Objective Tolerogenic DCs (Tol-DCs), a group of cells with imDC phenotype, can stably induce T cells low-reactivity and immune tolerance. We systematically reviewed the adoptive transfusion of Tol-DCs induced by different ways to prolong cardiac allograft survival and its possible mechanism. Method MEDLINE (1966 to March 2011), EMbase (1980 to March 2011), and ISI (inception to March 2011) were searched for identification of relevant studies. We used allogeneic heart graft survival time as endpoint outcome to analyze the effect of adoptive transfusion of Tol-DC on cardiac allograft. By integrating studies’ information, we summarized the mechanisms of Tol-DC in prolonging cardiac grafts. Results Four methods were used to induce Tol-DC in all of the 44 included studies including gene-modified, drug-intervened, cytokine-induced, and other-derived (liver-derived amp; spleen-derived) DCs. The results showed that all types of Tol-DC can effectively prolong graft survival, and the average extension of graft survival time for each group was as follows: 22.02 ± 21.9 days (3.2 folds to control group) in the gene modified group, 25.94 ± 16.9 days (4.3 folds) in the drug-intervened groups, 9.00 ± 8.13 days (1.9 folds) in the cytokine-induced group, and 10.69 ± 9.94 days (2.1 folds) in the other-derived group. The main mechanisms of Tol-DCs to prolong graft survival were as follows: a) induceT-cell hyporeactivity (detected by MLR); b) reduce the effect of cytotoxic lymphocyte (CTL); c) promote Th2 differentiation; d) induce Treg; e) induce chimerism. Conclusion For fully MHC mismatched allogeneic heart transplant recipients of inbred mouse, adoptive transfusion of Tol-DC, which can be gene-modified, drug-intervened, cytokine-induced, spleen-derived or liver-derived, can clearly prolong the survival of cardiac allograft or induce immune tolerance. Gene-modified and drug-induced Tol-DC can prolong graft survival most obviously. Having better reliability and stability than drug-induction, gene-modification is the best way to induce Tol-DCs at present. One-time intravenous infusion of 2 × 106 Tol-DC is a simple and feasible way to induce long-term graft survival. Multiple infusions will prolong it but increase the risk and cost. Adoptive transfusion of Tol-DC in conjunction with immunosuppressive agents may also prolong the graft survival time.
Abstract: Objective To study the antiacute rejection effect of Pachymic acid (PA) in heart transplantation rats, in order to select a new antirejection medicine with low side effect from traditional Chinese medicine. Methods We established the model by transplanting Wistar rats (32,donor) heart allografts into the abdomen of SD rats (32,receptor). The homologous hearttransplanted rats were then randomly divided into 4 groups with 16 rats in each group. Olive oil solution with PA 1 mg/(kg·d), PA 10 mg/(kg·d), Cyclosporine (CsA) 5 mg/(kg·d) and olive oil solution 0.5 ml/(kg·d) were respectively given intragastrically to lowdosage PA group, highdosage PA group, CsA group and the control group till the end of observation. Survival time of heart allografts, heart beating and the histological changes of allografts were examined and serum level of interleukin2 (IL-2) and interferon-γ (IFN-γ) were determined by enzymelinked immunosorbent assay (ELISA). Results Survival time in the highdosage PA group, the lowdosage PA group and the CsA group were 24.90±0.99 d, 15.50±1.60 d and 26.80±0.88 d respectively, which is much better than the control group (6.10±1.10 d, q=22.363, P=0.000; q=44.793, P=0.000; q=49.272,P=0.000). IL-2 serum level in the highdosage PA group, the lowdosage PA group and the CsA group were all lower than that in the control group (q=14.483, P=0.000; q=3.705, P=0.000; =21.418,P=0.000), whileIL-2 serum level in the highdosage group was lower than that in the lowdosage group (q=10.778,P=0.000). Similarly, IFN-γ serum level in the first three groups were all lower than that in the control group (q=16.508,P=0000; q=4.281, P=0.000;q=19.621, P=0.000) and IFNγ serum level in the highdosage group was also lower than that in the lowdosage group (q=14.975, P=0.000). Pathological examination 7 days after the surgery showed that pathologic lesion was much more relieved in the two PA groups and the CsA group than the control group. Conclusion Acute rejection of heart transplantation can be effectively suppressed by PA.
