Bakgrund: Organtransplantation ger nytt hopp och nytt liv till sjuka patienter. Njursvikt är en kronisk, försvagande sjukdom som påverkar många aspekter av patienternas liv. Den effektivaste behandlingen mot kronisk njursvikt är transplantation. Forskning visar hur patienterna upplever livet efter njurtransplantation.Syfte: Syftet är att sammanställa vetenskapliga artiklar som belyser patienters upplevelse av livet efter njurtransplantation.Metod: Litteraturstudie med tematisk analys av tio vetenskapliga artiklar med kvalitativ ansats.Resultat: Studiens resultat visade att en del av patienterna upplevde många positiva förändringar men det fanns också en del som upplevde ett antal begränsningar. Att leva med en ny njure ledde till en känsla av frihet, glädje, lycka och en möjlighet till att kunna planera mer långsiktigt. Rädsla och oro över att den nya njuren kunde stötas bort, skuld över att ta emot någon annans njure, livslångbehandling och för höga förväntningar ledde till ett begränsat liv. Resultatet visade inte på någon tydlig skillnad mellan kvinnor och mäns upplevelser av livet efter njurtransplantationen men vissa variationer kunde urskiljas.Konklusion: I studien framkom olika aspekter kring hur patienterna såg på livet efter en njurtransplantation. Före uppsatsen förväntade vi oss att patienterna skulle vara lättade då de tidigare varit på gränsen till döden. Men även om patienterna upplevde att de hade en högre livskvalitet efter transplantationen kom det ändå stunder då de misströstade och trodde att förbättringarna endast var tillfälliga. / Background: Organ transplantation gives new hope and new life to patients. Renal failure is a chronic, devastating disease that affects many aspects of the patients' lives. The most effective treatment for chronic kidney failure is transplantation. Research shows how patients experience life after kidney transplantationAim: The aim is to collect scientific articles that highlight the patient's experience of life after transplantation.Method: Literature study with thematic analysis of ten scientific articles with qualitative approach.Results: The study results showed that some of the patients experienced many positive changes, but there were also some who experienced a few limitations. Living with a new kidney led to a sense of freedom, joy, happiness, and opportunity to be able to plan more over a long term. The fear and concern that the new kidney could be rejected, guilt over receiving someone else's kidney, life-long treatment and high expectations led to a limited life. The results showed no significant difference between women’s and men's experiences of life after kidney transplantation, but certain variations could be discerned.Conclusion: The study revealed different aspects of the experience of life after renal transplantation. Before this study was expected only the good aspects and believed that it would only be a relief for patients as the previously lasted on the verge of death. Even if patients feel that they had a better life than before the transplant there are times when they despair, and think that the improvements they experience only temporary.

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京都大学 / 新制・課程博士 / 博士(医学) / 甲第23770号 / 医博第4816号 / 新制||医||1056(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 長船 健二, 教授 安達 泰治, 教授 遊佐 宏介 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Allogeneic hematopoietic chimerism leading to central tolerance has significant therapeutic potential. Establishment of hematopoietic chimerism created by stem cell transplantation has been shown to prevent and cure a number of autoimmune diseases and induce the most robust and long-lasting form of transplantation tolerance known. However, the realization of the vast clinical potential of hematopoietic chimerism for induction of transplantation tolerance has been impeded by the toxicity of the host conditioning regimen and the development of graft-versus-host disease (GVHD). This thesis describes the development of stem cell transplantation protocols that 1) reduce the host conditioning regimen; and 2) abrogate the development of GVHD. When applied to the treatment of autoimmune diabetic NOD mice, a model of type 1 diabetes, stem cell transplantation was able to 3) prevent autoimmune recurrence; and 4) permit