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La decision de la justice de condamner l’Etat pour inaction climatique est une occasion de s’interroger. Que peut faire au juste l’Etat ? qu’attendent de lui les associations ecologiques ou les entreprises ? Quelles mesures sont applicables, lesquelles soulevent des difficultes ou de fortes reticences ? Comment s’articulent l’Etat, l’Europe et les collectivites locales ? Les recours judiciaires pousseront-ils efficacement les autorites a respecter leurs engagements ou provoqueront-ils leur frilosite ?

Resume La mise en place de la couverture sante universelle est un des principaux objectifs du developpement en sante. Le systeme d’assurance maladie, peu a peu mis en place dans un pays developpe, ne peut pas etre transpose tel quel dans un pays en developpement. Pour autant, les lecons tirees de cette mise en place peuvent etre utiles pour les pays s’engageant vers la couverture sante universelle. Dans un tel but, cinq exigences principales ont ete identifiees : la volonte politique ; l’effectivite de l’offre de soins ; la largeur de la population couverte, plutot que l’exhaustivite des soins pris en charge ; l’obligation assurantielle ; le controle des depenses liees aux soins.

RÉSUMÉ Le Règlement Sanitaire International est le principal instrument légal pour la prévention de la propagation internationale des maladies, en particulier liées à des agents infectieux. Il incite en particulier à des échanges de prélèvements entre pays. Ces échanges sont aujourd’hui influencés par l’attente exprimée, par de nombreux pays, d’un partage des bénéfices résultant des échanges de prélèvements. Dans le domaine des virus influenza, l’Accord international de 2011 sur la préparation à une pandémie grippale y apporte une réponse. Le contexte de ces échanges est aussi modifié par les progrès en génétique. Le Protocole de Nagoya entré en vigueur en 2014 constitue le nouveau cadre international de l’utilisation des ressources génétiques, y compris touchant les pathogènes. Il aura un impact favorable en termes de santé publique s’il facilite les échanges et permet un partage international des avantages découlant des ressources génétiques liées aux pathogènes. Une telle évolution est possible si la mise en œuvre du Protocole prend appui et modèle sur l’Accord-cadre pour la préparation à une pandémie grippale.

RESUME Un conflit d’interet a ete defini comme une situation d’interference entre une mission de service public et l’interet prive d’une personne qui concourt a l’exercice de cette mission. Initialement, la reflexion sur le sujet a surtout ete orientee vers la securite sanitaire et l’independance de l’evaluation des risques et de leur gestion. La qualite d’expert est etroitement liee a l’experience, aboutissant a l’assimilation des qualifications de specialiste et d’expert. Il est alors presque ineluctable que l’expert medical ait eu ou ait un lien d’interet avec les firmes pharmaceutiques et les fabricants de dispositifs medicaux. Paradoxalement, alors que les exigences sur les liens d’interets des experts sont de plus en plus pregnantes, depuis quelques annees le populisme scientifique et la suspicion generalisee vis-a-vis de toute decision ont abouti a contester les expertises. Les conflits d’interet ont ete definis de facons de plus en plus pertinentes et precises qui ont entraine une grande complexite des procedures et l’elimination inutile de candidats utiles. La collegialite de l’expertise minimise les risques que l’expertise soit entachee, mais expose a des influences predominantes. L’independance de jugement et l’objectivite des experts peuvent et doivent etre controlables et controlees par l’expertise methodologique a partir de donnees factuelles et de leurs niveaux de preuve. De facon generale, c’est a l’organisme qui sollicite les experts de se garder des marges de manœuvre suffisantes pour determiner des regles de comportement qui leur paraissaient adaptees aux questions particulieres qui se posent. Le role d’expertise des Academies par l’independance de ses membres, leur pluridisciplinarite, leur declaration de liens d’interet pourraient aujourd’hui en faire des instances privilegiees d’expertise.

Le cycle naturel du carbone met en jeu de vastes echanges biogeochimiques entre la biosphere, l’atmosphere et l’ocean. Ces echanges sont aujourd’hui en desequilibre a cause des emissions anthropiques de CO2 issues essentiellement de la combustion d’energie fossile et aggravees par la deforestation. Le surplus d’emissions de CO2 dans l’atmosphere s’accumule et provoque le phenomene du rechauffement climatique.Si la moitie de ce surplus est reabsorbee par des puits de carbone naturels – dissolution de CO2 dans l’ocean, conversion photosynthetique par la biosphere... –, le rechauffement deja en cours risque de reduire la capacite d’absorption de ces derniers. L’homme peut agir, en premier lieu, en reduisant les emissions de CO2 dont il est responsable. Il peut egalement maximiser l’efficacite de trois puits de carbone dont les capacites sont a meme de reduire notablement l’accumulation atmospherique de CO2 : la transformation de l’usage des sols, le stockage geologique de CO2 et, enfin, la transformation du CO2 en divers produits.C’est par une meilleure complementarite entre ces differentes approches que la lutte contre le rechauffement climatique sera la plus efficace.

