Graft Acceptance Research Articles

Safe Procedure for Efficient Hydrodynamic Gene Transfer to Isolated Porcine Liver in Transplantation.

Although calcineurin inhibitors are very effective as immunosuppressants in organ transplantation, complete graft acceptance remains as a challenge. Transfer of genes with immunosuppressant functions could contribute to improving the clinical evolution of transplantation. In this sense, hydrodynamic injection has proven very efficacious for liver gene transfer. In the present work, the hIL-10 gene was hydrofected 'ex vivo' to pig livers during the bench surgery stage, to circumvent the cardiovascular limitations of the procedure, in a model of porcine orthotopic transplantation with a 10-day follow-up. We used IL-10 because human and porcine proteins can be differentially quantified and for its immunomodulatory pleiotropic functions. Safety (biochemical parameters and histology), expression efficacy (RNA transcription and blood protein expression), and acute inflammatory response (cytokines panel) of the procedure were evaluated. The procedure proved safe as no change in biochemical parameters was observed in treated animals, and human IL-10 was efficaciously expressed, with stationary plasma protein levels over 20 pg/mL during the follow-up. Most studied cytokines showed increments (interferon-α, IFN-α; interleukin-1β, IL-1β; tumor necrosis factor α, TNFα; interleukin-6, IL-6; interleukin-8, IL-8; interleukin-4, IL-4; and transforming growth factor-β, TGF-β) in treated animals, without deleterious effects on tissue. Collectively, the results support the potential clinical interest in this gene therapy model that would require further longer-term dose-response studies to be confirmed.

Skin grafting with the modified Meek technique in the standing horse using full thickness skin: Evaluation of acceptance, wound contraction and wound closure in chronic wounds.

The modified Meek technique is not commonly used in equine wound management, despite the consistent reliable and superior results compared with other grafting techniques. Major drawbacks are the need for specialised, expensive equipment and general anaesthesia. To describe adjustments of the modified Meek technique enabling use in the standing horse without the need for the full equipment. This implied the use of full-thickness skin grafts manually harvested from the pectoral area and manually cut into micrografts. Graft acceptance; healing progress; and final functional and cosmetic result were outcome parameters. Descriptive case series. Eight horses with traumatic wounds at the dorsal side of the carpus or tarsus, healing by second intention, were treated. Original wound areas and areas of graft acceptance and rejection were determined from post-processing of digital photographs and percentage acceptance, wound contraction and epithelialisation were calculated. The initial mean wound area was 55.4 cm2. Graft acceptance was 95.3 ± 2.5%. Wound closure was due to 46.0 ± 25.6% wound contraction and 54.0 ± 25.6% epithelialisation and resulted in 96.8 ± 1.9% reduction of the initial wound area 28.0 ± 8.5 days after grafting. The scar was flat, flexible and functional, usually with thin and regular hair growth. The adapted procedure was fast and efficient, with a learning curve for the increased manual work. Small study population. This adapted modified Meek technique can successfully be performed in the standing horse and obviates the need for the full expensive equipment and general anaesthesia. The acceptance of the full-thickness grafts is excellent resulting in fast and satisfactory healing.

Elucidating T cell dynamics and molecular mechanisms in syngeneic and allogeneic islet transplantation through single-cell RNA sequencing.

Islet transplantation is a promising therapy for diabetes treatment. However, the molecular underpinnings governing the immune response, particularly T-cell dynamics in syngeneic and allogeneic transplant settings, remain poorly understood. Understanding these T cell dynamics is crucial for enhancing graft acceptance and managing diabetes treatment more effectively. This study aimed to elucidate the molecular mechanisms, gene expression differences, biological pathway alterations, and intercellular communication patterns among T-cell subpopulations after syngeneic and allogeneic islet transplantation. Using single-cell RNA sequencing, we analyzed cellular heterogeneity and gene expression profiles using the Seurat package for quality control and dimensionality reduction through t-SNE. Differentially expressed genes (DEGs) were analyzed among different T cell subtypes. GSEA was conducted utilizing the HALLMARK gene sets from MSigDB, while CellChat was used to infer and visualize cell-cell communication networks. Our findings revealed genetic variations within T-cell subpopulations between syngeneic and allogeneic islet transplants. We identified significant DEGs across these conditions, highlighting molecular discrepancies that may underpin rejection or other immune responses. GSEA indicated activation of the interferon-alpha response in memory T cells and suppression in CD4+ helper and γδ T cells, whereas TNFα signaling via NFκB was particularly active in regulatory T cells, γδ T cells, proliferating T cells, and activated CD8+ T cells. CellChat analysis revealed complex communication patterns within T-cell subsets, notably between proliferating T cells and activated CD8+ T cells. In conclusion, our study provides a comprehensive molecular landscape of T-cell diversity in islet transplantation. The insights into specific gene upregulation in xenotransplants suggest potential targets for improving graft tolerance. The differential pathway activation across T-cell subsets underscores their distinct roles in immune responses posttransplantation.

