16/05/2015

PRINCIPLES OF IMMUNOLOGY AND SOLID ORGAN TRANSPLANTATION

DR SR RAMPERSHAD
Moderators : MR C BHULA Commentators : DR N NAIDOO
MR S MOODLEY DR S ISMAIL

INTRODUCTION(1,21)
The modern period of transplantation began in the late 1950’s. It has evolved from an experimental
and risky procedure to a highly successful medical therapy. An increasing number of diseases and
patients are now potentially treatable with transplants. Although some of the pioneering work
originated in South Africa, the country has an urgent need for improving solid organ
transplantation. Currently there are 4300 South African adults and children awaiting a life-saving
solid organ and cornea transplant. Only 335 solid organs were transplanted in 2013. Restricted
resources has widened the gap between transplants performed and an exponentially increasing list
of patients awaiting transplants.

TRANSPLANT TERMINOLOGY
Autograft: Transplantation of an individual’s own tissue to another site.
Isograft: Transplantation of tissue between genetically identical members of the same species.
(eg identical twins)
Allograft: Transplantation of tissue between genetically non-identical members of the same
species.
Xenograft: Transplantation of tissue between members of different species.

HISTOCOMPATIBILITY(4)
Histocompatibility refers to the quality of cellular or tissue graft enabling it to be accepted and
functional when transplanted into another organism. According to their relative potencies in
eliciting rejection, the major antigens in mammalian species are encoded by a closely linked series
of genes called Major Histocompatibility Complex. In humans, these genes reside in the short arm
of chromosome 6 and are known as Human Leucocyte Antigen (HLA). The proteins encoded by the
MHC are expressed on the surface of cells, and present both self and non-self antigens to T cells,
which have the capacity to kill or co-ordinate the killing of pathogens, and infected or
malfunctioning cells.
The gene products of the MHC are divided into 3 classes on the basis of their structure, tissue
distribution, function and the specific type of antigen expressed on their surface.

MHC class I: Present antigen fragments to cytotoxic T- cells via the CD8 molecule.
MHC class II: Present antigen fragments to T-helper cells by binding to the CD4 receptors on the
T- helper cells.
MHC class III: Encodes for complement and certain cytokines

Minor histocompatibility antigens (mHags) induce a weaker response than the MHC, because it is
almost impossible to raise antibodies to them. Few have been identified, and these include:
• H-Y, an antigen encoded on the Y chromosome. Thus only present in male tissue.
• HA-2, an antigen derived from the contractile protein myosin.

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 HISTOCOMPATIBILITY TESTING(2)

Predicting humoral alloimmune potential in transplant reciepients is the objective of

histocompatibility testing and depends on accurate donor typing and sensitive and specific testing
for antibodies to human leucocyte antigen.

ABO incompatibity: Basic ABO compatibility depends on the presence or absence of antigens on
donor RBCs and the presence or absence of specific antibodies to these antigens in the recipient's
serum. Anti-ABO antibodies are of the IgM classification and cause agglutination, complement
fixation, and hemolysis. If an ABO-incompatible graft is transplanted, hyperacute rejection will
occur.

Minor Red cell antigen typing: Besides the ABO antigen system, at least 15 different red cell
antigen systems have been identified, of which the Lewis system is most important. These are only
tested in patients at risk of sensitization (e.g. multiple prior blood transfusions).

Human Leucocyte Antigen typing:

All nucleated cells in the body express HLA class I molecules (A, B, Cw) whereas HLA class II
(DR, DP and DQ), molecule expression is limited to B cells, antigen presenting cells(APC’s) and
activated microvascular endothelial cells.

Various methods of typing include:

Serologic typing:
Utilizes various sera containing well characterized antibodies to a wide range of HLA specifities.
Patient lymphocytes are mixed with various sera and incubated with complement and a dye. This
method of testing is useful in detecting MHC class I antigens

Molecular typing:
PCR (Polymerase chain reaction) is used to amplify DNA sequences. HLA typing is assigned by
matching the primers of resulting amplification products to the DNA sequence of the various
candidate alleles.

HLA Antiboby Screening

Cytotoxic antibody screening:
The purpose of this test is to detect antibodies in the recipient’s serum that react with other HLA
antigen types. This involves the admixture of a recipient’s serum with a panel of potential donor
lymphocytes. The principle of complement dependant microlymphocytotoxicity is used to
determine a positive reaction; the percentage of which is expressed as the panel reactive antibody
(PRA), amongst the total cell panel. The PRA merely indicates broad sensitization and does not
reflect antibody strength or titer.

