Allogeneic Tissue Transplantation Research Articles

Subdominant H60 antigen-specific CD8 T-cell response precedes dominant H4 antigen-specific response during the initial phase of allogenic skin graft rejection.

In allogeneic transplantation, including the B6 anti-BALB.B settings, H60 and H4 are two representative dominant minor histocompatibility antigens that induce strong CD8 T-cell responses. With different distribution patterns, H60 expression is restricted to hematopoietic cells, whereas H4 is ubiquitously expressed. H60-specific CD8 T-cell response has been known to be dominant in most cases of B6 anti-BALB.B allo-responses, except in the case of skin transplantation. To understand the mechanism underlying the subdominance of H60 during allogeneic skin transplantation, we investigated the dynamics of the H60-specific CD8 T cells in B6 mice transplanted with allogeneic BALB.B tail skin. Unexpectedly, longitudinal bioluminescence imaging and flow cytometric analyses revealed that H60-specific CD8 T cells were not always subdominant to H4-specific cells but instead showed a brief dominance before the H4 response became predominant. H60-specific CD8 T cells could expand in the draining lymph node and migrate to the BALB.B allografts, indicating their active participation in the anti-BALB.B allo-response. Enhancing the frequencies of H60-reactive CD8 T cells prior to skin transplantation reversed the immune hierarchy between H60 and H4. Additionally, H60 became predominant when antigen presentation was limited to the direct pathway. However, when antigen presentation was restricted to the indirect pathway, the expansion of H60-specific CD8 T cells was limited, whereas H4-specific CD8 T cells expanded significantly, suggesting that the temporary immunodominance and eventual subdominance of H60 could be due to their reliance on the direct antigen presentation pathway. These results enhance our understanding of the immunodominance phenomenon following allogeneic tissue transplantation.

Kill the Messenger: T-cell/B-cell Interactions in cGVHD

Chronic graft-versus-host disease (cGVHD) is a common complication in patients after receiving an allogeneic tissue transplant, such as hematopoietic stem cell transplantation from unrelated donors. cGVHD was viewed predominantly as a T-cell mediated disease but the emerging evidences indicate the crucial role of B-cell and other immune cells in its pathogenesis. In their original paper in Blood [1], Flynn et al. show that increased frequency of T follicular helper (Tfh) cells and germinal center (GC) Bcells correlates with the development of cGVHD in a murine model and that blocking monoclonal antibodies (mAbs) for interleukin-21 (IL-21), inducble T-cell costimulator (ICOS) and CD40 ligand reverse cGVHD. These data demonstrate the importance of T follicular helper (Tfh) and germinal center (GC) Bcells in the pathogenesis of cGVHD and associated bronchiolitis obliterans syndrome (BOS) and suggest that new therapies using monoclonal antibodies (mAbs) targeting Tfh cells, GC B cells, and their interactions could potentially reverse established pulmonary cGVHD.

Generation and Characterization of Severe Combined Immunodeficiency Rats

Severe combined immunodeficiency (SCID) mice, the most widely used animal model of DNA-PKcs (Prkdc) deficiency, have contributed enormously to our understanding of immunodeficiency, lymphocyte development, and DNA-repair mechanisms, and they are ideal hosts for allogeneic and xenogeneic tissue transplantation. Here, we use zinc-finger nucleases to generate rats that lack either the Prkdc gene (SCID) or the Prkdc and Il2rg genes (referred to as F344-scid gamma [FSG] rats). SCID rats show several phenotypic differences from SCID mice, including growth retardation, premature senescence, and a more severe immunodeficiency without "leaky" phenotypes. Double-knockout FSG rats show an even more immunocompromised phenotype, such as the abolishment of natural killer cells. Finally, xenotransplantation of human induced pluripotent stem cells, ovarian cancer cells, and hepatocytes shows that SCID and FSG rats can act as hosts for xenogeneic tissue grafts and stem cell transplantation and may be useful for preclinical testing of new drugs.

