Lung transplantation is the only therapeutic approach for patients presenting end-stage pulmonary failure. Despite progress made in organ preservation and immunosuppression, primary graft dysfunction and obliterative bronchiolitis still hamper short-term and long-term outcomes, respectively. Interleukin-17 recently emerged as a major actor in several immuno-inflammatory disorders. Clinical and experimental evidence also suggest the implication of interleukin-17 or type 17 CD4+ T cells in lung rejection. We therefore investigated the contribution of this cytokine to graft pathology in a murine model of tracheal transplantation that recapitulates pathological features of lung rejection including the development of obliterative airway disease.<p>We first demonstrated that interleukin-17 contributes to inflammatory lesions in the early phase post-transplantation. Interleukin-17 was found to be produced by &61543;&61540;+ T cells and CD4+ T cells infiltrating the graft and interleukin-17 neutralization significantly reduced the development of epithelial lesions together with inhibition of interleukin-6 and heat-shock-protein 70 gene transcription.<p>We then investigated the contribution of interleukin-17 to obliterative airway disease. Although interleukin-17 did not play a dominant role in absence of immunosuppression, it was found to contribute to airway pathology in animals receiving cyclosporin A. Under this treatment, we first observed dramatic changes in the composition of the lymphocyte populations infiltrating the graft: the numbers of CD8+ T cells producing interferon-&61543; and type 1 CD4+ T cells were dramatically decreased while the numbers of type 17, and also type 2 CD4+ T cells were unaffected. The pathological relevance of these findings was first demonstrated by the prolongation of graft survival afforded by the depletion of CD4+ T cells in cyclosporin A-treated animals. Furthermore, graft rejection was also delayed in mice genetically deficient in either interleukin-17 or interleukin-4, providing evidence that type 17 and type 2 CD4+ T cells actively contribute to graft rejection in cyclosporin A-treated recipients. On the other hand, parallel experiments in interferon-&61543;-deficient mice revealed that interferon-& / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Bakgrund: Organtransplantation är en rutinmässig behandling i vården. Ett underskott på organ gör väntetiden lång, vilket leder till långa väntetider och medför oro och rädsla. När en människa placeras på väntelistan är en organtransplantation den sista utvägen eftersom organet är så pass skadat. Syfte: Syftet var att belysa patientens upplevelse av väntan på en organtransplantation. Metod: Studien är en litteraturstudie med induktiv ansats där åtta artiklar ligger till grund för resultatet. Datan analyserades och delades in i kategorier och subkategorier med utgångspunkt från syftet. Resultat: Tre huvudkategorier med tillhörande subkategorier framkom; Känslor till följd av väntandet på en organtransplantation, Behovet av stöd och information och Ett begränsat liv. Patienter som väntar på en organtransplantation upplevde osäkerhet och oro för döden blandat med hopp inför framtiden. Denna osäkerhet kunde kännas större vid upplevd brist på information från vården. Begränsningen i vardagen upplevdes svår och då blev stödet från sjuksköterskor och anhöriga viktigare, tillsammans med att skapa strategier för att hålla hoppet uppe. Konklusion: Litteraturstudien visar att upplevelsen av väntan på en transplantation är liknande runt om i världen. Det finns ett behov av information och stöd från sjuksköterskan då detta skapar mer trygghet. Det är av vikt för sjuksköterskan att ha en förståelse för denna patientgrupp. / Background: Organ transplantation is a routine treatment in modern healthcare. Due to lack of organs in relation to the need, waiting is increased which causes anxiety and fear for patients. When a person is placed on the waiting list, an organ transplant is the last resort since the organ is highly damaged. Aim: The aim was to illustrate the patient’s experience of waiting for an organ transplant. Method: This study is a literature study and have an inductive approach and is based on eight articles. The data was analyzed and categorized in regard to the aim. Results: The result reports three categories and associated subcategories; Feelings about waiting for an organ transplant, The need for support and information and A limited life. Patients experience uncertainty and anxiety during the waiting time and a fear of death alongside hope. The uncertainty grew with lack of information from care givers. Limitations of daily life perceived tough hence the nursing and family support became paramount, all together creating strategies to inspire hope. Conclusion: The literature study shows that the waiting experience for a transplant is similar around the world. There is a need for information and support from nurses, therefore, the nursing sympathy, information and knowledge is essential in creating a safe environment.