The International Health Regulations are the main legal instrument to prevent the international propagation of diseases, particularly related to infectious agents. It supports the exchange of samples between countries. These exchanges have raised expectations, in many countries, about the sharing of the benefits resulting from these exchanges. About influenza viruses with pandemic potential, the 2011 pandemic influenza preparedness framework Agreement is a response to these expectations. These exchanges are also influenced by the progress made in genetics.The Nagoya Protocol, which came into force in 2014, creates a new framework concerning the use of genetic resources, including about pathogens. It will have a positive impact on public health, if it facilitates the exchanges of gene sequence data about pathogens and if it permits benefits sharing internationally. Such a result is possible, if its implementation builds upon the pandemic influenza preparedness framework Agreement.

Mad cow disease: 20 years after. Twenty years after the peak of the mad cow disease crisis, an overview was made by the National Food Council about the public health consequences, scientific advances, management measures taken to control the disease, persistent uncertainty about long-term impact on human health, and the difficulty to communicate in such a critical context. An in depth work to follow and explain the evolution of food production and transformation methods is indispensable. In a critical phase, the expression of the multiple actors requires to be made as coherent and coordinated as possible.La vache folle : 20 ans après. Vingt ans après le pic de la crise de la vache folle, le Conseil national de l'alimentation a voulu tirer des leçons de la crise en termes de communication. Après un bilan des conséquences de santé publique, des avancées scientifiques, des mesures de gestion qui ont été prises pour maîtriser la maladie, et des incertitudes persistantes pour la santé humaine, les difficultés de communication dans un tel contexte ont été analysées. Un travail de suivi et de pédagogie sur l'évolution des techniques de production dans le secteur agroalimentaire est indispensable. En période de crise, l'expression des multiples acteurs de ce secteur gagne à être rendue aussi cohérente et coordonnée que possible.

La pandemie de COVID-19 a joue un role de catalyseur des tensions internationales, en particulier entre la Chine et les Etats-Unis. Le president americain a fortement critique l’Organisation mondiale de la sante, accusee de servir les interets de Pekin et d’inefficacite. Pourtant, cette organisation a agi avec celerite et a facilite la cooperation sanitaire internationale. Elle œuvre notamment a la production d’un vaccin qui pourrait etre considere comme un bien public mondial.

Health international agreements: what are they? for what purpose?. Under the auspices of the World Health Organization, the efforts made to strengthen public health at the world level are reflected in three international agreements. The commitment of Member States to contribute to the protection of the health of the world population is underlined in the International Health Regulation and in the Pandemic influenza preparedness Framework. The Framework Convention on tobacco control aims at protecting the population of each Member State from the major health risks linked to tobacco use.Quels sont et à quoi servent les accords internationaux de santé ?. Trois accords internationaux soulignent les efforts faits, sous l’égide de l’Organisation mondiale de la santé, en vue de renforcer la santé publique au niveau mondial. Le Règlement sanitaire international et le Cadre de préparation en cas de grippe pandémique soulignent l’engagement des États membres à contribuer à la protection de la santé de la population mondiale. La convention-cadre de lutte anti-tabac vise à protéger la population de chaque État membre vis-à-vis du risque sanitaire majeur auquel expose l’usage du tabac.

Une analyse de difficultes et leviers d’action lies a la coproduction de l’evaluation, visant a en accroitre la qualite et la legitimite, est conduite dans le champ de l’enseignement superieur et de la recherche. Elle porte sur des entites de tailles variees, s’echelonnant de programmes d’enseignement superieur a des grands organismes de recherche, en passant par des unites de recherche et par des universites. La coproduction de l’evaluation prend des formes variees, selon les differentes etapes du processus d’evaluation. Sa methode permet de mieux repondre aux attentes des differentes categories de destinataires de l’evaluation et constitue en cela un facteur de qualite et de legitimite de l’evaluation. En revanche, la methode de coproduction de l’evaluation ne permet de faire face, ni a des critiques radicales de l’evaluation, ni a des attentes quant a la demonstration de l’impact de l’evaluation sur la qualite des resultats des activites des entites evaluees.

Le secteur des transports doit faire face a des mutations profondes : il doit repondre a une demande de mobilite toujours croissante aussi bien pour le transport des biens que pour celui des personnes, tout en integrant les contraintes environnementales locales, liees a la pollution et a la qualite de l’air, et globales, liees a ses emissions de CO2 qui representent un quart des emissions mondiales.Ce secteur, toujours dependant a hauteur de 90 % des carburants issus du petrole, doit se transformer dans ses differents segments (vehicules, camions, bateau, avion…) et contribuer au developpement des technologies bas carbone, comme les biocarburants, le gaz, le moteur electrique ou l’hydrogene.Decarboner le secteur des transports pour construire une mobilite durable est un enjeu majeur qui necessitera de repenser non seulement les motorisations et les carburants, mais aussi la gestion du trafic et de l’infrastructure, et demandera meme une modification des comportements afin de pouvoir proposer les solutions pertinentes de demain.