Intragraft regulatory T cells in the modern era: what can high-dimensional methods tell us about pathways to allograft acceptance?

Replacement of diseased organs with transplanted healthy donor ones remains the best and often only treatment option for end-stage organ disease. Immunosuppressants have decreased the incidence of acute rejection, but long-term survival remains limited. The broad action of current immunosuppressive drugs results in global immune impairment, increasing the risk of cancer and infections. Hence, achievement of allograft tolerance, in which graft function is maintained in the absence of global immunosuppression, has long been the aim of transplant clinicians and scientists. Regulatory T cells (Treg) are a specialized subset of immune cells that control a diverse array of immune responses, can prevent allograft rejection in animals, and have recently been explored in early phase clinical trials as an adoptive cellular therapy in transplant recipients. It has been established that allograft residency by Tregs can promote graft acceptance, but whether intragraft Treg functional diversification and spatial organization contribute to this process is largely unknown. In this review, we will explore what is known regarding the properties of intragraft Tregs during allograft acceptance and rejection. We will summarize recent advances in understanding Treg tissue residency through spatial, transcriptomic and high-dimensional cytometric methods in both animal and human studies. Our discussion will explore properties of intragraft Tregs in mediating operational tolerance to commonly transplanted solid organs. Finally, given recent developments in Treg cellular therapy, we will review emerging knowledge of whether and how these adoptively transferred cells enter allografts in humans. An understanding of the properties of intragraft Tregs will help lay the foundation for future therapies that will promote immune tolerance.

Low Prevalence of HLA-G Antibodies in Lung Transplant Patients Detected using MAIPA-Adapted Protocol.

Lung transplantation is often complicated by acute and/or chronic rejection leading to graft-function loss. In addition to the HLA donor-specific antibodies (HLA-DSA), a few autoantibodies are correlated with the occurrence of these complications. Recently, antibodies directed against non-classical HLA molecules, HLA-G, -E, and -F have been detected in autoimmune diseases, like systemic lupus erythematosus. Non-classical HLA molecules are crucial in the immunological acceptance of the lung graft, and some of their isoforms, like HLA-G*01:04 and -G*01:06, are associated with a negative clinical outcome. The aim of this study is to determine the frequency of detection of HLA-G antibodies in lung transplant recipients (LTRs) and their impact on the occurrence of clinical complications. After incubating the cell lines SPI-801, with and without three different HLA-G isoform expression, with sera from 90 healthy blood donors and 35 LTRs (before and after transplantation), HLA-G reactivity was revealed using reagents from commercial monoclonal antibody immobilization of platelet antigen assay (MAIPA ApDIA®). Only one serum from one blood donor had specific reactivity against the HLA-G transduced lines. Non-specific reactivity in many sera from LTRs was observed with transduced- and wild-type cell lines, which may suggest recognition of an autoantigen expressed by the SPI-801 cell line. In conclusion, this study allowed the development of a specific detection tool for non-denatured HLA-G antibodies. These antibodies seem uncommon, both in healthy subjects and in complicated LTRs. This study should be extended to patients suffering from autoimmune diseases as well as kidney and heart transplant recipients.

Immune Checkpoints in Solid Organ Transplantation.