Human allograft rejection in humanized mice: a historical perspective

Basic research in transplantation immunology has relied primarily on rodent models. Experimentation with rodents has laid the foundation for our basic understanding of the biological events that precipitate rejection of non-self or allogeneic tissue transplants and supported the development of novel strategies to specifically suppress allogeneic immune responses. However, translation of these studies to the clinic has met with limited success, emphasizing the need for new models that focus on human immune responses to allogeneic tissues. Humanized mouse models are an exciting alternative that permits investigation of the rejection of human tissues mediated by human immune cells without putting patients at risk. However, the use of humanized mice is complicated by a diversity of protocols and approaches, including the large number of immunodeficient mouse strains available, the choice of tissue to transplant and the specific human immune cell populations that can be engrafted. Here, we present a historical perspective on the study of allograft rejection in humanized mice and discuss the use of these novel model systems in transplant biology.

Reduktion der immunologischen Abstoßungsreaktion in Composite Tissue Allotransplantation durch Hitzeschock-Präkonditionierung

In spite of great advances in the field of composite tissue allotransplantations (CTA), there is still a major need for optimisation in terms of immunosuppression. Heat shock proteins are produced as a reaction of the body during a stress situation. Once elevated, they protect against a second stress and reduce ischaemia-reperfusion injury within transplantations. In the literature the effect of heat shock and HSP70 on rejection after CTA has not been described. The purpose of this experimental study was to examine the effect of heat shock proteins on rejection in a rat model of CTA. Evaluated was the effect of preconditioning by prior heat stress.Brown Norway rats were systemically heated to a core temperature of 42 °C in order to up-regulate HSP70. The expression of HSP70 in muscle was measured by Western blot analysis and showed a peak 24 h after heat shock. Allogeneic hindlimb transplantations were performed between Brown Norway rats (donor) and Lewis rats (recipients). Group 1 (n=12) was preheated 24 h prior to transplantation. In group 2 (n=12) the transplantation was performed without prior heat shock. Group 3 (n=6) was used as a control group with syngeneic hindlimb transplantations between Lewis rats. Postoperatively the appearance of the transplanted hindlimb was evaluated every 12 h. The beginning of rejection was defined when plantar erythema and foot oedema could be observed at the same time. To verify these discrete signs of rejection, the observation was continued for a further 24 h. In this time erythema and oedema spread over the whole transplanted hindlimb. The rat was sacrificed after specimens of skin and muscle had been taken for histological assessment.The rejection in group 1 (with preconditioning heat shock) began after 4.83±0.44 days, in group 2 (without heat shock) already after 3.88±0.53 days. The difference between these groups was significant because of the small standard deviation (Whitney-Mann U test: p<0.01).In our model of allogeneic composite tissue transplantation, a heat shock and subsequent up-regulation of HSP70 led to a significant delay of the immunological rejection. As the graft rejection is an important item influencing the outcome of allogeneic transplantations, these results represent an option to improve the final functional outcome of composite tissue allotransplantations.

Uso de células-tronco cultivadas ex vivo na reconstrução da superfície ocular

Lesions on the ocular surface can destroy the stem cells from the limbus and cause limbal stem cell deficiency. The limbal stem cell deficiency is marked by conjunctivalization, which can be defined as the invasion of conjunctival epithelium over the cornea. This process is accompanied by varying degrees of corneal changes such as neovascularization, inflammation, recurrent erosions, persistent epithelial defects, destruction of basement membrane of epithelium and stromal healing. Often, these changes are associated with poor visual acuity, photophobia and ocular discomfort. The best treatment for this disease is not known and varies in unilateral or bilateral cases. Among the treatments available, transplantation of limbal autograft or allograft is one of the most used. To improve the outcome of allotransplantation, some researchers use the transplantation of corneal epithelium cultured in the laboratory by ex vivo expansion of limbal stem cells, but due to limited availability of autologous tissue from the limbus and the risk of complications associated with immunosuppression in allogeneic tissue transplantation, researches of others options of stem cell cultured ex vivo have been described in experimental and clinical stage. This review describes the new types of stem cells cultured ex vivo, their current results and future potential.