curative pancreatic islet transplantation. I first describe a tolerance-based stem cell transplantation protocol that combines sub-lethal irradiation with transient blockade of the CD40-CD154 costimulatory pathway using an anti-CD154 antibody. With this protocol, I established hematopoietic chimerism in BALB/c mice transplanted with fully allogeneic C57BL/6 bone marrow. All chimeric mice treated with anti-CD154 antibody remained free of graft vs.host disease (GVHD) and accepted donor-origin but not third party skin allografts. It was similarly possible to create allogeneic hematopoietic chimerism in NOD/Lt mice with spontaneous autoimmune diabetes. Pancreatic islet allografts transplanted into chimeric NOD/Lt mice were resistant not only to allorejection but also to recurrence of autoimmunity. I conclude that it is possible to establish robust allogeneic hematopoietic chimerism in sub-lethally irradiated mice without subsequent GVHD by blocking the CD40-CD154 costimulatory pathway using as few as two injections of anti-CD154 antibody. I also conclude that chimerism created in this way generates donor-specific allograft tolerance and reverses the predisposition to recurrent autoimmune diabetes in NOD/Lt mice, enabling them to accept curative islet allografts. In order to further reduce the impediments associated with the implementation of allogeneic hematopoietic chimerism as a therapeutic modality, I adapted a costimulation blockade-based protocol developed for solid organ transplantation for use in stem cell transplantation. The protocol combines a donor-specific transfusion (DST) with anti-CD154 antibody to induce peripheral transplantation tolerance. When applied to stem cell transplantation, administration of DST, anti-CD154 antibody, and allogeneic bone marrow led to hematopoietic chimerism and central tolerance with no myeloablation (i.e. no radiation) and no GVHD in 3 different strains of mice. The development of donor-specific tolerance in this system was shown to involve deletion of both peripheral host alloreactive CD8+ T cells and nascent intrathymic alloreactive CD8+ T cells. In the absence of large numbers of host alloreactive CD8+ T cells, the cell transfusion that precedes transplantation need not be of donor-origin, suggesting that both allo-specific and non-allo-specific mechanisms regulate engraftment. Agents that interfere with peripheral transplantation tolerance partially impair establishment of chimerism. I conclude that robust allogeneic hematopoietic chimerism and central tolerance can be established in the absence of host myeloablative conditioning using a peripheral transplantation tolerance protocol.

Made available in DSpace on 2015-07-22T20:49:22Z (GMT). No. of bitstreams: 0 Previous issue date: 2010-10-29. Added 1 bitstream(s) on 2015-08-11T03:25:34Z : No. of bitstreams: 1 Publico-018.pdf: 1910669 bytes, checksum: a40b61267560276f1db47642341c6e56 (MD5) / Introdução: Polimorfismos genéticos estão associados com um aumento do risco de tromboembolismo venoso (TEV) e outras doenças cardiovasculares. Estudos prévios sugerem que a doença venooclusiva hepática (DVOH), que se desenvolve intra transplante de medula óssea pode ser atribuída à polimorfismos gênicos. Objetivos: Avaliar a correlação entre polimorfismos genéticos e o risco de doença venooclusiva hepática no transplante de medula óssea e a associação com a presença de variáveis como o uso de vancomicina, drogas citotóxicas usadas no regime de condicionamento, presença de disfução hepática anterior ao transplante, presença de infecção por citomegalovírus, e grupos de doenças avaliáveis. Pacientes e métodos: Este estudo caracteriza-se por um estudo clinico observacional multicêntrico. Foram avaliados 120 pacientes, submetidos a transplante alogênico de medula óssea. Cada paciente foi avaliado propectivamente para DVOH, confirmado pelo critério de Seattle modificado, idade variando de 2 a 65 anos. Fatores de risco para DVOH severo foram analisados usando modelos estatisticos de avaliação. Detectamos simultaneamente através de PCR seguido de digestão e detecção através de eletroforese em gel de agarose, mutação do HFE C282Y, H63D, S65C; MTHFR C677T; Fator V de Leiden, Protrombina 20210A e glutationa S-tranferase. Resultados: Neste estudo observacional de pessoas, submetidas a transplante de medula óssea alogênico, a presença de disfução hepática pré transplante foi um fator de risco significante para DVOH. Nós tambem observamos uma associação entre a presença de mutação HFE S65C e disfunção hepática. Conclusões: Em resumo, nossos dados sugerem que disfunção hepatica observada pré transplante de medula óssea é um fator de risco estatisticamente significante para DVOH e que a presença da mutação do HFE S65C apresenta uma tendência ao desenvolvimento de dano hepático. Contudo, não evidenciamos associação dos polimorfismos estudados com DVOH. / TEDE