Allogenic graft acceptance is only achieved by life-long immunosuppression, which comes at the cost of significant toxicity. Clinicians face the challenge of adapting the patients' treatments over long periods to lower the risks associated with these toxicities, permanently leveraging the risk of excessive versus insufficient immunosuppression. A major goal and challenge in the field of solid organ transplantation (SOT) is to attain a state of stable immune tolerance specifically towards the grafted organ. The immune system is equipped with a set of inhibitory co-receptors known as immune checkpoints (ICs), which physiologically regulate numerous effector functions. Insufficient regulation through these ICs can lead to autoimmunity and/or immune-mediated toxicity, while excessive expression of ICs induces stable hypo-responsiveness, especially in T cells, a state sometimes referred to as exhaustion. IC blockade has emerged in the last decade as a powerful therapeutic tool against cancer. The opposite action, i.e., subverting IC for the benefit of establishing a state of specific hypo-responsiveness against auto- or allo-antigens, is still in its infancy. In this review, we will summarize the available literature on the role of ICs in SOT and the relevance of ICs with graft acceptance. We will also discuss the possible influence of current immunosuppressive medications on IC functions.

Cryoprecipitate and platelets-rich-plasma as a combined assisted therapy for burns: A promoted case series for future trials

IntroductionIn this paper, we present the first application of split-thickness skin autografts soaked in a combination of platelet-rich plasma (PRP) and cryoprecipitate for four cases of second and third-degree burns. Case presentationWe describe four cases of second and third-degree burns in males aged 35, 10, 24, and 5 years, respectively. The total body surface area (TBSA) affected in these cases ranged from 10 % to 35 %. The burn areas included the entire upper and lower back, the lower limbs, and the head, with involvement of the outer table of the calvarium according to Harrison's classification. To expedite wound healing, we applied split-thickness autografts soaked in a mixture of cryoprecipitate and PRP. Additionally, we covered the grafts with dressings soaked in the same mixture, resulting in successful graft acceptance and improved burn healing. DiscussionSkin wound healing involves increased angiogenesis, re-epithelialization, and modulation of inflammation. PRP has been shown to enhance re-epithelialization, a crucial process in skin wound healing. However, there is a lack of studies on the role of cryoprecipitate in re-epithelialization. Therefore, we propose the use of autologous skin grafts soaked in a combination of cryoprecipitate and PRP to expedite healing. ConclusionThis case series demonstrates that the use of split-thickness autografts soaked in a mixture of cryoprecipitate and PRP significantly improves and accelerates burn healing while contributing to acceptable graft outcomes.

ABO Incompatible Kidney Transplant in a Patient With Atypical Hemolytic Uremic Syndrome: Case Report

Kidney transplant (KT) or renal transplant is 1 of the preferred treatment options for patients with end-stage renal disease, but the presence of atypical hemolytic uremic syndrome (aHUS) further increases the risk of reoccurrence with graft rejection, and poor outcomes. ABO incompatibility further adds to the rejection risk. Here, we present a case of a young adult with a history of aHUS undergoing a successful ABO-incompatible (ABOi) renal transplant. ABO incompatibility desensitization was carried out, and the antibody titer was reduced to nullify the risk of rejection. Graft acceptance was facilitated by triple immunosuppression (steroid, tacrolimus, and mycophenolate mofetil), and 4-month serum creatinine follow-up indicated the absence of antibody-mediated rejection and recurrence of aHUS. This case demonstrates that in patients with aHUS, ABOi renal transplant can be performed successfully.

Nothing but NETs: Cytokine adsorption correlates with lower circulating nucleosomes and is associated with decreased primary graft dysfunction

Elevated levels of neutrophil extracellular traps (NETs) have been reported in primary graft dysfunction, making methods to reduce or remove them highly valuable. The mechanisms behind primary graft dysfunction (PGD) remain rudimentarily understood but its relation to higher rates of acute and chronic rejection necessitates the development of preventative treatments. This case series explores the use of a cytokine adsorber during lung transplantation with the focus of reducing circulating nucleosome levels as a measure of NETs. Treated patients showed reduced levels of circulating nucleosomes and remained free from PGD and histopathological signs of acute rejection at 1- and 3-month post-transplant. In contrast, patients without the adsorber experienced higher levels of circulating nucleosomes, PGD grades 1 and 3, and histopathological signs of acute rejection. Using a cytokine adsorber during transplantation may provide a reduced systemic inflammatory state with lower levels of NETs and consequently support graft acceptance.