Mechanisms of tolerance to parental parathyroid tissue when combined with human allogeneic thymus transplantation

The induction of tolerance toward third-party solid organ grafts with allogeneic thymus tissue transplantation has not been previously demonstrated in human subjects. Infants with complete DiGeorge anomaly (having neither thymus nor parathyroid function) were studied for conditions and mechanisms required for the development of tolerance to third-party solid organ tissues. Four infants who met the criteria received parental parathyroid with allogeneic thymus transplantation and were studied. Two of 3 survivors showed function of both grafts but subsequently lost parathyroid function. They demonstrated alloreactivity against the parathyroid donor in mixed lymphocyte cultures. For these 2 recipients, parathyroid donor HLA class II alleles were mismatched with the recipient and thymus. MHC class II tetramers confirmed the presence of recipient CD4(+) T cells with specificity toward a mismatched parathyroid donor class II allele. The third survivor has persistent graft function and lacks alloreactivity toward the parathyroid donor. All parathyroid donor class II alleles were shared with either the recipient or the thymus graft, with minor differences between the parathyroid (HLA-DRB1∗1104) and thymus (HLA-DRB1∗1101). Tetramer analyses detected recipient T cells specific for the parathyroid HLA-DRB1∗1104 allele. Alloreactivity toward the parathyroid donor was restored with low doses of IL-2. Tolerance toward parathyroid grafts in combined parental parathyroid and allogeneic thymus transplantation requires matching of thymus tissue to parathyroid HLA class II alleles to promote negative selection and suppression of recipient T cells that have alloreactivity toward the parathyroid grafts. This matching strategy may be applied toward tolerance induction in future combined thymus and solid organ transplantation efforts.

Regulation of cell‐based medicine – the German experience

In the member states of the European Union, the field of cell‐based medicine and tissue preparations is determined by the law of the European Community (EC). The implementation of the EC directives is mandatory and makes Community law binding in the EU Member States. The Tissues and Cells Act of July 20, 2007 transposed the Directive 2004/23/EC, which is setting standards for human tissues and cells, into German law. This Tissue Act is not a law on its own, but makes significant amendments of the Medicinal Products Act, the Transplantation Act and the Transfusion Act. According to the Amsterdam Treaty (1997) and the Directive 2004/23/EC itself, the national legislators may stipulate stricter provisions, thus exceeding the minimum requirements specified in this EC directive. Accordingly, a real harmonization of the standards for human tissues and cells within the European Union is not intended and not possible. The Directive 2004/23/EC includes minimum standards to ensure high quality and safety margins for human tissues and cell preparations released for clinical application in humans. The standards cover the donation, procurement, testing, processing, preservation, storage, and distribution of human tissues and cells. The German Tissue Act defines tissues and cell preparations as pharmaceutical drugs governed by the German Drug Act. The need for high standards in quality and safety is highlighted, most of the loopholes that might otherwise allow operation outside national drug legislation in the field of local tissue banking and tissue engineering have been closed. As a consequence, donated tissues and stem cell preparations are subjected to strict regulations which mainly aim to prevent the most serious adverse effects of allogeneic tissue transplants, the transmission of infectious pathogens. Whenever possible, a validated inactivation procedure should be included in the manufacturing process. Tissues and stem cell preparations now usually require national approval, a procedure which in principle is comparable, although somewhat simplified, to the well‐established national licensing procedure for blood components seeking post‐marketing approval from the national authorities (Paul Ehrlich Institute). According to the highly positive experiences obtained with the standardization and licensing of blood components combined with a local and national system for surveillance, it can be expected that the national approval and local and national surveillance of stem cell and tissue preparations will contribute to a significantly improved quality and higher safety profile for the patients. However, the bureaucratic efforts which are inevitable consequences of the new regulations are still a matter of some dispute.