Despite major changes in its composition over the past two decades, the French health security infrastructure, currently consisting of eight agencies, has endured. This infrastructure has reinforced the French state's capacity to protect the health of its population, but it did not yet provide total protection. The future of national health agencies will depend on their ability to maintain the priority given to public health security ; to preserve credible, high-level scientific expertise ; to meet the challenges of healthcare safety ; and to organize health security at the European level.

The Direction generale de la sante, created fifty years ago as part of the French Ministry of Health, is devoted to public health. Among the current challenges which the Direction generale de la sante must meet are various types of potential health crisis, preparing the country for major health threats, reinforcing disease prevention and risk management, coordinating health institutions at the national level, and promoting French health policies within Europe and internationally.

The aim of this study was to review our experience in orthotopic liver transplantation (OLT) for biliary atresia (BA) in children and analyze the survival and prognostic factors, and long-term outcome. We reviewed 332 OLTs performed in 280 children between the years 1986 and 2000. Univariate and multivariate analysis were performed on patient and graft survivals according to recipients' and donors' characteristics as well as intraoperative data. The long-term outcome among the 80 children living at 10 years after OLT was studied according to growth, immunosuppressive therapy, and liver and renal functions. Liver graft status was eventually documented by liver biopsy. Status of rehabilitation was assessed by reviewing school performance and employment. Overall patient survival rates at 1, 5, and 10 years were 85, 82, and 82%, respectively, and the corresponding overall graft survival rates were 77, 73, and 71%. In the multivariate analysis, we identified 4 independent prognostic factors: polysplenia syndrome (P = .03), United Network for Organ Sharing (UNOS) status (P = .05), donor's age (P = .01), and perioperative surgical complications (P = .03). At 10 years after transplant, 80 children were alive and had normal growth rates. Liver histology was abnormal in 73% of these long-term survivors, mainly due to chronic rejection and centrilobular fibrosis. A total of 63 of the 80 children attended normal school and in 55 children (69%) school performance was not delayed. In conclusion, we discovered that a good long-term survival could be achieved after liver transplantation for BA, with a 82% survival rate at 10 years with normal scholastic studies in the majority of recipients.

Background. The aim of this study was to evaluate calcineurin activity and interleukin-2 (IL-2) expression by peripheral blood cells as a means of assessing the immune status of liver transplant recipients. Methods. Twenty-one patients were studied in a randomized study comparing cyclosporine and tacrolimus as the main immunosuppressive drug. Calcineurin activity was determined after separation of phosphorylated and dephosphorylated products of a calcineurin specific peptide substrate by high performance liquid chromatography (HPLC). Intracellular IL-2 expression was measured by flow cytometry. In 34 additional patients, intracellular IL-2 expression was prospectively measured. Results. Calcineurin activity fell after transplantation. Values were marginally higher in patients with acute rejection (P=0.059). The percentage of IL-2-producing T cells fell after transplantation. This percentage did not differ between patients with and without rejection. In contrast, the proportion of IL-2-producing CD8+ T cells was higher in patients with acute rejection than in patients free of acute rejection (P=0.003). Moreover, pretransplantation IL-2 expression by CD8+ T cells was higher in patients who subsequently developed acute rejection, suggesting that IL-2 production may be constitutively higher in those patients. The results obtained in the 34 additional patients confirmed these results. Conclusions. These data suggest that quantification of intracellular IL-2 in CD8+ T cells may be a useful index of immune status in liver transplant recipients. Preoperative IL-2 levels might serve to individually tailor the immunosuppressive regimen.

Background. The activity of interleukin (IL)-15, a cytokine produced by macrophages, is similar to that of IL-2. We investigated whether IL-15 plays a role in liver allograft rejection. Methods. We evaluated plasma levels and intrahepatic expression of IL-15 in 35 patients after liver transplantation, and then analyzed in vitro the influence of anticalcineurin drugs or steroids on IL-15 production and secretion. Finally, we examined the effects of IL-15 on lymphocyte proliferation in mixed lymphocyte culture in the presence or absence of anticalcineurin drugs or steroids. Results. Plasma levels and in situ expression of IL-15 were enhanced during liver allograft rejection, particularly during steroid-resistant acute rejection and during chronic rejection. In vitro, IL-15 production and secretion were inhibited by neither anticalcineurin drugs nor steroids. Exogenous IL-15 enhanced cell-mediated immune response, and this effect was not inhibited by immunosuppressive drugs. Conclusions. IL-15 can play a role in the initiation and outcome of acute and chronic rejection. Anti-IL-15 therapy in combination with classic immunosuppression therapy might thus be beneficial in the prevention of acute, and especially chronic, allograft rejection.