Single-cell RNA sequencing reveals peripheral blood mononuclear immune cell landscape associated with operational tolerance in a kidney transplant recipient

Operational tolerance (OT) after kidney transplantation is defined as stable graft acceptance without the need for immunosuppression therapy. However, it is not clear which cellular and molecular pathways are driving tolerance in these patients. In this first-of-its-kind pilot study, we assessed the immune landscape associated with OT using single-cell analyses. Peripheral mononuclear cells from a kidney transplant recipient with OT (Tol), 2 healthy individuals (HC), and a kidney transplant recipient with normal kidney function on standard-of-care immunosuppression (SOC) were evaluated. The immune landscape of the Tol was drastically different from that of SOC and emerged closer to the profile of HC. TCL1A+ naive B cells and LSGAL1+ regulatory T cells (Tregs) were in higher proportions in Tol. We were unable to identify the Treg subcluster in SOC. The ligand-receptor analysis in HC and Tol identified interactions between B cells, and Tregs that enhance the proliferation and suppressive function of Tregs. SOC reported the highest proportion of activated B cells with more cells in the G2M phase. Our single-cell RNA sequencing study identified the mediators of tolerance; however, it emphasizes the requirement of similar investigations on a larger cohort to reaffirm the role of immune cells in tolerance.

776 Importance of Adequate Nutrition Support in Severely Burned Patients

Abstract Introduction The importance of optimal nutrition for burned patients has been well established through research. Provision of adequate nutrition is believed to improve healing outcomes, reduce complications and overall length of stay for burned patients. Enteral Nutrition (EN) support is the favored method of feeding for a severely burned patient, however timing of initiation of feeding and ability to meet estimated nutritional needs throughout a hospital stay still needs to be further established. The objective of this study was to evaluate not only the timing of initiation of EN for severely burned patients, but also the adequacy of the nutritional provisions the patients received. Methods Patients admitted to a Regional Burn Center with a burn ≥20% TBSA, intubated and started on EN support were eligible for the inclusion in this retrospective review. Specific variables that were assessed included time for burn team to consult Registered Dietitian (RD), time from consult until RD assessed patient, time from admission to initiation per order, total tube feed volume (in mL) actually infused per RN documentation, and percentage of EN received compared to order. Results Forty-two patients were included in this retrospective review. All patients had EN initiated within 24 hours of admission. Out of twenty-five patients that specific EN initiation time (by the minute) was able to be identified, the average time for EN to start was 9.5 hours. Average time for enteral nutrition to reach RD recommended goal rate was 26.2 hours, with 59% of patients reaching goal rate in ≤24 hours. Average amount of EN formula (in mL) patients actually received compared to what was ordered was 80.9%. Some complications observed for those patients whose EN did not reach goal rate in ≤24 hours or those who received a lower percentage of EN formula included difficulties with GI tolerance, high residuals, and incidence of ileus. However, these complications were only seen in 19% of patients included in the study. Conclusions The average time for initiation of EN support was within the SCCM/ASPEN guidelines for the critically ill patient. Additionally, more than half the patients reached the RD recommended EN goal rate in ≤24 hours. The investigator found that early initiation of EN and aggressive advancement to goal, as tolerated, to be safe. Applicability of Research to Practice A standard of practice for timing of EN initiation and advancing to goal would be beneficial, with possibility of reaching EN goal rates faster helping to increase the provisions of total EN received during admission and therefore closer meeting estimated nutritional needs. The effects of adequate nutrition in relation to overall burn healing / graft acceptance, complications, length of stay and mortality all warrant further studies prior to implementation of early EN/aggressive advancement to goal into practice.