Management of Articular Cartilage Defects of the Knee

Articular cartilage has a poor intrinsic capacity for healing. The goal of surgical techniques to repair articular cartilage injuries is to achieve the regeneration of organized hyaline cartilage. Microfracture and other bone marrow stimulation techniques involve penetration of the subchondral plate in order to recruit mesenchymal stem cells into the chondral defect. The formation of a stable clot that fills the lesion is of paramount importance to achieve a successful outcome. Mosaicplasty is a viable option with which to address osteochondral lesions of the knee and offers the advantage of transplanting hyaline cartilage. However, limited graft availability and donor site morbidity are concerns. Transplantation of an osteochondral allograft consisting of intact, viable articular cartilage and its underlying subchondral bone offers the ability to address large osteochondral defects of the knee, including those involving an entire compartment. The primary theoretical advantage of autologous chondrocyte implantation is the development of hyaline-like cartilage rather than fibrocartilage in the defect, which presumably leads to better long-term outcomes and longevity of the healing tissue. Use of synthetic scaffolds is a potentially attractive alternative to traditional cartilage procedures as they are readily available and, unlike allogeneic tissue transplants, are associated with no risk of disease transmission. Their efficacy, however, has not been proven clinically.

Transplantation immunology: Solid organ and bone marrow

Development of the field of organ and tissue transplantation has accelerated remarkably since the human MHC was discovered in 1967. Matching of donor and recipient for MHC antigens has been shown to have a significant positive effect on graft acceptance. The roles of the different components of the immune system involved in the tolerance or rejection of grafts and in graft-versus-host disease have been clarified. These components include antibodies, antigen-presenting cells, helper and cytotoxic T-cell subsets, immune cell-surface molecules, signaling mechanisms, and cytokines. The development of pharmacologic and biological agents that interfere with the alloimmune response has had a crucial role in the success of organ transplantation. Combinations of these agents work synergistically, leading to lower doses of immunosuppressive drugs and reduced toxicity. Reports of significant numbers of successful solid-organ transplantations include those of the kidneys, liver, heart, and lung. The use of bone marrow transplantation for hematologic diseases, particularly hematologic malignancies and primary immunodeficiencies, has become the treatment of choice in many of these conditions. Other sources of hematopoietic stem cells are also being used, and diverse immunosuppressive drug regimens of reduced intensity are being proposed to circumvent the mortality associated with the toxicity of these drugs. Gene therapy to correct inherited diseases by means of infusion of gene-modified autologous hematopoietic stem cells has shown efficacy in 2 forms of severe combined immunodeficiency, providing an alternative to allogeneic tissue transplantation.

Dasatinib inhibits recombinant viral antigen-specific murine CD4 + and CD8 + T-cell responses and NK-cell cytolytic activity in vitro and in vivo

Dasatinib (BMS-354825) is a small molecule Src/Abl tyrosine kinase inhibitor approved for the treatment of chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia. Members of the Src family of kinases are involved in the induction of innate and adaptive immunity. The purpose of this study was to evaluate the inhibitory action of dasatinib on antigen-specific CD8(+) and CD4(+) T-cell function, as well as natural killer (NK) cell cytotoxicity. To assess dasatinib-mediated inhibition of antigen-specific T-cell proliferation, transgenic CD4(+) and CD8(+) T cells specific for ovalbumin were utilized. Endogenous CD4(+) and CD8(+) T-cell responses were determined following immunization of dasatinib-treated or control mice with a nonreplicating recombinant virus. Clearance of the RMA-S cells, a major histocompatibility complex (MHC) class I-deficient thymoma sensitive to NK-cell lysis, was analyzed in mice undergoing dasatinib treatment. Dasatinib inhibited antigen-specific proliferation of murine CD4(+) and CD8(+) transgenic T cells in vitro and in vivo. Endogenous antigen-specific helper T-cell recall responses and induction of T-cell-mediated cytotoxicity following immunization with a nonreplicating recombinant virus were also inhibited. So to was the ability of NK cells to eliminate MHC class I-deficient cells in vivo. These findings suggest that dasatinib has the potential to modulate the host immune response at clinical doses and highlights scope for off target applications, e.g., therapeutic immunosuppression in the context of autoimmune pathogenesis and allogeneic tissue transplantation.