Persufflation (PSF; gaseous oxygen perfusion) is an organ preservation technique with a potential for use in donor heart preservation. Improved heart preservation with PSF may improve outcomes by maintaining cardiac tissue quality in the setting of longer cold ischemia times and possibly increasing the number of donor hearts available for allotransplant. Published data suggest that PSF is able to extend the cold storage times for porcine hearts up to 14 hours without compromising viability and function, and has been shown to resuscitate porcine hearts following donation after cardiac death. This review summarizes key published work on heart PSF, including prospective implications and future directions for PSF in heart transplantation. We emphasize the potential impact of extending preservation times and expanding donor selection criteria in heart allotransplant. Additionally, the key issues that need to be addressed before PSF were to become a widely utilized preservation strategy prior to clinical heart transplantation are summarized and discussed.

Thesis (PhD)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: HISTORICAL PERSPECTIVE Stem cell therapy was commenced after using rabbits as research models. Once this process was successful, the first human transplant was done in 1974. Certain prerequisites were necessary and these were achieved - a protected environment, an apheresis unit, protocols and accreditation with International Registries. Initially, unmanipulated bone marrow and peripheral blood stem cells were used together with immunosuppressive drugs followed by the use of Cyclosporin A then the addition of ex vivo Campath®. AUDIT OF ACUTE ASSOCIATIONS (468 subjects in initial cohort) NEPHROLOGY Creatinine was used as an indication of renal function. Of the 76 available for analysis, 47% had acute kidney injury. Dialysis had a poor outcome as reported in the literature. Renal complications occurred frequently mostly due to infection. CARDIOLOGY A total of 119 individuals were available for analysis. Echocardiograms and electrocardiograms were part of pre-transplant assessment. Left ventricular systolic dysfunction predicted for increasing post transplant problems. Cardiac complications occurred at a lower frequency than other post-transplants side-effects consistent with the published data. DERMATOLOGY Cases were evaluated on a daily basis and referred to a dermatologist when necessary. To confirm Graft-Versus-Host Disease (GVHD), a skin biopsy was done to differentiate it from drug hypersensitivity or viral infections. The exposure to ex vivo Campath® significantly improved outcome by reducing the incidence and severity of GVHD. Quality of life was enhanced with substantial cost saving. GASTROENTEROLOGY Foregut symptoms occurred in 90% of patients. Nutritional problems were encountered. Altered liver functions were relatively common attributable to drugs, sepsis and conditioning regimens. Liver biopsies were not performed in this series and endoscopy performed only when necessary. A STUDY ON LATE COMPLICATIONS (55 subjects) RESPIRATORY Spirometry and diffusing capacity were done in this cohort. All the lung function studies were within the predicted normal range apart from some marginal reduction in diffusing capacity. In none of these patients did late consequences such as Bronchiolitis Obliterans Organising Pneumonia and Late Onset Non-Infectious Pulmonary complications occur. Cytomegalovirus reactivation was common but early intervention prevented serious complications. IMMUNOLOGY An in vitro functional study was done. Both the innate and adaptive systems were evaluated. Taken into consideration were the type of transplant, age from transplant, diagnosis and conditioning. The granulocyte Burst-test was done for the innate profile. Reduced activity was shown in all the subgroups. It appears as if the innate response of the granulocytic cells never recovered due to reduced granulocytic function in vitro. The adaptive responses were evaluated in vitro and only the autografts showed better CD4+ and CD8+ cytokine production. No major differences were seen in other groups. Normal cytokine production by CD4+ and CD8+ T cells were present when these were activated in vitro to produce regulatory cytokines, implying that their lymphoid component was intact post-transplant. BONE DISEASE Here both the Dual energy X-ray Absorptiometry (DXA) and Quantitative Computed Tomography (QCT) were used to evaluate bone mineral density. There was a discrepancy present between the two modalities. DXA