Solid Phase antibody screening:

These methods utilize soluble or recombinant HLA molecules. Purified HLA molecules are applied
to solid phase media (ELISA or microbeads), and therefore will bind only HLA antibody when
reciepient serum is added. Antibodies to human IgG are then added to detect any HLA antibody in
the serum.

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Complement dependant cytotoxicity crossmatch:
The recipient serum is incubated with donor lymphocytes and the subsequent addition of
complement results in lysis of lymphocytes that have been bound by antibody. Cell death indicates
a positive crossmatch inferring that a substantial amount of donor specific antibody (DSA) had been
bound to the cell surface.

Flow cytometry crossmatch:

Basic flow cytometry crossmatch differs from cytotoxic crossmatching in that it detects DSA
regardless of the ability for complement fixation. It is less subjective than the the visual assessment
of cell death that occurs in cytotoxic crossmatching and more biologically representative of the
continuous nature of antibody amount. DSA have been shown to appear in serum as early as one-
month post-transplantation; however, the mean time for detection is 11 months post-transplantation
and 29 months prior to allograft loss. It has been suggested that this assay may play a role in the
post-transplant period in identifying subclinical rejection and individualizing immune suppression,
in view of the side effect profile.

Virtual Crossmatching:
A Virtual Crossmatch is a crossmatch that involves a determination of the presence or absence of
donor HLA specific antibodies (DSA) in a patient by comparing the patients’ HLA antibody
specificity profile to the HLA type of the proposed donor without carrying out a ‘wet’ crossmatch
such as a Complement Dependent Cytotoxic (CDC) or flowcytometric crossmatch. Mean
flouresence intensity value is used to measure the strength of the antibody. This method of cross-
match has been shown to be particularly valuable in heart and lung transplants, by avoiding
unnecessary transport of organs between transplant centers.

The evolution of the immune response following transplantation:

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 CLINICAL REJECTION

Hyperacute rejection
This type of rejection, which usually occurs within minutes to hours after the transplanted organ is
reperfused, is due to the presence of preformed antibodies in the recipient. These antibodies may be
directed against the donor's HLA antigens or they may be anti-ABO blood group antibodies. They
bind to the vascular endothelium in the graft and activate the complement cascade, leading to
platelet activation and to diffuse intravascular coagulation. Hyperacute rejection most commonly
occurs while the patient is still in the operating room, the kidney turns black before the surgical
teams eyes. Risk factors for hyperacute rejection include multiple transfusions or pregnancies and
previous transplantation. Ensuring ABO compatibility and avoiding positive lymphocyte cross-
matches are universally accepted methods for prevention of hyperacute rejection.

Accelerated acute rejection

A variation of hyperacute rejection, accelerated acute rejection, is a cellular immune response.
Accelerated acute rejection can occur when the recipient has been exposed previously to low levels
of donor tissue antigens and makes a rapid memory response when the donor organ is transplanted.
Accelerated acute rejection manifests within a few days to a few weeks following transplantation,
and leads to allograft loss.

Acute rejection
This type of rejection occurs within a week to approximately 4 months after transplantation. The
risk is greatest during the first 6 months and few episodes occur after the first year post-
transplantation. Acute rejection is a cellular immune response involving mononuclear, cytotoxic
and T- helper cells, monokines, and lymphokines. Acute rejection occurs when antigen is trapped
within recipient macrophages and cannot be cleared by the reticulo-epithelial system. Clinical signs
of rejection are nonspecific and vary depending on the organ transplanted. A biopsy is required to
make a definitive diagnosis of acute rejection.

Chronic allograft injury

Chronic rejection probably begins at the time of transplantation, but may take months or years to
manifest clinically. While the clinical and biochemical signs are organ-specific, the result of chronic
rejection is the same for all solid organ allografts. Slowly deteriorating graft function caused by
fibrosis of the graft parenchyma and widespread arteriopathy are the hallmarks of chronic rejection
that lead to loss of function and eventual graft loss
The cause of chronic rejection is unclear. However, there is evidence that both immune and
nonimmune events are responsible. T cells and B cells contribute to the damage characteristic of
chronic rejection The understanding that allograft loss and dysfunction can occur due to immune
and non-immune factors, have led to several adjustments to terminology used in this regard.
Chronic rejection refers only to cases caused by immune factors, whilst chronic allograft injury has
replaced chronic allograft nephropathy due to the misconception in literature, that the latter is a
specific disease entity.