The adaptation model of immunity: allograft rejection versus allograft adaptation

Abstract Rejection of allografts and acceptance of grafts between identical twins appear to be associated with allogeneity or nonself entity of allografts as suggested by the self-nonself (SNS) model of immunity. Nevertheless, such guilt by association does not necessarily follow a cause-effect direction. The adaptation model proposes that graft rejection or tolerance is determined by the expression of the tissue-specific adaptation receptors (AdRs) which are linked to anti-apoptotic pathways for tolerating the recipient’s alloreactive immune response induced by surgical procedure during organ transplantation. A better engraftment of less matched living-donor organs compared with matched cadaver-donor organs is because of a severely altered AdRs in the latter. To this end, tissue adaptation to an anti-graft immune response suggests that AdRs can be restored in allografts if treated properly. Re-transplantation studies demonstrated that second fresh skin allograft rejection while the first adapted allograft from the same donor remaining viable in the presence of all-reactive T cells. Also, constitutive expression of a bidirectional AdR, B7-H1 linked to Bcl-xL anti-apoptotic pathway, in the cornea and retina protects them from rejection while block-ade of B7-H1 accelerates allograft rejection. Also, severe GVHD following autologous stem cell transplantation could be due to chemotherapy-induced alterations in the AdRs in target tissues. This is supported by demonstrating that autologous T RMcells that are involved in local tissue homeostasis but not alloreactive T EMcells are involved in GVHD. Interestingly, restoration of the putative AdR, B7-H1, expression by parenchymal tissues could prevent or ameliorate GVHD in humans. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Breast Cancer Research Program under Award No. W81XWH2210793. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the U.S. Department of Defense. This work was also supported by multi-investigator pilot funding from the VCU Massey Cancer Centre, supported in part with funding from NIH/NCI Cancer Centre support grants P30 CA016059.

Assessment of donor compatibility in human solid organ transplantation and evaluation of allogeneic responses using a novel humanized mouse model.

Abstract The end result of solid organ transplantation is dictated by selection of a well-matched donor, leading to allograft survival. An allogeneic immune response is the main immunological barrier for successful organ transplantation. Donor and recipient human leukocyte antigen (HLA) mismatching results in poor graft acceptance, inflammation and rejection. The current evaluations for donor-recipient HLA incompatibility does not provide adequate information on the immunogenicity of individual HLA mismatches and impact of non-HLA-related alloantigens, especially in vivo. Here we demonstrate a novel method for analysis of alloimmune responsiveness between donor and recipient in vivoby introducing a humanized mouse model. Using molecular, cellular, and genomic analyses, we demonstrated that a recipient’s personalized humanized mouse provided the most sensitive assessment of allogeneic responsiveness to potential donors. In our study, HLA typing and mixed lymphocyte reaction (MLR) for assessment of allogeneic response was indistinguishable between 2 related donors of the recipient. Contrastingly in recipient’s humanized mouse model, the donor selected by HLA typing induced the strongest allogeneic response with increased infiltration of cytotoxic GzmB +CD8 +T cells. Moreover, the same donor induced upregulation of genes involved in the allograft rejection identified by transcriptomic analysis of graft infiltrating CD45 +cells. Humanized mouse model determined the lowest degree of recipient-donor alloimmune response, allowing for better selection of donor and minimized immunological risk of allograft rejection in transplantation. This approach can be used to evaluate alloresponses in cell based therapies as well. This study was supported by research funding from the Carlos and Marguerite Mason Trust, and by U.S. National Institutes of Health, National Cancer Institute Grant CA 172230

Deleting Runx3 in CD4+ T Cells Disrupts Effector Functions and Facilitates Tolerance Induction in Solid Organ Transplantation

Abstract Long-term transplantation tolerance depends on the control of graft-reactive T cells. In particular, the alloreactivity of CD4+ T cells needs to be suppressed as these cells are both necessary and sufficient for cardiac allograft rejection. Although experimental protocols such as anti-CD154-mediated co-stimulation blockade can stably induce donor-specific tolerance in MHC-mismatched cardiac allografts, other more immunogenic organs such as skin are less susceptible to tolerogenic treatments, in part due to additional reactivity of the host against donor commensals that accompany the graft. The transcriptional mechanisms that enable CD4+ T cells to drive rejection and whose targeting can promote tolerance are not well understood. RNAseq comparison of the transcriptome in graft-reactive T cells from rejecting versus tolerant heart allograft recipients revealed several transcription factors differentially expressed between rejected and tolerant mice in both spleen and graft. Here, we report that the transcription factor Runx3 in alloreactive CD4+ T cells promotes Th1 and cytotoxic response against the allograft and resistance to tolerance induction. Conversely, ablating Runx3 in alloreactive CD4+ T cells augments the efficacy of anti-CD154 blockade treatment enabling skin graft acceptance.

