SLI~V~V~I~ - Welcome to [email protected]/3483/1/31735062123744.pdf · homograf t. Curiously, the development of host-graft nollreactivity appears to be a much

HETEROGRAFTING PROBLEMS AND LIVER TRANSPLANTATION I

bccn responsible for fi~ilurc to obti~iil chronic S L I ~ V ~ V ~ I ~ with lifc-sustain- 1 ing function of vital organs other thi111 the kidney, cxce1)ting only I the liver. Reciluse of this fact and bccausc we Lclievc that the livcr will ])robably be the next major organ to be transplanted successfully and since its study demonstrates the variety of unique requirements which must be met with each new organ system, I would like to tell you what we have learned about hepatic transplantation (1).

Figure 21 shows a dog, about 4% months postoperative. Through !

FIGURE 22. Use of temporary portacaval shunt during hepatic homotransplantation. By connecting the splanchnic and vena caval systems a single external bypass con bc rlsetl for venous decompression during the actual insertion of the homograft (by permission of Surg., Gywc. & Obst. (3 ) ) .

TRANSPLANTATION OF THE LIVER

an upper l~lidline irlcision, an orthotopic homotransplantation WiIS pcr- formed with removal of her own liver and replacement with a homograft. The chronic survivi~l of this and otl~cr dogs cilrrics inlplicatiolls of the future clinical usefulness of such open~tions.

Orthotopic Transplantation in the Untreated Dog

The technical requirements for hepatic homotransplantation are stringent. In dogs, we first perform a temporary portacaval shunt con-

FIGURE 23. Mrthod of livcr preservation used for the dog. Total body hypothekin is initially carried out to 29 to 31°C. Just before removal of the liver, chilled lactated Ringer's solution is perfused i n the portal vein at the same time the animal is exsanguinated through the aorta. The temperature of the homograft falls to 10-15°C. Livers cooled in this way can tolerate an ischemic interval of as long as 2 hours (by permission of Surg., Gynec. d Obst. (3)).

1 m n

HETEROGRAFTING PROBLEMS AND LIVER TRANSPLANTATION

0 3 6 9 12 I S IS Days after liver transplantation

FIGURE 28. Changes in blood sugar in untreated dogs after orthotopic liver transplantation. Note the tendency to terminal hypoglycemia (by permission of Surg., Gymc. R. Obsf. (4)).

dogs, and then later mention the alterations in experimental protocol - which preceded the improved results, hastening to add that we are not sure that the changes were responsible for the increased success.

Figure 33 sliows a liver 34 days after transplantation into a dog which died of subacute bacterial endocarditis. He had essentially normal liver function. Histologically, there were some focal accumulations I of round cells. Figure 34 represents a liver biopsy from a dog with good liver function after 60 days. Figure 35 shows a biopsy from a dog 120 days after operation. I apologize for the artifact in the portal

i area. There nj)j)eilrs to be hyprcellularity of the hepatic j)arenchyma, hut those pathologists who have looked a t this illustration do not believe i t has any clear stigmata of rejection.

The late behavior of dogs after hepatic homotransplantation deserves special comment (7-10). In the past, several laboratories have


planted to nn untreated recipient. A: Aftcr 5 cloys. Architwture is intact hut there arc ~nononuclenr ccll infiltrates

in the portnl arcn (lou~cr lrfl). B: After 13 days. Porcllchynlnl pattern is clisorgnnizcd ond there is a nlnssive

cellulnr infiltrntc. The periportol and cen~rizot~ulnr arms nre nffert~cl most severely. (11 & E x 60). (I3y I,c.t.t~~ission of S l i r ~ . Clitr. N.A. .I.L'.55. l')(r?,).

HETEROGRAFTING PROBLEMS A N D LIVER TRANSPLANTATION

H H - 4

FIOURE 31. Homografted liver after 25 days' residence in host treated with azathioprine. Architecture is essentially normal (H & E X 80).

TUX IN DAYS

FIGURE 30. Contrasting courses of an untreated ( l e f t ) and a treated ( r i g h t ) dog after orthotopic livcr transplantation. Note the absence of early jaundice in the latter dog and the variations in alkaline phosphatase and SGOT (by permission

1

of Ann. Surg. ( 1 3 ) ) .

demonstrated that some dogs which receive renal homogriifts devclop a state of host-graft nonreactivity and that immuno-suppressive therapy can be discontinued with continuing function of the kidney. The ex- planation for this happy circumstance is unclear. The phenomenon is unpredictable even after a pear or more, and the majority of animals challenged by \vithdrilwal of therapy proreeded to reject their I

homograf t. Curiously, the development of host-graft nollreactivity appears to

be a much more common event after orthotopic hepatic homotransplantation, possibly because a much greater antigenic mass is involved than with the kidney. To date, 5 dogs with orthotopic liver transplants have had all therapy stopped after 120 days (Fig. 3 6 ) . There has been no delayed rejection in any of these animals in subsequent fol- low-up intervals of 1 to 5 months. In scvcrill, 11el)ntic fullctiorl has actually improved. If these animals continue to do well, it will be

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imm~inology but \vliich 11a\.e to do with the mctiibolic and nutritiollal requirenients for successful transplantation of a secolld or "auxiliary" liver. These esl)erimcnts were designed to test the potential clinical value of the preparation originally described by Welch, Goodrich and their associates (1 1,12). With this operation, the homograft is placed in an ectopic site in the right paravertebral gutter, leaving the recipient liver in siiu (Fig. 38A).