Objective To investigate the effect of alltrans retinoic acid (atRA) on proliferative artery disease after heart transplantation. Methods Heterotopic heart transplantation model was established by Ono model with 16 inbred healthy male Wistar rats as donors and 16 SD rats as recipients. The rats were divided into chronic rejection group and atRAtreated group by complete random design, and there were 8 rats in each group. Rats in chronic rejection group were given Cyclosporine A 10 mg/(kg·d) by subcutaneous injection after operation, and those in atRAtreated group were given Cyclosporine A 10 mg/(kg·d) in the same way and atRA 10mg/(kg·d) by gavage. The transplanted hearts of rats were taken out 60 days after the transplantation. HE stain, masson stain and Van Gieson were done to analyze the rejection of transplanted hearts, the degree of vascular stenosis and myocardial fibrosis respectively.Immunohistochemistry was used to test proliferating cell nuclear antigen (PCNA). Results The area of myocardial fibrosis in chronic rejection group was obviously larger than that in atRAtreated group（63.99%±11.91% vs.34.68%±6.34%）, and there was significant difference between two groups（t=8.377，P=0.000）. The index of vascular stenosis in chronic rejection group was higher than that in atRAtreated group（62.86±17.18 vs. 40.10±8.20）. Vascular stenosis in atRAtreated group alleviated significantly, and there was significant difference between two groups（t=3.913, P=0.006）. The PCNA positive cells in chronic rejection group were obviously more than that in atRAtreated group（60.17±17.74 vs. 33.96±8.65）, and there was significant difference between two groups（t=5.387, P≤0.001）. There was a positive correlation between the PCNA positive cell ratio and the index of vascular stenosis（r=0.854, P=0.007）. Conclusion Alltrans retinoic acid can inhibit vascular disease after heart transplantation by cell proliferative pathway.
Objective To summarize the experiences of donor heart procurement of heart transplantation so as to improve the efficiency of donor heart protection. [WTHZ]Methods [WTBZ]From April 2002 to October 2006, sixtyone patients with endstage heart disease had undergone orthotopic heart transplantation. Donors were all male brain deaths, aged from 21 to 53, and 5 of them were older than 40. There were 6 cases in which the weight difference between donor and recipient＞20%, and the rest ≤±20%. Fortyfive cases had the same ABO blood type, and 16 had matching ABO blood type. Four donor hearts were procured under the condition of stable hemodynamics and enough oxygen after brain death(typeⅠ), fortyfour donor hearts were procured under the condition of brain death with acute hemorrhage and hypovolemia (typeⅡ), and 13 donor hearts were procured under the condition of brain death with cardiac arrest (typeⅢ). Twenty cases underwent standard transplantation procedure, one underwent total heart transplantation procedure and 40 underwent bicaval transplantation procedure. The donor heart cold ischemic period ranged from 52 to 347 min（92±31 min）, and 13 cases were more than 240 min. Results Two cases died of low cardiac output syndrome on 7th and 9th day after operation respectively, and their donor heart cold ischemic period were 327 and 293 min respectively. The rest of patients all recovered and discharged. One died of acute rejection on 18th month after operation because of rejecting immunosuppressive agents, and 1 died in traffic accident on 23rd month after transplantation. The rest 57 cases survived 6-59 months(mean 35 months), and had good life quality with NYHA cardiac function classification in 0-I grade. Conclusions Heart transplantation with donor aged over 40 may also have satisfactory results. Patients with endstage dilated cardiomyopathy can procure donor heartsfrom donors with heavy weight. Using different techniques to procure donor hearts may furthest reduce myocardial injury. Donor hearts which have been protected by myocardium protecting liquid for a long time should be used with caution.