A new slow-releasing formulation of butyrate prolongs allograft survival

Abstract The microbiota consists of diverse microbes producing metabolites that can influence the immune system locally as well as systemically. These bioactive metabolites (postbiotics) have therapeutic potential and may prove useful to facilitate graft acceptance. Short-chain fatty acids (SCFA) promote intestinal homeostasis and have been linked to health and disease. The Hubbell-Nagler laboratories at the University of Chicago have developed a micelle-based platform that can deliver the SCFA butyrate systemically, with long-term retention and induction of tolerogenic responses. We hypothesized that the administration of this butyrate formulation will improve graft survival by suppressing the alloimmune response. Our preliminary data showed that only oral delivery of the butyrate formulation prolonged survival of a C57Bl/6 male to female minor-mismatched skin graft significantly, whereas sub-cutaneous and intra-peritoneal administration were ineffective. Improved graft survival was associated with diminished production of TNFα by splenic and skin-draining lymph node myeloid cells upon LPS stimulation, suggesting that butyrate modulates the myeloid compartment to reduce levels of pro-inflammatory cytokines. The postbiotic also enhanced survival of a BALB/c to C57Bl/6 major-mismatched skin graft, without the use of immunosuppressive drugs, and resulted in lower levels of donor-specific alloantibodies. Prolonging the administration of butyrate post-transplantation ameliorated graft survival even further, confirming the micelle-based platform has therapeutic potential. Current efforts focus on determining if the butyrate formulation drives myeloid cell polarization toward an anti-inflammatory phenotype. This project was supported by grant NIH/NIAID 2R01AI115716

Leveraging the tolerogenic potential of TNF-α and regulatory B cells in organ transplantation.

A subset of B-cells with tolerogenic functions, termed B-regulatory cells or Bregs, is characterized by the expression of anti-inflammatory/tolerogenic cytokines, namely IL-10, TGF-β, and IL-35, that contribute to their regulatory functions. Breg regulation favors graft acceptance within a tolerogenic milieu. As organ transplantation invariably triggers inflammation, new insights into the crosstalk between cytokines with dual properties and the inflamed milieu are needed to tailor their function toward tolerance. Using TNF-α as a proxy of dual-function cytokines involved in immune-related diseases and transplantation settings, the current review highlights the multifaceted role of TNF-α. It focuses on therapeutic approaches that have revealed the complexity of TNF-α properties tested in clinical settings where total TNF-α inhibition has proven ineffective and often detrimental to clinical outcomes. To improve the efficacy of current TNF-α inhibiting therapeutics, we propose a three-prong strategy to upregulate the tolerogenic pathway engaging the TNFR2 receptor while simultaneously inhibiting the inflammatory mechanisms associated with TNFR1 engagement. When combined with additional administrations of Bregs-TLR that activate Tregs, this approach may become a potential therapeutic in overcoming transplant rejection and promoting graft tolerance.

Extracorporeal Photopheresis Suppresses Transplant Fibrosis by Inducing Decorin Expression in Alveolar Macrophages.

Extracorporeal Photopheresis Suppresses Transplant Fibrosis by Inducing Decorin Expression in Alveolar Macrophages.

Immunosuppression Protocols in Intestinal and Multivisceral Transplantation—A Literature Review