With the Welch the homograft is fully vascularized. The hepatic artery is anastomosed to the aorta or iliac artery. Portal venous inflow is from the inferior vena cava (Fig. 38A,B), a situation comparable to that of portacaval transposition.

These animals were treated with azathioprine. Postoperatively, ret- rograde angiograms were obtained through the contralateral femoral artery and vein. There was good vascularization of the homograft (Fig. 39). In spite of this, the behavior of the auxiliary hornograft was quite different from that observed in the orthotopic livers.

Figure 40 shows the changes in the gross structure of the liver. The homograft undergoes a remarkable symmetrical shrinkage, begin- ning within 2 weeks. The dog's own liver is not altered (13). Under

FIGURE 39. Angiographic study of auxiliary liver homograft 27 days postoperative. A: Hepatic arterial supply. B: Venous supply. Note excellent filling of small ramifications of both systems

(by permission of Ann. Surg. (13)).


FIGURE 44). An auxiliary liver homograft (right) and the recipient dog's own liver (left) after revascularization by the method depicted in Fig. 38A. The specimens were obtained 45 days after transplantation. Note the extraordinary atrophy of the auxiliary homograft (by permission of Ann. Sttrg. (13)).

low-power microscopic study, it can be seen that the portal areas of 1 the homotransplanted liver are compressed (Fig. 41). Hepatocytes have

disappeared, but there is good preservation of the duct system. Reticulin collapse is widespread. Under higher power, one can see aggregates of round cells. There are large areas of hepatocyte loss which tend to be centrilobular in location (Fig. 42).

These atrophic auxiliary livers cannot provide life-sustaining function. In several experiments the recipient animal's own liver was re- moved from 25 to 35 days after transplantation. All of these animals died within 48 hours.

The remarkable shrinkage of the auxiliary livers in the foregoing experiments was discouraging in regard to any possible clinical applica- tion of the method. Since this acute atrophy had not been seen in orthotopic homografts, the possibility remained that this change was

a lver. in some way caused by the abnormal blood supply of the extr 1' Inasmuch as the auxiliary liver is revascularized by the same prin-


FIGURE 41. Low-power scan of an auxiliary dog liver vascularized as shown in Fig. 38A. Note thc good prcscrvation of the gnllhlndder and the apparent conlpres- sion of the intrnhepntir portnl trncts. Mallory tricllronle striin (Ily pcr~nission of ,411n. Si~rg . (1 3 ) ).

cipal as with portacaval transposition, the metabolism was re-investi- gated of animals receiving transposition alone (14). In these dogs, it was observed that a remarkable decrease in hepatic glycogen content follo\ved within 1 to 2 months after operation (Fig. 43). The total glycogen concentration was halved, and the TCA soluble (labile) glycogen was reduced by an average of 70 per cent. Despite a number of previous reports to the contrary, these findings indicated that the liver in dogs with transposition is not normal. The conclusion seemcd justified that this method of reconstructing the blood supply placed the auxiliary liver a t a physiologic disadvantage.

In order to test this concept, a new experinlent with auxiliary transplantation was designed. The exha liver was placed in exactly the same position and arterialized in the same way as before. Instead of providing a venous inflow from the inferior uena cava, the portal vein was anastornosed to the superior mesenteric vein of the recipient animal (Fig. 3813). Proximal ligation of the recipient portal vein was then carried out so that most of the splanchnic flow was directed through

FIGURE 42. Auxiliary liver homograft after 30 days using vascularization shown in Fig. 38A. Note the diffuse loss of hepatocytes and the focal accumulation of mononuclear cells (H & E X 80).

TOTAL GLYCOGEN

P!?E -b POST TRANSPOSITION

TCA TCA SOLUBLE INSOLUBLE GLYCOGEN GLYCOGEN I PRE 4 POST PRE --k POST

TRANSPOSITION TRANSPOSITION

FIGURE 43. Mean changes in liver glycogen fractions of 17 dogs following transposition. V~rt ical lines represent 2 1 SE.

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TRANSPLANTATION O F THE LIVER

FIOUNE 46. Method of extracorporeal cadaveric perfusion used for procurement of liver homografts. The cannulas are inserted into the abdominal aorta and vena cava shortly after death. A heat exchanger is incorporated into the pump oxygenator circuit. Note the clamp on the lower thoracic aorta which is used to increase perfusion to the lower half of the body. The pump is primed with electrolyte glucose solution to which heparin and procaine are added (by permission of W. B. Saunders Company, Experience in Renal Transplantation, 1964.).