Objective To summarize and analyze the clinical outcomes and experiences of continuous renal replacement therapy(CRRT) in patients with acute renal insufficiency after heart transplantation. Methods There were 39 patients received orthotopic heart transplantation from September 2007 to September 2008 in Fu Wai hospital. Seven cases required the use of PRISMA CRRT machine (Gambro Healthcare,Inc.) because of acute renal insufficiency after heart transplantation, and received continuous venovenous hemodiafiltration(CVVHDF) treatment via M100 blood filter (hemofilters). Activated coagulation time (ACT) was maintained in 160200 s. Results Six survivals with New York Heart Association (NYHA)Ⅰdischarged ，1 case died of multiple system organ failure (MSOF) and severe infection. The time of CRRT was 48658 h, with an average of 252 h. Seven patients were oliguric or anuric during CRRT, but hemodynamics and internal environment were stable. After stopping CRRT, the creatinine level rose to 267.1±68.5 μmol/L， then the creatinine level decreased to normal range with urine increasing gradually. Postoperative glomerular filtration rate (GFR) was 56.5±19.0 ml/min， and there was no statistical significance compared with preoperative GFR（Pgt;0.05）. Six survivals were followed up for 513(9.7±3.8)months，and their creatinine level was in normal range(90.6±26.7 μmol/L). There was no statistical significance compared with the creatinine level at discharge (83.2±26.5 μmol/L, Pgt;0.05）. Conclusion The prognostic outcomes of patients with acute renal insufficiency after heart ransplantation are excellent after using CRRT. No significant renal dysfunction is found.
Abstract: Objective To summarize the surgical outcomes and clinical experience of surgical disease for patients having undergone orthotopic heart transplantation. Methods Five cardiac transplant recipients requiring surgical management due to other surgical diseases including acute cholecystitis in 2 patients, acute appendicitis, bilateral mammary hypertrophy and lung tumor in 1 patients, respectively. The mean age of the entire group at the time of reoperation was 44. 6 years (14-60 years) and the average time of operative procedures after transplant was 16. 4 months (4-37 months). Four patients were treated with t riple immunosuppression, including cyclosporine A (CsA ) or tacroimus, mycophenolate mofetil and corticosteroids, respect ively. One patient received double-therapy of CsA and mycophenolate mofetil withearly withdrawal of corticosteroids. All the acute cholecystitis and appendicitis patients underwent open cholecystectomy and appendectomy emergently. Reduction mammaplasty was performed on the bilateral mammary hypert rophy patients. For the lung tumor patient, right upper lobectomy and nodes excision were undertaken radically after the sample proved to be malignancy by the thoracoscopy. Closely surveillance at concentration of CsA or FK506 was performed continueously in o rder to adjust the effect ive blood concentration in a steady way by which acute rejection can be avoided. The pathways which pathogen organisms invading the human body were controlled strictly as well as intension on ant i-infection treatment during perioperative period. Results Four patients discharged to home within 2 weeks. Only one patient needed further treatment in Digestive Department after emergent cholecystectomy due to gastric retention. And shewas discharged after 66 days. No acute reject ions or operative complications such as severe infection or bleeding were found during the perioperative period. The average length of stay was 21. 3 days (8-66 days). During the fo llow -up from 1month to 13months, there was no relapse or allograft disfunction performed on any patients. All of them enjoy quality lives. Conclusions More attention should be paid to regular follow -up after transplantation, by which the emergent surgical diseases can be diagnosed and treated earlier and more effectively. Cardiac transplant recipients who subsequently require surgical intervention do quite well overall. Most of them can obtain excellent surgical outcomes.