No influence of collagenous proteins of Achilles tendon, skin and cartilage on the virus-inactivating efficacy of peracetic acid–ethanol

The risk of transmitting human pathogenic viruses via allogeneic musculoskeletal tissue transplants is a problem requiring effective inactivation procedures. Virus safety of bone transplants was achieved using peracetic acid (PAA)–ethanol sterilisation. Proteins are known to have an adverse effect on the virus-inactivating capacity of PAA. Therefore we investigated virus inactivation by PAA in collagenous tissues. Achilles tendon, skin and cartilage were cut into small pieces, lyophilised and contaminated with pseudorabies virus (PRV) or porcine parvovirus (PPV). The inactivating capacity of PAA–ethanol was investigated by determining virus titres in the supernatant or the tissue pellet at different time-points. In all virus-contaminated tissue samples treatment for 10 min with PAA–ethanol resulted in titre reductions by a factor of >10 3. PRV was rapidly inactivated below the detection limit (≤2.8 × 10 1 TCID 50/ml). After 240 min a reduction by a factor of >10 4 was obtained for PPV in all samples, but a residual infectivity remained. Collagenous proteins of Achilles tendon, skin and cartilage had no adverse effect on the virus-inactivating capacity of PAA. PAA–ethanol used in the production process at the Charité tissue bank can therefore be recommended for treatment of non-osseous musculoskeletal tissues.

Vascularized composite islet-kidney transplantation in a miniature swine model

Previous work from this laboratory has demonstrated that transplantation of allogeneic thymic tissue as part of a composite vascularized graft is far more successful in terms of both engraftment and long-term survival than transplantation of thymic tissue or cells alone. We have subsequently extended this concept to transplantation of allogeneic islets, comparing survival of islet cell suspensions to that of vascularized composite islet-kidneys (IK), prepared by injection of autologous islets underneath the renal capsule 2-3 months prior to allogeneic transplantation of the composite organ. We have utilized partially inbred miniature swine with defined MHC loci as the experimental large animals for this study, permitting reproducible transplantation across specific MHC barriers. Composite IK have been transplanted successfully across minor and full MHC mismatch barriers, using treatment regimens previously demonstrated to induce long-term tolerance of kidney allografts across these barriers. IK allografts containing > or =5000 islet equivalents (IE)/kg recipient body weight were found capable of reversing surgically induced diabetes, while injection of comparable numbers of purified islets via the portal vein or under the renal capsule did not. Studies are also being directed toward preparation of autologous "thymo-isletkidneys" (TIK), for potential use as xenografts, in which the thymic component is intended to induce tolerance and the islets to reverse diabetic hyperglycemia. The use of both types of composite organ transplants may eventually be applicable to the treatment of type I diabetic patients suffering from end-stage diabetic nephropathy.

Identification of Their Epitope Reveals the Structural Basis for the Mechanism of Action of the Immunosuppressive Antibodies Basiliximab and Daclizumab

