin was observed on post-transplantation day 7, which occurred at the peak of the rejection in this tolerogenic OLT model. The expression of clusterin remained strong even after tolerance was achieved. The intensity of clusterin expression was much stronger when compared with the syngenic OLT (DA-DA) model after OLT. A strong expression of clusterin mRNA was also observed in the tolerogenic model on post-OLT day (POD) 7 and the expression persisted when compared with the syngenic model on post-OLT day 60. Our data have shown that the strongest levels of clusterin during the reaction phase in tolerogenic OLT may be involved in tolerance induction.