:onizad bypass

F~curre 47. External bypass system used for clinical orthotopic transplantation I t was found that the shunt connecting the splanchnic to the jugular systems was unnecessary since portal occlusion was well tolerated in the human (by permission

, , -, .

FIGURE 48. Completed orthotopic clinical homotransplantation. The T-tube is placed through a stab wound in the recipient common duct (by permission of Ann. Surg.

(13)).

FI~UXE 49. Enormously enlarged liver of Patient 5 in the University of Colorado series of liver transplants. The tumor was a hepatoma which developed in a liver with pstnecrotic cirrhosis.

HETEROGRAFTING PROBLEMS A N D LIVER TRANSPLANTATION

asks, "How much importance does the panel attach to the careful matching of blood.groups in the selection of homo-transplants?"

DR. CROSNIER: In all our cases, we have required an identity or a compatibility between the groups and subgroups of donor and recipient.

DR. STARZL: We have done about 20 patients in whom the donors and recipients had different blood groups. There were in this group 4 that had a major mismatch in which the kidney was placed in the direction of the preformed hemagglutinins. The direction was A to 0 , B to 0 and B to A. Of these 4, in which we challenged the kidney in this way, 2 were destroyed immediately, and 2 others worked for a long period of time. One of them is our best case, now almost 2 years postoperative. This mismatch is exactly the same as one tried unsuccessfully by Dr. Hume. One of the A to 0 transplants went 7 months, with good renal function. The B to A homograft has perfect function and this patient has been off steroids for about a year. The transplants that failed acutely were A to 0 and B to 0.

The subgroups might deserve a comment. We sent our blood sub-. groups, as well as donor and recipient bloods, to Dr. Paul Terasaki (U.C.L.A.) for examination. He was anxious to compare the results with his leukocyte antigen typing with the data that we already had on the subgroups. There appears to be no correlation whatsoever with the blood subgroups, although there was good correlation of results with his white cell antigen typing.

I think that the only significance that the blood group has, accord- ing to the data which we have, is in the avoidance of an acute immunologic reaction, which I do not think is rejection, but which is killing the kidney in another way, with pre-formed antibody.

CHAIRMAN MERRILL: YOU would not do an incompatible blood type transplant?

DR. STARZL: Not in the direction that places the kidney in contact with preformed hemagglutinins. As for the other direction, we would have no hesitation about doing that.

CHAIRMAN MERRILL: One could say, for the ABO blood groups and probably for the minor ones, too, you cannot quantitate histocompatibi- lity on that basis. This was very nicely shown by Dr. Woodruff some time ago.

On the other hand, there is good reason for not perfusing a kidney with obviously mis-matched blood. The perfusion of kidneys with in-

TRANSPLANTATION O F THE LIVER

compatible blood has certainly caused acute tubular necrosis. Further- more, we know that at least one of the major red cell antigens is present on tubular cells and perfusion of such a kidney with anti-A containing blood might well be harmful. I think it is possible that you might get away with it, but I doubt whether it should be done if you have a choice.

Dr. Onesti of Philadelphia asks, "Would you give some more details on the 'wasting disease' of the recipient and its relationship to immuno-suppressive therapy? How much of this is due to steroids?"

The question is for either Dr. Lawrence or Dr. Simonsen. But I might ask either one of them to comment on the disease which we see with general immuno-suppressive therapy, which is similar to the secondary disease one sees in the experimental animal. Is this a good analogy?

D17. SIMONSEN: I do not believe that the wasting disease you see in your patients during that treatment has an early phase of splenic and lymphoid hypertrophy as has immunologic runt disease before lymphoid airophy sets in.

CHAIRMAN MERRILL: But do you conceive of this wasting disease as a block in the normal inlmunologic mechanism, and, if so, would you visualize it as destruction of the recipient's spleen by the graft-versus- host reaction or possibly by repopulation by donor cells, or alternatively might the whole syndrome be due to nonspecific drug suppression of general immunologic potential?

1 DR. SIMONSEN: It is obvious that the nonspecific drug suppression may promote wasting, but I think that there might be more to i t than

I

that. As I tried to say this morning, if you do manage to exhaust the reactivity to a strong antigen, with or without the help of immuno- suppressive drugs, I would predict that reactivity to many other antigens would be diminished at the same time. Therefore, the ability of the patient to react to other foreign antigens, including his bacterial

I flora, also would be impaired. This has nothing to do with graft-vcrsus- host reaction, but with exhaustion of the host's own apparatus. The same may not happen during exhaustion to weak transplantation antigens.

May I say that I am surprised at the statement of Dr. Lawrence that the graft-versus-host reaction should be impaired in germ-free animals. My information does not support that. Miller says that germ- free animals do not waste after neonatal thymectomy, whereas the

SLI~V~V~I~ - Welcome to [email protected]/3483/1/31735062123744.pdf · homograf t. Curiously, the development of host-graft nollreactivity appears to be a much

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