Interleukin-2 (IL-2) and its receptor (IL-2R) play a major role in cellular immunity. The monoclonal antibodies basiliximab and daclizumab directed against the IL-2R subunit CD25 are widely used to prevent graft or host rejection after allogeneic tissue transplantation. Although these antibodies have been used for this purpose for many years, their common epitope within the CD25 protein is unknown. We screened a random phage display library to isolate peptides specifically binding to basiliximab. A striking amino acid sequence motif was enriched. This motif is homologous to the peptide ERIYHFV comprising amino acid positions 116 to 122 within the extracellular domain of CD25, suggesting that this is the basiliximab epitope. Basiliximab and daclizumab binding of selected phage was specific, as no binding was observed to isotype antibody controls. Phage binding could be inhibited by the cognate peptide. In cells expressing mutant CD25, binding of basiliximab was abolished when two or more amino acids of the suspected epitope were changed. In contrast, basiliximab binding remained unaffected in cells expressing CD25 versions with mutations outside this epitope. We therefore conclude that the (116)ERIYHFV(122) string within CD25 is the epitope recognized by basiliximab and daclizumab. This epitope overlaps with the interaction site of CD25 and IL-2, thus revealing the structural basis for the inhibition of IL-2R binding by this class of immunosuppressive antibodies.

Antigen-specific precursor frequency impacts T cell proliferation, differentiation, and requirement for costimulation

After a brief period of antigenic stimulation, T cells become committed to a program of autonomous expansion and differentiation. We investigated the role of antigen-specific T cell precursor frequency as a possible cell-extrinsic factor impacting T cell programming in a model of allogeneic tissue transplantation. Using an adoptive transfer system to incrementally raise the precursor frequency of antigen-specific CD8+ T cells, we found that donor-reactive T cells primed at low frequency exhibited increased cellular division, decreased development of multifunctional effector activity, and an increased requirement for CD28- and CD154-mediated costimulation relative to those primed at high frequency. The results demonstrated that recipients with low CD4+ and CD8+ donor-reactive T cell frequencies exhibited long-term skin graft survival upon CD28/CD154 blockade, whereas simultaneously raising the frequency of CD4+ T cells to ∼0.5% and CD8+ T cells to ∼5% precipitated graft rejection despite CD28/CD154 blockade. Antigenic rechallenge of equal numbers of cells stimulated at high or low frequency revealed that cells retained an imprint of the frequency at which they were primed. These results demonstrate a critical role for initial precursor frequency in determining the CD8+ T cell requirement for CD28- and CD154-mediated costimulatory signals during graft rejection.

Tissue oversight in hospitals: the role of the transfusion services

Tissue oversight in hospitals: the role of the transfusion services

Towards the Generation of Patient-Specific Pluripotent Stem Cells for Combined Gene and Cell Therapy of Hematologic Disorders

Hematopoietic stem cell transplantation (HSCT) has proven successful for the treatment of a host of genetic and malignant diseases of the blood, but immune barriers to allogeneic tissue transplantation have hindered wider application. Likewise, gene therapy now appears effective in the treatment of various forms of immune deficiency, and yet insertional mutagenesis from viral gene transfer has raised safety concerns. One strategy for addressing the limitations of both gene therapy and allogeneic transplantation entails the creation of pluripotent stem cells from a patient's own somatic cells, thereby enabling precise in situ gene repair via homologous recombination in cultured cells, followed by autologous tissue transplantation. In murine model systems, the methods of somatic cell nuclear transfer, parthenogenesis, and direct somatic cell reprogramming with defined genetic factors have been used to generate pluripotent stem cells, and initial efforts at therapeutic gene repair and tissue transplantation suggest that the technology is feasible. Generating patient-specific autologous pluripotent stem cells provides an opportunity to combine gene therapy with autologous cell therapy to treat a host of human conditions. However, a number of technical hurdles must be overcome before therapies based on pluripotent human stem cells will appear in the clinic.