Backround. Recent advances in gene transfer technology render gene therapy an attractive treatment of disseminated liver metastases for which other treatments remain disappointing. In this setting, total vascular exclusion of the liver could improve gene transfer to cancer cells and prevent extrahepatic vector spreading during portal infusion of therapeutic genes. We evaluate the efficiency of combined herpes simplex virus type-1 thymidine kinase (HSV1-TK) and interleukin-2 retrovirus-mediated gene transfer through the portal vein, under total vascular exclusion of the liver, in a model of macroscopic multiple liver metastases in rats. Methods. Multifocal liver metastases were established in BDIX rats with intraportal injection of DHDK12 colon cancer cells. On randomization, rats received either vector-producing cells or saline solution under total vascular exclusion of the liver. Vector-producing cells released retroviral vectors encoding Lac-Z in marking studies or HSV1-TK or interleukin-2 in therapeutic studies. Rats were either killed for pathologic studies, or followed for survival. Results. Total vascular exclusion of the liver markedly improved gene transfer efficacy in marking studies. In therapeutic studies we observed a significant reduction in tumor volume of treated rats compared with untreated controls (2170 ± 310 mm 3 ). Although singular HSV1-TK or interleukin-2 gene transfer showed significant efficacy, the greatest tumor volume regression was observed in rats treated with combined HSV1-TK + interleukin-2 gene therapy (145 ± 60 mm 3 ; P =.0001 vs control). This translated into an increased median survival rate compared with either control rats ( P =.006) or rats treated with single gene therapy. Conclusion. In a rat model, a significant antitumoral effect against macroscopic multifocal liver metastases can be observed after retrovirus-mediated HSV1-TK and interleukin-2 gene transfer through the portal vein under total vascular exclusion of the liver, followed by ganciclovir administration. We believe that this well-tolerated and efficient therapeutic approach deserves clinical evaluation in patients with disseminated colorectal liver metastases. (Surgery 2003;133:669-77)

Background: Hyperacute rejection (HAR) of discordant xenografts in the pig-to-human combination can be prevented using tranplants expressing transgenic molecules that inhibit human complement. Hypodermin A (HA), a serine esterase that degrades C3, was tested in the guinea-pig-to-rat and in the pig-to-human combinations. Methods: Hypodermin A was tested in vitro, ex vivo, and in vivo models of HAR in the guinea-pig-to-rat combination. Hamster ovary cells (CHO) and a line of porcine aortic endothelial cells (PAEC11) were transfected with HA complementary DNA (cDNA). Results: The pattern of degradation of rat and human C3 by HA was different (multiple bands lower than 40 kDa) from the physiologic pattern observed after spontaneous degradation of rat C3 or physiologic activation of human C3. The CH50 activity in serum was significantly lower in rats treated with 3.2 mg HA/kg than in untreated rats (45 ± 16 U/ml vs. 700 ± 63 U/ml, P

P-glycoprotein (P-gp) and MDR1 mRNA expressions were assessed in tumoral and peritumoral specimens from patients with hepatocellular carcinoma (HCC) and in cirrhotic livers without HCC, using immunohistochemistry (C494 monoclonal antibody) and reverse transcription-polymerase chain reaction (RT-PCR) analysis. P-gp overexpression was detected in 24/28 tumoral livers (85%). In the peritumoral liver, staining was strong in cirrhotic nodules, and fainter in non-cirrhotic specimens. P-gp expression was as intense in the cirrhotic specimens free of HCC as in the peritumoral tissue of HCC developing in cirrhotic patients. These results were confirmed by RT-PCR analysis.

La repartition et l’attribution des organes aux malades en attente de greffe sont fondees sur les principes d’equite et d’efficacite medicale. Alors que l’ecart entre le nombre croissant de candidats a la greffe et le nombre d’organes preleves ne cesse de croitre, les organismes charges de l’organisation du prelevement et de la greffe ont developpe des systemes, parfois complexes, qui integrent les nombreux criteres medicaux, ethiques et logistiques qui doivent etre pris en compte. Les organes peuvent etre repartis a une equipe qui se charge de les attribuer au malade de son choix, ou directement attribues a un malade. L’organisation Eurotransplant utilise un systeme informatise centralise (ETKAS) qui calcule, au moment d’un prelevement de reins, un score pour chaque malade en attente, additionnant des points affectes a chaque critere choisi : appariement HLA, duree d’attente, distance entre le lieu de prelevement et la greffe, et ponderation entre les nations. Un nouveau systeme de score (MELD) a ete recemment mis en place aux Etats-Unis pour la repartition des foies. Il utilise des criteres biologiques mis au point par une etude de modelisation de la survie des malades. De tels systemes permettent d’ameliorer la transparence de la distribution des organes, de progresser vers l’equite d’acces a la greffe, et ils ont enfin demontre leur efficacite par rapport aux objectifs de sante publique et medicaux qui leur avaient ete fixes.

Resume La greffe de foie a debute dans les annees 1960 mais s'est reellement developpee a partir des annees 1980. Ses indications se sont constamment elargies et elle represente aujourd'hui un traitement efficace de l'insuffisance hepatique terminale. En 2000, 806 greffes de foie ont ete effectuees en France, contre 699 en 1999 et 693 en 1998 [1]. Elle est soumise a un encadrement juridique commun aux autres greffes d'organes, qui definit precisement l'organisation des activites de prelevement et de greffe. Elle pose cependant des questions specifiques sur le plan ethique. Celles-ci concernent essentiellement les difficultes a trouver un compromis entre la recherche de l'equite dans l'acces au greffon et la meilleure efficacite possible, ainsi que les problemes poses par le developpement des greffes hepatiques a partir de donneurs vivants.