Intestinal transplantation (IT) and multivisceral transplantation (MVT) are curative therapies for patients with intestinal failure and severe complications associated with total parenteral nutrition. High levels of immunosuppression are required to prevent acute cellular rejection (ACR) from the bowel. Studies regarding pre-treatment, induction, and post-transplant therapy have improved graft acceptance, reducing immunosuppression doses and infectious complications. However, the low rate of IT and MVT and the small number of specialized centers have resulted in a limited number of evidence-based immunosuppression protocols. We reviewed immunosuppression in IT and MVT to draw useful conclusions regarding the best protocol strategies for the induction, maintenance, and management of ACR. A review was performed using the PubMed database. Articles on immunosuppression protocols in IT and MVT that addressed graft rejection, infection, or survival, published between 2006 and 2022, were selected. A total of 690 articles were selected. Two researchers applied the inclusion and exclusion criteria and selected 14 articles independently. For induction, thymoglobulin, alemtuzumab, and basiliximab are the most frequently used immunosuppressants for induction. Classic maintenance therapy consists of a combination of corticosteroids and tacrolimus. Methylprednisolone with an increased tacrolimus dose is used most frequently to manage ACR. Depending on the receptor response, such as thymoglobulin, infliximab, adalimumab, or bortezomib, other immunosuppressants should be considered. There have been great advances in IT and TMV immunosuppression. We conclude that the gold standard immunosuppressive protocol is triple therapy, comprising induction with thymoglobulin, maintenance with steroids for a few months, and tacrolimus and mycophenolate therapy. Innovative approaches for treating intestinal rejection episodes with more appropriate drugs, such as infliximab, adalimumab, or bortezomib, are necessary.

SURVIVAL OF SPLIT SKIN GRAFT IN DIABETIC ULCER VERSUS NON - DIABETIC ULCER

Introduction:Chronic ulceration of the lower leg and foot is a frequent condition and wide in distribution they may be associated with a number of Medical, Surgical & Dermatological condition the patient suffering is very immense, commonly seen in most of the surgical wards and OPD Material & Method: Present prospective cohort study was conducted among the patients with foot ulcers presenting to department of General Surgery, AVMCH and were posted for elective surgeries during a period of 2 years. The patients posted for split skin graft were admitted a day prior to surgery. A detailed history including the identication detail of the patient, presenting complaints, were obtained. General Examination and detailed clinical examination was done. The outcome among the patients were analysed as graft uptake and any complications noted between the groups. Result: In present study, total of 170 patients fullling inclusion criteria were included with mean age of 51.4±13.2yr of age. On assessment of the 1st acceptance of graft, it was signicantly higher in group B (78.8%) compared to the group A(60.3%).(p<0.05) On assessment of different post operative day the percentage of acceptance was signicantly higher in group B compared to the group A patients.(p<0.05) On assessment of complications, there is no signicant complication documented in group B compared to the group Apatient. Conclusion: The study documented the improvement in the graft acceptance in both the group, of which the non-diabetic group had signicantly early healing compared to the diabetic foot ulcer.

TYMPANOPLASTY AND ITS OUTCOME IN VARIOUS AGE GROUPS USING THE MIDDLE EAR RISK INDEX SCALE AT A TERTIARY CARE CENTRE IN EASTERN NEPAL

Background: Tympanoplasty is done in cases of chronic otitis media. Middle Ear Risk Index (MERI) Scale is used to predict the outcome of tympanoplasty, based on various risk factors like otorrhoea, perforation, ossicular chain status, cholesteatoma, smoking and middle ear granuation/effusion. The objective of the study was to report the success rate of graft uptake, postoperative gain in hearing threshold and to find out the association of success to the different categories of MERI scale. Methods: A prospective study of 75 cases of chronic otitis media who underwent tympanoplasty, was done over one year. Convenience sampling method was done. Clinical and audiological evaluation was done pre- and post- operatively. Risk categorization based on MERI scale was done. Data were recorded and analyzed using SPSS 16. Results: Out of 75 cases, 39 (52%) cases were male and 36 (48%) were female. The mean age was 24.55 years±11.545. Overall, 53 (70.66%) cases had successful graft uptake. MERI 1-3 group had 82.6 % (38/46), MERI 4-7 group had 64.7 % (11/17) and MERI 8-12 group had only 33.33% (4/12) graft uptake, (p-value 0.003). Above-10-year age group had higher graft uptake rate and hearing gain. Graft acceptance was seen equal in dry or wet ear, and in unilateral or bilateral perforation. Conclusions: Tympanoplasty done in cases with lower MERI scale and more than 10 years age group was associated with higher graft acceptance. More than 10 years age group had better hearing gain. The status of middle ear, dry or wet and laterality of perforation had no association for graft acceptance.