Engraftment of human T, B and NK cells in CB.17 SCID/beige mice by transfer of human spleen cells

Models of severe combined immuno-deficient (SCID) mice reconstituted with a competent human immune system represent a valuable tool for the study of human immune responses in vivo. Reconstitution with human cells can be achieved using large numbers of peripheral blood lymphocytes, but levels of engraftment are poor and graft versus host disease (GVHD) frequently occurs. SCID/beige mice are at the same time deficient for adaptive and innate immunity and the objective of this study was to develop a safe and efficient way to achieve human lymphocyte engraftment in these mice using human spleen cells. After institutional authorisations and informed consent of relatives, a piece of spleen was obtained from cadaveric organ donors and the splenocytes were isolated and cryopreserved for later use. Single intraperitoneal injections of 5–100 × 10 6 splenocytes were performed into SCID/beige mice. Reconstitution of a human immune system was monitored weekly by the presence of human cells and IgG in peripheral blood. The mice were sacrificed 4 weeks after the injection and the engraftment in lymphoid organs was studied. A reproducible reconstitution was obtained with intraperitoneal injection of 30–40 × 10 6 spleen cells. Human T, B and NK cells as well as human IgG were present in peripheral blood. In lymphoid tissues, the same lymphocytic subpopulations were detected and in addition some antigen presenting cells. The reconstitution was functional because graft rejection was observed after transplantation of human allogeneic tissues. When less than 30 × 10 6 cells were injected, the reconstitution was variable. When more than 40 × 10 6 cells were injected, GVHD occurred with increasing frequency. In conclusion, we show that intraperitoneal injection of 30–40 × 10 6 human splenocytes into SCID/beige mice induces a quick and functional engraftment of human T, B and NK cells with no risk of GVHD. This model may be used to study human transplantation immunobiology in vivo.

Alterations of the Female Reproductive System in Recipients of Islet Grafts

Transplantation of allogeneic tissues is becoming a wider practice for the replacement of organ function lost to congenital or acquired pathologies. Chronic immunosuppression remains a necessity to prevent organ rejection, despite increased risks of infection, organ toxicity, and malignancies. Abnormalities of female gonadal function in patients of reproductive age are recognized, however, pathological alterations of the reproductive system in patients treated with new generation immunosuppressive drugs are still poorly documented. We report herein our observations of abnormalities of the reproductive system in 13 female recipients of allogeneic islets for type 1 diabetes, under immunosuppression therapy based on daclizumab induction and tacrolimus/sirolimus maintenance. Menstrual cycle alterations and clinically significant ovarian cysts were frequently observed in our patients, some requiring medical or surgical intervention. All ovarian cysts appeared of benign nature. Our findings suggest that pre- and posttransplant evaluation of female patients should include menstrual history, baseline pelvic ultrasound, and hormonal levels to assess the presence and monitor the progression of such alterations.

Thymic transplantation for complete DiGeorge syndrome: Medical and surgical considerations

Background/purpose Complete DiGeorge syndrome results in the absence of functional T cells. Our program supports the transplantation of allogeneic thymic tissue in infants with DiGeorge syndrome to reconstitute immune function. This study reviews the multidisciplinary care of these complex infants. Methods From 1991 to 2001, the authors evaluated 16 infants with complete DiGeorge syndrome. All infants received multidisciplinary medical and surgical support. Clinical records for the group were reviewed. Results Four infants died without receiving a thymic transplantation, and 12 children survived to transplantation. The mean age at time of transplantation was 2.7 months (range, 1.1 to 4.4 months). All 16 infants had significant comorbidity including congenital heart disease (16 of 16), hypocalcemia (14 of 16), gastroesophageal reflux disease or aspiration (13 of 16), CHARGE complex (4 of 16), and other organ involvement (14 of 16). Nontransplant surgical procedures included central line placement (15 of 16), fundoplication or gastrostomy (10 of 16), cardiac repair (10 of 16), bronchoscopy or tracheostomy (6 of 16), and other procedures (12 of 16). Complications were substantial, and 5 of the 12 transplanted infants died of nontransplant-related conditions. All surviving infants have immune reconstitution, with follow-up from 2 to 10 years. Conclusions Although the transplantation of thymic tissue can restore immune function in infants with complete DiGeorge syndrome, these children have substantial comorbidity. Care of these children requires coordinated multidisciplinary support.