Le système immunitaire nous protège contre les infections et les cancers. Cependant, des réponses immunitaires excessives ou incontrôlées peuvent causer des pathologies potentiellement mortelles comme le choc endotoxinique, des maladies auto-immunes, ou le rejet d’allogreffe. Une compréhension claire des mécanismes de régulation des réponses immunes permettrait d’envisager de nouvelles thérapeutiques plus ciblées. Dans ce travail réalisé chez la souris, la modulation de la réponse inflammatoire à une toxine bactérienne, le lipopolysaccharide (LPS), a été utilisée comme archétype de la régulation immunitaire. Ceci nous a permis de démontrer que la régulation de la prolifération homéostatique de lymphocytes T CD4+CD25- par des lymphocytes T régulateurs naturels tempère la réponse inflammatoire au LPS. Cet effet est notamment dépendant d’une diminution de la sécrétion d’IFN-γ par les lymphocytes activés par la prolifération induite par la lymphopénie. Nous avons aussi observé, que la désensibilisation du système immunitaire inné vis-à-vis du LPS, suite à des injections répétées d’endotoxine, induit le développement de cellules myéloïdes suppressives (myeloïd-derived suppressor cells MDSC) capables de réguler des réponses lymphocytaires T in vitro et in vivo. Nous avons pu mettre en évidence que l’effet suppresseur des MDSC est dépendant de leur expression de l’enzyme hème oxygénase-1 et de leur production d’IL-10. Le dialogue constant entre les cellules de l’immunité innée et de l’immunité acquise assure donc à la fois l’activation et la régulation du système immunitaire. Dans la majorité des cas, ceci permet aux réponses immunitaires d’être efficaces sans être excessives. La mise en évidence de ces processus identifie les lymphocytes T régulateurs et les cellules myéloïdes suppressives comme des éléments clefs de la régulation d’un processus inflammatoire. Les traitements immunosuppresseurs, les thérapies cellulaires et les greffes de moelle ont des effets variables et mal connu sur ces populations de cellules régulatrices. Tenir compte de ces interférences thérapeutiques avec les processus naturels de régulation de notre système immunitaire permettra certainement d’optimaliser l’utilisation de ce type de traitements. D’autre part, l’utilisation thérapeutique de ces deux types de cellules régulatrices pourrait être envisagé dans de nouvelles stratégies d’immuno-modulation plus « physiologique ».<p> / Doctorat en Sciences médicales / info:eu-repo/semantics/nonPublished

Indiana University-Purdue University Indianapolis (IUPUI) / Living donors have contributed about 6,000 kidneys per year in the past 10 years, but more than 100,000 individuals are still waiting for a kidney transplant. Living kidney donors undergo a major surgical procedure without direct medical benefit to themselves, but comprehensive follow-up information on living donors’ health is unfortunately limited. Expert recommendations suggest capturing clinical information beyond traditional sources to improve surveillance of co-morbid conditions from living kidney donors. Currently the United Network for Organ Sharing is responsible for collecting and reporting follow-up data for all living donors from U.S. transplant centers. Under policy implemented in February of 2013, transplant centers must submit follow-up date for two years after donation, but current processes often yield to incomplete and untimely reporting. This dissertation uses a statewide Health Information Exchange as a new clinical data source to 1) retrospectively identify a cohort of living kidney donors, 2) understand their follow-up care patterns, and 3) observe selected clinical outcomes including hypertension, diabetes and post-donation renal function.