Objective To insure early detection and hence efficient prevention of allograft rejection in transplanted heart, investigate possible applications of NAD(P)H fluorescence components analysis at the level of living cardiac cells to propose new approaches for diagnosis of rejection. Methods NAD(P)H was studied for noninvasive fluorescent probing of the mitochondrial function. Human cardiomyocyte were isolated from one additional endomyocardial biopsy (EMB) of 14 pediatric patients with heart ransplantation. Rat cardiomyocyte (n=5, 13-14 week old) were also isolated by the same approach for human myocytes. Autofluorescence(AF) was recorded in living cardiomyocytes following excitation with 375 nm UVlight and detection by spectrallyresolved time correlated single photon counting (TCSPC), based on the simultaneous measurement of the fluorescence spectra and lifetimes. Rat cardiac cells were divided into four groups: normoxic condition, normoxia with Rotenone, ischemic condition and ischemia with Rotenone. Comparison of cardiomyocyte AF between human and rat; compared kinetics of rat cardiomyocytes AF in normoxic conditions to ischemiamimicking ones, induced at physiological temperatures by reducing cell pH and oxygen content; comparison of cardiomyocyte AF dynamic changes in transplanted pediatric patients presenting either no rejection (R0) or mild rejection (R1). Results We have achieved appropriate isolation of living cardiomyocytes from human biopsies, as well as from rat cardiac tissues and determined their AF. At least a 3-exponential decay with 0.5-0.7ns, 1.9-2.4 ns and 9.0-15.0 ns lifetime pools is necessary to describe human cardiomyocyte AF within 420560 nm spectral range. Rat cardiomyocyte steadystate AF in ischemiamimicking condition was significantly increased when compared normoxic ones (Plt;0.05); application of Rotenone induced a significant increase in AF intensity in ischemic and normoxic condition, however no significant difference between the two groups (Plt;0.05).Human cardiomyocyte AF was found significantly lower in comparison to experimental rat model in the same condition(Plt;0.05). A correlation between changes in steadystate NAD(P)H fluorescence and rejection grades was found when comparison of R1 to R0. R1 showed significantly increased fluorescence intensity (Plt;0.05), without change in the spectra shape, results can be comparable to the effect of ischemiamimic conditions. Conclusion Our studies clearly demonstrated that spectrallyresolved fluorescence spectral analysis coupled to fluorescence lifetime are high sensitive approaches to examine mitochondrial metabolic oxidative state directly in living human cardiomyocytes with good reproducibility. Human cardiomyocytes are more metabolically active than the rat ones, while this activity (and thus ATP production) seems lowered during rejection process. In perspective, the advantage of this method is the possibility of its combination to multiphoton confocal microscopy, which can result in the adaptation of this approach directly to tissue biopsy, as well as in vivo directly via cardiac catheterization without the necessity of cell isolation. This approach provides promising new tool for clinical diagnosis and treatment of allograft rejection, and will enhance our knowledge about cardiomyocyte oxidative metabolism and/or its dysfunction at a cellular level.
Objective To analyze the relation between preoperative pulmonary artery pressure(PAP) and postoperative complications in heart transplant patients, and summarize the experience of perioperative management of pulmonary hypertension (PH), to facilitate the early period heart function recovery of postoperative heart transplant patients. Methods A total of 125 orthotopic heart transplant patients were divided into two groups according to preoperative pulmonary arterial systolic pressure(PASP) and pulmonary vascular resistance(PVR), pulmonary [CM(1583mm]hypertension group (n=56): preoperativePASPgt;50 mm Hg or PVRgt;5 Wood·U; control group (n=69): preoperative PASP≤50 mmHg and PVR≤5 Wood·U. Hemodynamics index including preoperative cardiac index (CI)，preoperative and postoperative PVR and PAP were collected by SwanGanz catheter and compared. The extent of postoperative tricuspid regurgitation was evaluated by echocardiography. Postoperative pulmonary hypertension was treated by diuresis，nitrogen oxide inhaling，nitroglycerin and prostacyclin infusion, continuous renal replacement therapy(CRRT)and extracorporeal membrane oxygenation(ECMO). Results