Summary Background Because cadaveric organ donors are in short supply, living donors are increasingly being used in transplantations. We have developed a safe and reproducible method for laparoscopic liver resection. Methods Left hepatic lobectomy (resection of segments 2and 3) was done by laparoscopy in one woman aged 27years and one man aged 31 years. The grafts were prepared under laparoscopy, without any vascular clamping, and were externalised through a suprapubic Pfannenstiel incision. Both grafts were transplanted conventionally to the patients' respective sons, who were both aged 1 year and had biliary atresia. Findings Donor operations lasted 7 h for the woman and 6 h for the man, and warm ischaemia times were 4 and 10 min, respectively. Blood loss was 150 and 450 mL, respectively, and no transfusions were required. Neither patient had complications during or after sugery; and hospital stay was 7 and 5 days, respectively. Both recipients are alive and have excellent graft function. Interpretation We have shown the feasibility of laparoscopic living donor hepatectomy from parent to child. If the safety and feasbility of this procedure can be shown in larger series, laparoscopic donor left lobectomy could become a new option for paediatric living donor liver transplantation.

Resume But de l’etude : Le cœur isole perfuse (CIP) et la greffe cardiaque dans la combinaison cobaye/rat representent des modeles d’etude du rejet suraigu xenogenique (RSX) dans lequel le complement joue un role central. L’hypodermine A (HA), une protease qui degrade le complement en fragments non physiologiques, pourrait etre utilisee pour retarder le RSX. Materiel et methodes : Mise au point d’un systeme original de CIP fonctionnant avec du serum (30 mL) et etude ex vivo du RSX et de l’HA. Resultats : La duree moyenne de survie des cœurs de cobayes perfuses par des serums normaux de rats etait de 38 ± 7 min : elle etait inferieure a celle des cœurs de cobayes perfuses par des serums de cobayes (210 ± 34 min) (p Conclusion : Ce modele de CIP permet l’etude ex vivo du RSX. L’HA retarde l’apparition du RSX et confirme le role central du complement dans le RSX. Grâce a ses proprietes l’hypodermine A pourrait etre utilisee pour retarder l’apparition du RSX.

Thousands of patients throughout Europe undergo organ generally remain within Europe. However, it must be noted transplantation each year. This raises two questions from a that, in the field of organ transplantation, few organs are European perspective. The first regards the possible impact actually exchanged. This is mainly due to the general of the European construction on procurement and transorgan shortage. At the same time, patients living in areas plantation and the second, probably more unusual, regards with low procurement rates (such as southern Italy during the possible influence of procurement and grafts on the the 1980s) often seek transplantation in large numbers in European construction. other countries, such as France or Belgium. Our intention is to show that, contrary to common As far as regulation is concerned, there is currently no expectations, transplantation may be more useful to Europe European law or directive on the subject, nor does a than Europe is useful for transplantation. European body in charge of procurement and graft coordination and exchanges exist. However, despite the lack of common regulations, a European dimension of procure1. Is there a European dimension to transplantation? ment and transplantation is likely to develop in the near future, as demonstrated by the following examples: From an epidemiological point of view, common trends can be identified in most European countries with regard to • Grafts are specifically mentioned in article 152 (ex cerebral death prevalence and morbidity related to diseases article 129) of the Amsterdam treaty, thus offering many leading to transplantation indications. opportunities for developing measures at the European While facing similar problems, the various health care level. This point broadens the European field of compesystems have developed different responses. These differtence in health, traditionally restricted to preventive ences are most noticeable in policies regarding regional policies, and needs to be emphasized; planning, the establishment of hospital programs related to • In the related field of tissue banking, the European procurement and transplantation, and the number of teams Ethics Group in Science and New Technologies to the performing these activities. The mix between public and European Commission recently adopted an opinion on private sector participation also varies from one country to ethical aspects, focusing on the need for common high the next, as does the type of procurement organization. standards in safety and ethics. Clearly, this also has Procurement may be the responsibility of a national public implications for organ transplantation. agency, as in France, Spain, Portugal, and the United Kingdom, or of a private body operating nationally, as in Switzerland, or it may be the responsibility of several 2. What can Europe do for transplantation? countries at a European level, such as Eurotransplant, which includes Germany, Austria, Belgium, Luxembourg, Three main areas need to be addressed: ethics, graft and the Netherlands. availability, and safety. In terms of exchanges, patients, organs, tissues, and cells As far as ethical issues are concerned, harmonization efforts at the European level are likely to promote a high *Tel.: 133-44-67-5599; fax: 133-44-67-5555. 1 level of ethical standards. Some countries, such as France, A work from the Etablissement Francais des Greffes, 5, Rue Lacuee, 75012 Paris, France. by passing the so-called ‘Bioethics’ laws of July 23, 1994