Résumé : Durant les dernières années, l’encapsulation d’îlots pancréatiques endocriniens a reçu une grande attention parce qu’elle pourrait constituer une solution pour diminuer les taux d'échecs des transplantations. Dans le contexte de la perte de la matrice extracellulaire (MEC) native des îlots lors de leur isolation et le rejet de greffes par le système immunitaire du receveur, cette thèse vise à améliorer la compréhension des interactions entre la MEC et les cellules des îlots pancréatiques endocriniens ainsi qu’à étudier les effets de stress apoptotiques associés à des éléments du système immunitaire sur la survie et les fonctions des îlots. Ces études pourraient permettre de raffiner notre compréhension des mécanismes associés au rejet des greffes d'îlots de Langerhans. Dans cette thèse, le premier chapitre constitue une revue de la littérature permettant de mettre en lumière les rôles réciproques de la MEC dans l'action des cellules immunitaires et l'influence de ces rôles sur le diabète de type 1 (DT1) et sur la transplantation d'îlots. Ce premier chapitre a été publié dans la revue Pathologie Biologie. Le premier travail expérimental comprend la culture de cellules d'insulinomes de rat (INS-1) sur des surfaces composées de carboxyméthyl dextrane (CMD) recouvertes de fibronectine, RGD ou YIGSR, un peptide synthétique de la laminine. Dans cette étude, l'effet bénéfique d’éléments de la MEC sur ces cellules productrices d'insuline a été démontré. Les cellules INS-1 ont davantage proliféré sur ces surfaces et sécrétaient plus d’insuline que les cellules INS-1 cultivées sur les surfaces contrôle de CMD, CMD+RGE et dans les plaques à multi-puits de polystyrène vendues pour la culture tissulaire (TCPS). Cette première étude a été publiée dans Acta Biomaterialia. La deuxième étude expérimentale avait pour objectif d’étudier l’effet protecteur de gels de fibrine pour enrober des îlots pancréatiques endocriniens isolés de jeunes porcs et exposés à deux concentrations de peroxyde d'hydrogène (H[indice inférieur 2]O[indice inférieur 2]). L’enrobage dans la fibrine a permis de réduire l'apoptose chez les cellules des îlots et d’améliorer la sécrétion d'insuline par ceux-ci lorsque les résultats étaient comparés à ceux des îlots non-enrobés. Ce travail a été publié dans la revue Islets. Dans la troisième étude expérimentale, des îlots porcins étaient enrobés dans des gels de fibrine et d'alginate et exposés à des monocytes humains pour comparer l’effet de l’enrobage par ces deux matériaux sur la survie et les fonctions des îlots. Les monocytes sécrétaient des concentrations importantes de cytokines TNFα, IL-6, IL-1β en réponse à la fibrine seule et aux îlots. Les cellules des îlots enrobés dans les gels de fibrine et d'alginate étaient moins apoptotiques et sécrétaient plus d'insuline que leurs contrôles respectifs non-enrobés. Cette étude a été acceptée dans la revue Pathologie Biologie. // Abstract : In recent years, the encapsulation of endocrine pancreatic islets has received enhanced attention as it might constitute a solution for islet transplantation failure. In the context of the loss of the native islet extracellular matrix (ECM) and graft rejection by the recipient’s immune system, this thesis aims to improve the understanding of ECM-islet cell interactions and immune system-related implications in islet survival and function in the context of type 1 diabetes mellitus (T1DM) and islet graft rejection. In the first chapter, a literature review introduces the reciprocal roles of the ECM in immune cell action and the influence of these interactions on T1DM and islet transplantation. The most important ECM components are discussed followed by an overview of immune cells and their possible implication in diabetes. Immune cell integrins and cytokines and their communication with and influence on ECM are highlighted, concluding in a brief discussion of the significance of these interactions for islet transplantation and encapsulation. This review has been accepted for publication by Pathologie Biologie. The first experimental work comprises the culture of rat insulinoma cells (INS-1) on welldefined low-fouling carboxymethyl-dextran (CMD) surfaces covalently grafted with fibronectin, RGD and YIGSR, a synthetic laminin peptide, resulting in higher cell proliferation and insulin secretion of INS-1 cells when compared to the controls CMD, CMD+RGE and tissue culture polystyrene (TCPS) plates. With this work, the beneficial effect of ECM cues on insulin-producing cells was proven. This study has been published in Acta Biomaterialia. The second experimental work aimed to study the effect of fibrin gels when used to embed endocrine pancreatic islets isolated from young pigs and exposed to hydrogen peroxide (H[subscript 2]O[subscript 2]). Fibrin-embedded islets showed less apoptosis and higher relative insulin secretion than islets on TCPS, verifying the protective effect of fibrin towards islets. This study has been published in Islets. In the third experimental study, porcine islets were encapsulated in fibrin and alginate gels and exposed to human monocytes to compare the two materials and to further investigate the immune protective properties of fibrin and alginate. Monocytes secreted high concentrations of TNFα, IL-6, and IL-1β in response to fibrin, but at the same time islets in both fibrin and alginate gels were less apoptotic and secreted more insulin then their TCPS controls. This study has been submitted to Pathologie Biologie.