Graft-versus-Host Disease (GVHD)(3):

Graft vs Host disease is a rare but lethal complication after solid organ transplantation. The
diagnosis is often delayed because the early signs such as skin rash, fever, diarrhea, or liver
dysfunction are mistaken for drug reactions or infections. Pancytopaenia is the most frequent cause
of death. It is associated with reduced levels of immunosuppression and occurs when donor
immuno-competent T-cells recognize immuno-incompetent recipient tissues as foreign and attempt
to destroy them. It usually resolves with immunotherapy, and is therefore not a major source of
mortality post-transplantation

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 IMMUNOSUPPRESSION(5,6,7,8)
Immunosuppression after solid organ transplantation is complex. Improved therapeutic strategies
have been associated with better patient and graft survival rates however the adverse effects
associated with these agents and the risk of long term immunosuppression present a number of
challenges. Treatment needs to be tailored to meet the individual patient’s characteristics and to
balance the risks and benefits of these medications.

The Evolutionary Timeline of Immunosuppressive Agents

Corticosteroids
Corticosteroids are used for induction and maintenance immunosuppression, as well as for acute
rejection. These agents prevent production of cytokines and vasoactive substances, including
interleukin (IL)–1, IL-2, IL-6, tumor necrosis factor-α, chemokines, prostaglandins, major
histocompatibility class II, and proteases. The most common corticosteroids used in transplantation
are oral prednisolone and intravenous methylprednisolone.

Calcineurin inhibitors (CNI):

Calcineurin inhibitors suppress the immune system by preventing interleukin- 2 (IL-2) production
in T cells.
Cyclosporine: Is used for induction and maintenance immunosuppression. Multiple drug
interactions are possible, primarily with agents affecting the cytochrome P-450 system.
Adverse effects- Nephrotoxicity, hyperkalemia, hirsutism, hypertrichosis.
Tacrolimus: Macrolide antibiotic. FK binding protein 12 active complex inhibits calcineurin. It is
used for maintenance immunosuppression and rescue therapy in patients with refactory rejection
under cyclosporine based therapy. Adverse effects similar to cyclosporine.

Mammalian target of rapamycin (mTOR) inhibitors:

Sirolimus: Also called rapamycin, a macrolide product of soil fungus found on Easter Island. It is
used for maintenance immunosuppression and chronic rejection.
Everolimus: A rapamycin analog with similar mechanism of action and adverse effect profile.
Sirolimus binds to FKBP12 complex and inhibits the mTOR pathway. Adverse effects of mTOR
inhibitors include hyperlipdiemia, thrombocytopaenia and anemia. When used in combination with
CNI it potentiates the nephrotoxicity.

Inhibitors of nucleotide synthesis (purine synthesis [IMDH] inhibitors)

Mycophenolate mofetil (MMF): Inhibits the enzyme inosine monophosphate dehydrogenase and
impairs B and T-cell proliferation. It is used for maintenance immunosuppression, chronic rejection
and rescue therapy. Adverse effects include nausea, vomiting, diarrhea, leukopenia and anemia.

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Azathioprine (AZA): AZA is the prodrug for 6-thioguanine, which is further converted to a purine
analog that competitively inhibits ionosine monophosphate. This inhibits DNA synthesis and
therefore leads to reduction in the numbers of bone-marrow-derived leucocytes.

Biologic agents:
Biologic agents are polyclonal and and monoclonal antibodies and are frequently used for induction
immunosuppression or treatment of rejection.

Polyclonal antibodies (antithymocyte globulins)

Antithymocyte globulins have been used commonly for induction immunosuppression and
treatment of acute rejection in solid organ transplantation. These agents are derived by injecting
animals (rabbit or horse) with human lymphoid cells, then harvesting and purifying the resultant
antibodies, which are then injected intravenously resulting in depletion of T cells. Preparations
include horse antithymocyte globulin (Atgam) and rabbit antithymocyte globulin (Thymoglobulin,
ATG)

Monoclonal antibodies
Muromonab-CD3 (OKT3): is a murine monoclonal antibody of immunoglobulin 2A which clones
to the CD3 portion of the T-cell receptor. It blocks T-cell function. It is no longer used due to its
association with severe systemic side effects.
Humanized monoclonal anti-CD52 antibody (alemtuzumab):
Alemtuzumab (Campath-1H), a humanized monoclonal antibody directed against CD52, is a
lymphocyte-depleting agent currently being evaluated as an induction agent in solid organ
transplantation. The use of alemtuzumab as induction immunosuppression for renal transplantation
introduces the possibility of long-term tacrolimus monotherapy, avoiding maintenance with both
corticosteroids and mycophenolate mofetil

Monoclonal anti-CD25 antibody:

Basiliximab (Simulect) and Daclizumab (Zenapax) are chimeric and humanized antimonoclonal
antibodies that target the IL-2 receptor (CD25). Clinically, both agents are very similar, and both
are used for induction. These agents bind to the IL-2 receptor α-chain (CD25 antigen) on activated
T cells, depleting them and inhibiting IL-2–induced T-cell activation.