The role of endothelin in the initial vasoconstrictor step of hyperacute xenogeneic rejection was investigated. Isolated rat livers were perfused in recirculation. Perfusion with human sera provided an ex vivo model of hyperacute rejection in a discordant combination. Perfusion of 10% xenogeneic serum induced a marked (70%) and sustained reduction of the liver flow and induced the release of endothelin into the perfusion medium. In contrast, perfusion of 10% allogeneic serum or of 10% decomplemented human serum induced a weak (25%) and transient reduction of the liver flow and induced the release of minimal amounts of endothelin. The simultaneous administration of BQ 123 and BQ 788, the respective antagonists of ETA and ETB endothelin receptors, or that of bosentan, a mixed ETA/ETB antagonist, antagonized the vasoconstrictor effect of 10% xenogeneic human serum, as well as that of 10−9 M endothelin-1. The vasoconstrictor effects of xenogeneic serum on liver circulation are, at least partly, mediated through the release of endothelin by the graft. British Journal of Pharmacology (2000) 130, 402–408; doi:10.1038/sj.bjp.0703295

Background. Orthotopic liver transplantation (OLT) is widely used to treat patients with end-stage liver disease. However, data on the cost of the procedure are fragmentary. We evaluated the costs, as calculated from resource use, and outcomes of OLT in adults, from registration on the transplant waiting list to the end of the 1st-year of follow-up after the transplant. Methods. Two parallel cohort studies were conducted from 1994 to 95. All patients ages 18 years and older, on the waiting list (n533) according to national criteria or having undergone transplants (n538) were followed for 1 year or until either the transplant (waiting list cohort) or death (waiting list and transplantation cohorts). Results. Eighty percent of the patients undergoing transplants were alive after 1 year, and no patient died while on the waiting list. However, the estimated cost of the procedure was high: more than £55,000 for the 1st year after OLT, to be added to £5,500 for evaluation and further costs motivated by the planned transplant during an average 6.5 months on the waiting list. Age over 40 and a baseline Child-Pugh score of 10 and over were predictive of high costs. The proportion of costs associated with immunosuppressive therapy and rejection were very high. Conclusions. This medical and economic cohort study suggests that OLT is still expensive; the study identifies sources of extra cost that could be limited either by improved selection of patients or, in the future, by technological advances in immunosuppressive therapy that help avoid medical complications. It also suggests the situation is precarious, with outcomes and costs being very sensitive to variation in graft availability.

Suicide gene therapy based on ganciclovir (GCV) metabolism by transgene herpes simplex thymidine kinase (HSV-1 TK) has been used to selectively kill proliferating cells in clinical settings such as cancer, vascular restenosis, and immunological disorders. We investigated whether encapsulation of ganciclovir (GCV) into liposomes would improve its efficacy, especially against hepatic tumors. Large unilamellar liposomes containing GCV were prepared by reversed-phase evaporation. Pharmacokinetic studies in rats showed that, compared with free GCV, the intravenous injection of liposome-encapsulated GCV (lip-GCV) led to a faster decrease in GCV plasma concentrations, but higher liver-blood ratios. After treatment of syngeneic HSV-1 TK+ liver metastases in rats, histologically active tumors were found in 95% of the transplanted lesions when physiological saline had been given and in 50% when free GCV had been given at 90.2 microM/kg twice daily. This dose is known to be insufficient for the eradication of HSV-1 TK+ tumors. In contrast, only 5% viable tumors were found in rats receiving lip-GCV at this same concentration. Average tumor volumes were 19 +/- 15, 7 +/- 9, and

Controlling the S phase of the hepatocyte cell cycle would be of considerable help for stable retroviral foreign gene transfer. The aim of this article is to study hepatocyte regeneration during S phase in isolated, perfused rat liver followed by liver transplantation. Normal livers (G I: n = 7) were perfused with blood from normal rats for 6.1+/-0.3 hours. Regenerating livers (G II; n = 7) obtained 18 hours after partial hepatectomy were perfused for 6.0+/-0.3 hours with blood from rats partially hepatectomized 18 hours before. Regenerating livers (G III; n = 7) obtained 22 hours after partial hepatectomy were perfused for 2.4+/-0.1 hours with blood from normal rats. In the normothermal perfusion system, a bolus of 25 mg of 5-bromo-2'-deoxyuridine (BrdU) was added to the perfusate. Liver biopsies were taken at the end of each experiment. In group II, a biopsy was also taken 1 hour after BrdU introduction. At the end of each experiment, livers were orthotopically transplanted. The percentage of BrdU positive hepatocyte nuclei was 0.2% in G I; 14.8% and 38.4% after 1 hour and 6.1 hours, respectively, in G II; and 46.5% after 2.4 hours in G III. In G I, five rats died at day 1, 5, 6, 7, and 48 and two rats were still alive after 17 months. In G II, all the rats died before day five. In G III, two rats died at day one, one at day six, and four were still alive after 12 months. This study shows that, after 6 hours of normothermal perfusion, organ viability allows successful liver transplantation and that rat hepatocyte regeneration during cell cycle S phase in isolated normothermal conditions progresses in a similar way-quantity and timing-to liver regeneration found in vivo after partial hepatectomy.