showed no osteoporosis but QCT 22%. Biomarkers were normal in all. There was no history of fracture and no objective evidence of vertebral fractures using vertebral fracture assessment. Although QCT was used for the study, DXA remains the gold standard in South Africa. CONCLUSION This doctoral provided information on the non-haematological consequences in South Africa with the use of Campath® ex vivo. / AFRIKAANSE OPSOMMING: HISTORIESE PERSPEKTIEF Stamsel terapie is voortgesit nadat konyne aanvanklik as navorsingsmodelle gebruik is. Na suksesvolle voltooiing van hierdie proses, is die eerste menslike oorplanting gedoen in 1974. Sekere voorvereistes was nodig en hierdie was bereik – ʼn beskermde omgewing, ʼn aferese eenheid, protokolle en akkreditasie by Internasionale Registers. Aanvanklik is ongemanipuleerde beenmurg- en perifere bloed stamselle gebruik, tesame met immuunonderdrukkende middels, gevolg deur die gebruik van Sikloporien A en daarna die toevoeging van ex vivo Campath®. OUDIT VAN AKUTE ASSOSIASIES (468 GEVALLE IN DIE OORSPRONKLIKE GROEP) NEFROLOGIE Kreatinien is gebruik as ʼn aanduiding van nierfunksie. Van die 76 gevalle beskikbaar vir ontleding, het 47% akute nierbeserings gehad. Dialise het ʼn swak uitkoms gehad soos gerapporteer in publikasies. Nier komplikasies het gereeld voorgekom, meestal as gevolg van infeksie. KARDIOLOGIE ʼn Totaal van 119 gevalle was beskikbaar vir ontleding. Eggokardiogramme en elektrokardiogramme was deel van die pre-oorplanting assessering. Linker ventrikulêre disfunksie was voorspelbaar van verhoogde postoorplanting probleme. Kardiale komplikasies het konstant volgens publikasies minder geredelik voorgekom as ander post-oorplantings newe-effekte. DERMATOLOGIE Gevalle is op ʼn daaglikse basis geëvalueer en verwys na ʼn dermatoloog wanneer nodig. ʼn Velbiopsie is gedoen om “Graft-Versus-Host” siekte (GVHD) te bevestig en dit te onderskei van middel hipersensitiwiteit of virale infeksies. Die blootstelling aan ex vivo Campath® het uitkomste aansienlik verbeter deur die voorkoms en erns van GVHD te verminder. Kwaliteit van lewe is verhoog met aansienlike koste besparing. GASTROENTEROLOGIE Boonste gastro-intestinale simptome het voorgekom in 90% van die pasiënte. Wanvoeding het voorgekom.. Abnormale lewerfunksies was relatief algemeen toeskryfbaar aan middels, sepsis en kondisionerings protokolle. Lewer biopsies is nie in hierdie reeks uitgevoer nie en endoskopie slegs wanneer dit noodsaaklik was. DIE STUDIE VAN LAAT KOMPLIKASIES (55 GEVALLE) RESPIRATORIES Spirometrie en diffusie kapasiteit is gedoen in hierdie groep. Al die longfunksie ondersoeke was binne die voorspelde normale waardes behalwe ʼn paar marginale afnames in die diffusie kapasitiet. In geen van hierdie pasiënte het laat nagevolge soos Bronchoilitis Obliterans Organiserende Pneumonie en Laat Aanvangs Nieinfektiewe Long komplikasies voorgekom nie. Sitomegaal virus heraktivering was algemeen maar vroeë intervensie het ernstige komplikasies voorkom. IMMUNOLOGIE ʼn In vitro funksionele studie is gedoen. Beide die spesifieke en nie-spesifieke immuun stelsels is geëvalueer. Die tipe oorplanting, tyd vanaf oorplanting, diagnose en kondisionering is in ag geneem. Die “Granulocyte Burst” toets is gedoen vir die nie-spesifieke profiel. Verminderde aktiwiteite is bewys in al die subgroepe. Dit wil voorkom asof die nie-spesifieke respons van die granulosiete nooit herstel nie as gevolg van die verlaagde in vitro granulosiet funksie. Die spesifieke immuun respons is in vitro geëvalueer en slegs die outotransplantaat het beter CD4+ en CD8+ sitokiene produksie getoon. Geen groot verskille is gesien in ander groepe nie. By CD4+ en CD8+ T selle was normale sitokiene produksie teenwoordig toe dit in vitro geaktiveer is om regulatoriese sitokiene produksie te produseer, wat beteken dat hul limfoïede komponent na oorplanting ongeskonde was. BEEN SIEKTE Beide die Dubbele energie x-straal absorpsiemetrie (DXA) en Kwantitatiewe rekenaar tomografie (QCT) is hier gebruik om been mineraal digtheid te evalueer. Daar was ʼn teenstrydigheid teenwoordig tussen die twee modaliteite. DXA het geen osteoporose getoon nie maar QCT het 22% getoon. Biomerkers was normaal in albei. Daar was geen geskiedenis van frakture en geen objektiewe bewyse van vertebrale frakture met Vertebrale Fraktuur Assessering nie. Alhoewel QCT gebruik is vir die studie bly DXA die goue standaard in Suid-Afrika. GEVOLGTREKKING Hierdie doktoraal verskaf inligting oor die nie-hematologiese gevolge in Suid-Afrika met die gebruik van Campath® ex vivo.