Anti-CD20 antibodies:
Rituximab (anti-CD20 monoclonal antibody) eliminates most B cells and is approved for treating
refractory non-Hodgkin B-cell lymphomas

Co-stimulation blockade
Belatacept is a selective costimulation blocker (CD80 antagonism) designed to provide effective
immunosuppression while avoiding the toxicities associated with calcineurin inhibitors.

Eculizumab is a humanized monoclonal IgG antibody that binds to complement protein C5 and
blocks the activation of terminal complement. It is FDA approved for paroxysmal nocturnal
hemoglobinuria and atypical hemolytic uremic syndrome. It has also been successful in reducing
antibodies in a highly sensitized patient with positive crossmatches prior to live donor transplant
and in prevention of antibody mediated rejection in a case series of patients with donor specific
antibodies and positive flow cytometry cross-matches, however further studies are needed.

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Bortezomib has been used for treatment of acute antibody mediated rejection, although it is
approved for multiple myeloma in the United States. It inhibits the degradation of cell-cycle
regulatory proteins resulting in cell-cycle death via apoptosis. Randomized trials are needed to
determine the influence of bortezomib on antibody removal.

Therapeutic Management
Phases:
Immunosuppressive treatment of the transplantation patient begins with the induction phase,
perioperatively and immediately after transplantation. Maintenance phase then continues for the
life of the allograft. Induction and maintenance strategies use different agents at specific doses or at
doses adjusted to achieve target therapeutic levels to give the transplant patient the best hope for
long-term graft survival.

Maintenance immunosuppression is the key to prevention of acute and chronic rejections

throughout the life of the graft.

The 2 types of induction strategies used to avoid early acute rejection are antibody-based therapy
and aggressive early immunosuppression.

• Antibody-based therapy: This therapy uses anti-CD25 antibodies (eg, basiliximab,

daclizumab) and is administered in the early posttransplant period. Antibody-based therapy
allows for avoidance or dose reduction of calcineurin inhibitors, possibly reducing the risk
of nephrotoxicity. All agents are effective for preventing acute rejections, although the anti-
CD25 antibodies may require concurrent administration of calcineurin inhibitors. The
adverse effect profile of the polyclonal and monoclonal antibodies limits their use in some
patients. Patients at highest risk of rejection may receive rabbit antithymocyte globulin
(Thymoglobulin).
• Aggressive early immunosuppression: This therapy uses maintenance drugs at higher doses
to achieve the strongest immunosuppressive effect soon after transplantation. Approximately
50% of patients do not receive antibody therapy at the time of transplantation. The highest
doses of calcineurin inhibitors place patients at increased risk of nephrotoxicity and may not
be the best strategy for patients at the highest risk for rejection.

Rejection
Acute rejection
The agents used to treat acute rejection are steroids and antithymocyte globulin.

Steroids: These agents are the mainstay of therapy for acute rejection episodes, preventing release
of IL-1 by macrophages and blocking synthesis of IL-2 by helper T cells. Steroids also have anti-
inflammatory properties. Methlyprednisolone is most commonly used in high dose short course (3
day) therapy. Steroids reverse 60-75% of rejection episodes.

Antithymocyte globulin: This agent binds all circulating T and B lymphocytes, which are then lysed
or phagocytosed by the reticuloendothelial system. Antithymocyte globulin has efficacy similar to
that of muromonab-CD3. It is reserved for steroid-resistant acute rejection secondary to cost,
toxicity, and the development of drug antibodies.

Chronic allograft injury

Changes in immunosuppressive regime have proven unhelpful in the management of chronic
rejection, the management of which centers on optimizing premorbid conditions by achieving
optimal blood pressure, glycaemic control and lipid profile.