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a malignant liver tumor which is thought to be a variant of conventional hepatocellular carcinoma (HCC). It accounts for a small proportion of HCC cases and occurs in a distinctly different group of patients which are young and usually not in the setting of chronic liver disease. The diagnosis of FL-HCC requires the integration of clinical information, imaging studies, and histology. In terms of the treatment options, the only potentially curative treatment option for patients who have resectable disease is surgery either liver resection (LR) or liver transplantation (LT). When performed in a context of aggressive therapy, long-term outcomes after surgery, particularly liver resection for FL-HCC, were favorable. The clinical outcome of patients with unresectable disease is suboptimal with median survival of less than 12 months. The aim of this review is to update the available evidence on diagnosis, treatment options, outcome predictors, and recent developments of patients with this rare disease and to provide a summarized overview of the available literature.

L’expansion des cellules souches hématopoïétiques ex vivo représente une option des plus intéressante afin d’améliorer les greffes de moelle osseuse. Le facteur de transcription HOXB4 semble être le candidat ayant le plus de potentiel jusqu’à présent. Cependant, la très courte demi-vie de la protéine représente un obstacle majeur dans l’élaboration de protocoles cliniques. Par contre, la substitution d’un acide aminé (3 mutations individuelles) dans la partie N-terminale de la protéine augmente de près de 3 fois la stabilité intracellulaire de HOXB4. Nous avons comparé l’activité biologique de ces mutants à celle de HOXB4 natif (« wt ») dans des essais in vitro et in vivo. Nous avons démontré que la surexpression de HOXB4 muté par infection des cellules souches hématopoïétiques n’affectait pas leur pouvoir de reconstitution hématopoïétique à long terme dans des souris transplantées. Par ailleurs, nous avons noté que dans les essais de reconstitution hématopoïétique en compétition et en non compétition, les cellules surexprimant les protéines mutées ont une expansion supérieure in vitro et reconstituent le sang et la rate avec une répartition de cellules lymphoïdes et myéloïdes plus près de souris non-transplantées comparativement aux cellules exprimant HOXB4 « wt ». De plus, les cellules surexprimant la protéine HOXB4 mutée apparaissent beaucoup plus rapidement et en plus grande proportion dans le sang comparativement aux cellules surexprimant la forme native. Une des protéines HOXB4 mutées (1426) ne permet pas l’expansion des progéniteurs myéloïdes immatures (CMP) contrairement à la protéine « wt ». Et finalement, par les études de modulation intracellulaire protéique, nous avons démontré que les comportements des protéines HOXB4 « wt » et mutées envers les cellules souches hématopoïétiques et progéniteurs n’étaient pas complètement dus à un effet de concentration protéique. / Ex vivo hematopoietic stem cell expansion represents a most appealing option to improve bone marrow transplantation. Utilization of the unique hematopoietic stem cell (HSC) expansion abilities of the transcription factor HOXB4 for clinical applications is hampered by its short intracellular half-life. To overcome this difficulty, 3 different single amino-acid substitution mutants of HOXB4 with 3-4 fold increased half-life were generated and their biologic activity compared to that of wild type (wt) HOXB4 using in vitro and in vivo assays. We have shown that overexpression of mutated HOXB4 in HSC using an infection strategy did not impair their long term hematopoietic reconstitution potential in transplanted mice. We have found that cells overexpressing mutant HOXB4 had greater expansion in vitro in competitive and non-competitive designs than wt HOXB4. Moreover, in vivo peripheral blood and spleen repopulation had lymphoid and myeloid contributions closer to untransplanted animals with mutant than wt HOXB4. In addition, cells overexpressing mutant HOXB4 protein were detected much more rapidly and in greater proportion in peripheral blood than cells overexpressing the wt form. One of the mutated HOXB4 proteins (1426) did not promote the expansion of common myeloid progenitors in comparison to wt HOXB4. Finally, using intracellular protein modulation studies, we have shown that the effects of mutated and wt HOXB4 proteins in hematopoietic stem and progenitor cells were not completely due to a HOXB4 concentration effect.