Background/Aims: Early liver transplantation is crucial in children with liver disease and pulmonary artery hypertension. Some severe pulmonary vascular anomalies associated with portal hypertension disappear after isolated liver transplantation. Evolution of pulmonary artery hypertension due to plexogenic arteriopathy is controversial, as this association is still considered a contraindication to isolated liver transplantation. Outcome of pulmonary hypertension after isolated liver transplantation is reported in three patients with portal hypertension. Methods: After echocardiographic diagnosis, the patients had a complete hemodynamic exploration, and two had a lung biopsy. After liver transplantation, the survivors had echocardiographic follow up and a second hemodynamic exploration. Results: In two children, pulmonary pressures and resistances returned to near-normal values 1 and 6 years after successful isolated liver transplantation. The third patient, with the most severe arteriopathy, had to wait 1 year for a donor, and the attempted transplantation was complicated by ventricular tachycardia; death occurred 2 days after surgery. Conclusions: Liver transplantation can reverse pulmonary artery hypertension due to high pulmonary resistances complicating liver disease with portal hypertension, provided it is carried out at an early stage. Early detection of pulmonary hypertension by systematic echocardiography may thus be crucial in these children with portal hypertension.

The establishment of cell lines allows reproductible in vitro studies that would be far more difficult to perform using primary cells that rapidly undergo phenotypical alterations in culture. The purpose of this work was to establish an endothelial cell line appropriate for in vitro study of endothelial cell activation during xenograft rejection. Porcine aortic endothelial cells were transfected with the early region of SV40 and selected on the basis of morphological, phenotypical, and functional features. By light and electron microscopy, the porcine aortic endothelial cell line (PAEC11) and primary cells were similar except that PAEC11 was slightly smaller. PAEC11 displayed endothelial cell characteristics since it endocytosed acetylated low density lipoproteins, produced von Willebrand factor, and expressed E-selectin. Human natural antibodies bound to the same xenoantigens on PAEC11 and primary cells. That binding was followed by human complement activation and cell lysis. In addition, PAEC11 was found appropriate for genetic engineering since it could be transfected with a plasmid encoding a foreign gene. Therefore, this cell line should be a useful model for in vitro study of endothelial cell function in general and human-to-swine xenograft rejection in particular.

We investigated which endothelin receptors mediate the vasoconstrictive effects of endothelin-1 on liver circulation.An isolated perfused rat liver model in recirculation was used.The perfusion of 10(-10) M endothelin-1 had no significant influence on the liver flow, whereas 10(-9) M endothelin-1 induced significant vasoconstriction, with flow dropping from 3.20 +/- 0.34 to 1.48 +/- 0.28 ml. min-1.g-1 liver tissue (p0.01 vs controls). The liver flow was interrupted following the perfusion of 10(-8) M endothelin-1. Sarafatoxin C and BQ 3020, two agonists of ETB receptor, had vasoconstrictive effects in this model. Sarafatoxin C decreased the liver flow in a dose-dependent manner, from 3.32 +/- 0.21 to 2.18 +/- 0.20, 1.60 +/- 0.09, and 1.01 +/- 0.06 ml.min-1. g-1, respectively, with 10(-9) M, 10(-8) M, and 10(-7) M. While BQ 123, an antagonist of ETA receptor, or BQ 788, an antagonist of ETB receptor, partially reversed the effect of 10(-9) M endothelin-1, the simultaneous administration of BQ 123 and BQ 788 completely reversed these effects.These results indicate that the vasoconstrictive effects of endothelin-1 on the liver circulation are mediated through both ETA and ETB receptors.

Between June 1990 and September 1995, 8 of 24 children with cystic fibrosis (CF) who were accepted either for combined transplantation or isolated liver transplantation died while waiting for a graft; 11 underwent transplantation and 5 are currently on the waiting list. Of the 11 children who had surgery, 7 (group 1) underwent one of the following procedures: heart-lung-liver (n = 4), sequential double lung-liver (n = 2), or bilateral lobar lung from a split left lung and reduced liver (n = 1). During the same period, the four other children (group 2) underwent isolated liver transplantation (three full-size livers, one partial liver). There was one perioperative death in each group. Pulmonary infection was the most common cause of morbidity in group 1. Other complications in group 1 included tracheobronchial stenosis (n = 2), biliary stricture (n = 2), and severe ascites (n = 2). All were successfully treated. Obliterative bronchiolitis developed in three patients. This was treated with FK 506. In group 2, pulmonary function tests improved or remained stable after liver transplantation. Surgical complications in group 2 included severe ascites (n = 1), biliary stricture (n = 1), and abscess of the liver (n = 1). Actuarial survival was 85.7% +/- 2% in group 1 at 1 year; it remained unchanged at 3 years and was 64.2% at 5 years.