published_or_final_version / abstract / Medicine / Master / Master of Research in Medicine

published_or_final_version / abstract / Medicine / Master / Doctor of Medicine

published_or_final_version / abstract / Medicine / Master / Master of Philosophy

published_or_final_version / Mechanical Engineering / Master / Master of Philosophy

published_or_final_version / Surgery / Doctoral / Doctor of Philosophy

Liver transplantation (LT) is the most effective treatment for hepatitis B virus (HBV) related liver failure and hepatocellular carcinoma (HCC). Nevertheless, HBV and HCC recurrence rate remains high after LT. Previous studies have shown that HBV reactivation is associated with HCC recurrence and poor prognosis after LT. The main objectives of this study are to investigate the risk factors for HBV and HCC recurrence after LT, the efficacy of antiviral drugs to prevent HBV reactivation and the underlying mechanisms contributing to HBV reactivation. Firstly, we investigate the risk factor for HBV and HCC recurrence in 551 HBsAg seropositive LT patients, of whom374 had no tumor and 177 had HCC. All patients received indefinite antiviral treatment after LT. The study showed that pre-LT HBV DNA levels and HCC recurrence were significantly associated with HBV reactivation after LT. Younger age, lower Child-Pugh score, beyond UCSF criteria, higher AST level, salvage LT, older donor, HBsAg seropositive at the last follow-up and HBV reactivation after LT were independent risk factors for HCC recurrence. HCC recurrence alone accounts for poor overall survival. The sequence analysis identified drug-resistant mutants as the main contributors to HBV reactivation. In addition, wild-type (antiviral drug-sensitive) HBV reactivation was identified in patients with HCC recurrence. Secondly, we investigate the efficacy of antiviral drugs monotherapy (Lamivudine or Entecavir) in preventing HBV reactivation. This study showed that patients receiving lamivudine (LAM) experienced significantly greater HBV reactivation and HCC recurrence than those receiving entecavir (ETV). In patients with no tumors, HBV reactivation was found in the LAM groups but not in the ETV groups, due to the appearance of a LAM drug-resistant mutant. In patients with HCC recurrence, HBV reactivation was found in both treatment groups. Wild-type HBV reactivation was identified in 17% (5/29) and 100% (1/1) of HCC patients receiving LAM and ETV respectively. This suggests that, although ETV had higher genetic barriers to HBV drug resistance; it still cannot prevent wild-type HBV reactivation in HCC-recurrent patients. Thirdly, we investigate the expression of HBV markers in HCC and adjacent non-tumor tissues. Origin of circulating HBV was identified using genetic distance analysis of HBV isolated from different compartments (i.e. HCC and adjacent non-tumor tissues). The study showed that, in some HCC cases, the expressions of HBsAg and HBV replicative efficiency are higher in HCC tissues than in adjacent non-tumor tissues. Moreover, through genetic distance analysis, we demonstrated that HBV reactivation could originate from recurrent HCC. These data suggest that HCC supports HBV replication and that HBV is secreted from recurrent HCC. Finally, we demonstrate that the up-regulation of drug-specific ABC-transporters is significantly associated with patients with HCC recurrence. In vitro studies also showed that the up-regulation of ABCG2 contributes to antiviral drug-resistant. Finally, we demonstrate that the up-regulation of drug-specific ABC-transporters is significantly associated with patients with HCC recurrence. In vitro studies also showed that the up-regulation of ABCG2 contributes to antiviral drug-resistant. / published_or_final_version / Surgery / Doctoral / Doctor of Philosophy