All patients survived except one patient in pulmonary hypertension group died of multiorgan failure and severe infection postoperatively in hospital. Acute right ventricular failure occurred postoperatively in 23 patients, 10 patients used ECMO support, 10 patients with acute renal insufficiency were treated with CRRT. 124 patients were followed up for 2.59 months，7 patients died of multiple organ failure, infection and acute rejection in follow-up period, the survivals in both groups have normal PAP, no significant tricuspid regurgitation. No significant difference in cold ischemia time of donor heart, cardiopulmonary bypass(CPB) and circulation support time between both groups; but the patients of pulmonary hypertension group had longer tracheal intubation time in comparison with the patients of control group (65±119 h vs. 32±38 h, t=2.17，P=0.028). Preoperative PASP，mean pulmonary artery pressure(MPAP) and PVR in pulmonary hypertension group were significantly higher than those in control group, CI was lower in pulmonary hypertension group ［PASP 64.30±11.50 mm Hg vs. 35.60±10.20 mm Hg; MPAP 43.20±8.50 mm Hg vs. 24.20±7.20 mm Hg; PVR 4.72±2.26 Wood·U vs. 2.27±1.24 Wood·U; CI 1.93±0.62 L/（min·m2） vs. 2.33±0.56 L/（min·m2）; Plt;0.05］. Postoperative early PASP, MPAP and PVR in pulmonary hypertension group were significantly higher than those in control group (PASP 35.40±5.60 mm Hg vs. 31.10±5.70 mm Hg, MPAP 23.10±3.60 mm Hg vs. 21.00±4.00 mm Hg, PVR 2.46±0.78 Wood·U vs. 1.79±0.62 Wood·U; Plt;0.05). Conclusion Postoperative right heart insuficiency is related to preoperative pulmonary hypertension in heart transplant patients. Donor heart can quickly rehabilitate postoperatively by effectively controlling perioperative pulmonary hypertension with good follow-up results.
Objective To investigate the effects of human recombinant hepatocyte growth factor(rh-HGF) on the expression of c-Met in intima of allograft vessels after cardiac transplantation in rats. Methods Heterotopic heart transplantation were established in abdominal cavity with eighty Wistar rats and forty SD rats. Donors’ cardiac grafts from Wistar rats were transplanted to SD rats(allograft) or Wistar rats(isograft).Sixty recipient rats were divided into three groups, control group：20 Wistar rats were injected with normal saline 1ml/kg·d intraperitoneally after transplantation; cyclosporine A (CsA) group:20 SD rats were injected with CsA 5mg/kg·d intraperitoneally on operation day; rhHGF group:20 SD rats were injected with rh-HGF 500μg/kg·d and CsA 5mg/kg·d intraperitoneally on operation day. The cardiac grafts were harvested at the 15th day and 60th day after transplantation. The crosssection of vascular tissues were used for immunohistochemistrical staining of c-Met, and investigated the expression of c-Met messenger ribonucleic acid (mRNA ) in intima of allograft vessels by reverse transcriptionpolymerase chain reaction(RT-PCR). The pathologic changes of allograft coronary vessels were observed with histopathological method. Results The allograft coronary arteries showed minimal intimal thickening, the endothelium and internal elastic lamina remained almost intact in rh-HGF group after transplantation.The expression of c-Met and c-Met mRNA in intima of allograft vessels after transplantation in rhHGF group were significantly higher than those in CsA group and control group（expression of c-Met at 60d: 1.85±0.26 vs. 0.96±0.10, t=8.491,P=0.000;1.85±0.26 vs. 0.58±0.03, t=13.725,P=0.000; expression of c-Met mRNA at 60d: 192±0.22 vs. 0.88±0.07, t=11.940,P=0.000;1.92±0.22 vs. 0.42±0.02,t=19.206,P=0.000）. Conclusion rh-HGF may prevent the progression of cardiac allograft vasculopathy through upregulating the expression of c-Met to stimulate endothelial cell repair and growth.
Abstract: Cardiac transplantation is an effective therapeutic method for terminalstage heart diseases. The immunosuppressive treatment based on calcineurin inhibitors (CsA and FK506) is most commonly used, monoclonal antibodies are also used in some recipients as induction therapy before and/or after transplantation. Some new immunosuppressive drugs, such as Rapamycin and Everolimus, can not only inhibit the acute transplant rejection but also prevent cardiac vasculopathy. The application of some relatively nontraumatic tests, such as immunological indexes, cardiac markers and other serological parameters, are helpful for diagnosis and preventing postcardiac transplant rejection at early stage and improving the result of cardiac transplantation.