The authors describe their experience with liver transplantation (OLT) for metastatic endocrine tumors (MET) in order to determine reasonable indications for OLT in patients with this disease. Removal of the primary lesion and subsequent liver transplantation were performed in two separate procedures in all patients except one. Only those patients suffering from objective tumor progression and symptoms with no evidence of extrahepatic spread after complete work-up (including endoscopic ultrasonography (US) and 123I-labeled Tyr3-octreotide body scanning) underwent liver transplantation. Fifteen patients were referred for liver transplantation. Seven patients were excluded either because of stability of liver metastases (n = 3), extrahepatic spread, general contraindication (n = 2), or feasibility of aggressive surgical resection (n = 2). Liver transplantation was undertaken in eight patients with carcinoid tumor (n = 4), gastrinoma (n = 3) and glucagonoma (n = 1). Three patients did not survive the surgical procedure itself, whereas two additional patients died from chronic rejection or from recurrent disease. Three patients who received transplants for metastatic carcinoid tumor are alive without biochemical or imaging evidence of disease recurrence at 6, 15, and 52 months. The best indication for transplantation seems to be patients with metastases restricted to the liver and unresponsive to adjuvant therapy after aggressive surgical resection including excision of the primary lesion and reduction of hepatic metastases. In such highly-selected patients, liver transplantation remains a high-risk operation, but it can yield long-term survival.

A multicenter randomized trial was performed to compare two immunosuppressive protocols after first ABO-compatible liver transplantation. Forty six patients were randomized to a 14-day treatment with Orthoclone (OKT3) in association with steroids and azathioprine, cyclosporine being progressively introduced on day 11 posttransplant. Fifty patients were randomized to a standard protocol of cyclosporine with steroids and azathioprine. Minimum follow-up was 1 year and graft and patient survivals were updated for the purpose of the study. The cumulative 1-year incidence of acute rejection tended to be greater in the cyclosporine group (75%) than in the OKT3 group (67%), especially when patients who did not receive full-course treatment with OKT3 were excluded (59%). Renal function was better preserved during the first two postoperative weeks in the OKT3 group than in the control group but plasma creatinine levels were comparable in both groups thereafter. The incidence of severe infections was lower in the OKT3 group (13.6%) than in the cyclosporine group (32%). The 4-year incidences of patient and graft survival in the OKT3 group (69% and 61%, respectively) were not different from those in the cyclosporine group (62% versus 54%, respectively). Thus this prospective trial shows that OKT3 immunoprophylaxis is a safe alternative to cyclosporine immunoprophylaxis in unselected recipients of a first liver graft.

Hyperacute rejection is rare after liver transplantation. We report a case of early graft failure following liver transplantation in a 46-year-old woman. On the 5th postoperative day, progressive loss of graft function occurred. Liver histology showed submassive hepatic necrosis. Computed tomography features showing large geographic areas of necrosis without anatomic distribution were suggestive of hyperacute rejection.

Complement activation is central to the rejection of discordant xenografts. In order to assess the respective roles of direct and alternative pathways, an in vitro model of hyperacute rejection in the swine-to-human donor-recipient combination was designed, using a complement-dependent cytotoxicity test with swine endothelial cells in culture as targets, and fresh human serum as the source of xenogeneic antibodies and complement. The cytotoxic activity of the sera was evaluated by a colorimetric assay using (3-[4,5-dimethyldiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT). Pure human serum lysed 58 +/- 5% of swine endothelial cells. Selective inhibition of the direct pathway by adding EGTA to the serum reduced cytolysis to 51 +/- 2% (P < 0.01 versus normal serum). Similarly, when using C1q-deficient human sera, only 37 +/- 7% of swine endothelial cells were killed (P < 0.001 versus normal serum). When the alternative pathway was selectively inhibited by heating for 20 min at 50 degrees C, the lytic activity of human serum dropped to 42 +/- 5% (P < 0.001 versus normal serum). Factor B-deficient human serum could only lyse 42 +/- 10% of porcine endothelial cells (P < 0.001 versus normal serum). Syngeneic normal swine serum and heat-inactivated serum were not cytotoxic. Mixing serum with deficient direct pathway and serum with deficient alternative pathway restored the cytotoxicity to normal levels. Similarly, the cytotoxic activity of deficient serum supplemented with purified C1q or factor B at physiological concentrations reached that of normal human serum. In this model of in vitro hyperacute rejection, both pathways of complement activation are involved, suggesting that regimens designed to inhibit hyperacute rejection of swine xenografts into humans should take into account the dual activation of complement in this donor-recipient combination.

Liver transplantation has been considered until recently as an absolute contraindication in hypoxemic patients. We report our experience in nine patients who had orthotopic liver transplantation between June 1986 and June 1992. These patients had cirrhosis-related hypoxemia with intrapulmonary shunting (IPS). The arterial oxygen pressure (PaO2) on room air ranged from 47 to 78 mmHg. OLT resulted in resolution of hypoxemia and closure of IPS in five patients whose hypoxemia was higher than 60 mmHg, and in death for the remaining four patients who had severe hypoxemia (PaO260 mmHg). We conclude that hypoxemia is no longer a contraindication to liver transplantation. Patients having PaO2 levels higher than 60 mmHg should have OLT as soon as possible before reaching lower levels of PaO2, and combined lung-liver transplantation or heart-lung-liver transplantation should be discussed in patients with severe hypoxemia (PaO260 mmHg).