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Steroid-free protocols
The known toxicity of long-term steroid exposure has prompted the development of steroid-free
immunosuppressive regimens. Benefits of the withdrawal or avoidance of steroids include normal
growth in children, improved lipid profiles, improved blood pressures, better glycemic control, and
lower risk of bone disease.
The development of cyclosporine prompted attempts to develop steroid-free protocols. Recent data
show the risk of rejection is higher in patients withdrawn from steroids on a cyclosporine-based
protocol. After tacrolimus became available, protocols with this drug showed that withdrawal of
steroids after 6 months was successful 80% of the time.

Calcineurin inhibitor-free protocols

Because of the risk of both acute and chronic nephrotoxicity attributed to calcineurin inhibitors, the
development of protocols free of these agents is desirable. The use of sirolimus, mycophenolate
mofetil, and anti-CD25 antibodies has been studied to determine whether graft survival and acute
rejection rates can be maintained at the present rates in the absence of a calcineurin inhibitor.
Many other protocols that minimize exposure to calcineurin inhibitors have been studied. Promising
protocols include sirolimus, mycophenolate mofetil, and steroids or the combination of anti-CD25
antibodies, sirolimus, mycophenolate mofetil, and steroids. The Benefit trial demonstrates that
belatacept plus mycophenolate mofetil or belatacept plus sirolimus provide primary
immunosuppression with acceptable rates of acute rejection, improved renal function compared to a
TAC-based regimen, and may avoid the need for calcineurin inhibitors and corticosteroids.

THE ORGAN DONOR(9)

Donors

Cadaveric Living

Brainstem dead, Non-heart

Related Unrelated
heartbeating beating

Living donors:
Living donation takes place when a living person donates an organ or part of an organ for
transplantation to another person. Living donation usually involves a single kidney, a segment of
the liver, the lobe of one lung, a portion of the pancreas or a portion of the intestine.
Living-related: Donor is genetically related to the recipient.
Living-unrelated: -Donor is genetically unrelated (eg. spouse)
-Paired exchange: incompatible paired donors perform an exchange, which
allows two antibody-compatible operations. In sophisticated programmes, this
can be extended to have a domino effect.

Cadaveric Donors:
The majority of organ donors are patients in ICU who have sustained irreversible brain damage for
a variety of reasons, with the final common pathway being the diagnosis of brainstem death. This is
made according to the Minnesota criteria

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Diagnosis of brainstem death according to the Minnesota criteria
• Known but irreparable intracranial lesion
• No spontaneous movement
• Apnoea (4 minutes)
• Absent brainstem reflexes
Above findings must remain unchanged for 12 hours
Exclusions:
1. Drug or alcohol intoxication
2. Neuromuscular blocking agents
3. Hypothermia and metabolic disturbances
4. Coma of unknown aetiology

Absent brainstem reflexes Apnoea test

• Absent pupil light reflex • No attempt to breath despite a
• Absent corneal reflex PaCO2>50mmHg. Avoid
• Absent vestibule-ocular reflex hypoxia by preoxygenation for
• Absent oculo-cephalic reflex (Doll’s eye 10 min @ 100% oxygen
movement)
• No motor response to stimulation in cranial
nerve distribution
• No cough/ gag reflex or response to
bronchial stimulation by suction catheter

Due to changing donor demographics, excessive waiting times, and the increasing disparity between
organ supply and demand, the use of organs from expanded criteria donors (ECD) has become
generally accepted and increasingly common. These ECD now increasingly include the use of non-
heartbeating donors.

Selection criteria for potential donors

• Brain dead patients
• Patients < 70 years of age (varies between centers)
• Absence of serious systemic diseases eg diabetes mellitus
• No serious systemic infection eg HIV and hepatitis B
• No malignancy (except primary brain tumors, BCC)

Non-heart beating ( NHBD ) donors

In the early days of transplantation, organs were obtained from NHBD. With time, better options for
organ sources became available (for example, living-related and "brain dead" donors), and the
practice of obtaining organs from NHBD fell out of favor. Improvements in the field of
transplantation have led to an increased demand for organs. Various strategies have been employed
recently to increase the supply, one of them being NHBD. Outcomes of organs obtained from
NHBD are comparable to those obtained from heartbeating donors. The practice of NHBD is
increasing and has proven that it can contribute to increasing organ availability.

Ethical concerns
Despite the comparable results of allografts procured from controlled NHBD and kidneys from both
groups of NHBD, there are still challenges to the widespread use of this donor pool. The definition
of death in NHBD as the irreversible cessation of circulatory and respiratory function has raised
ethical dilemmas, with reports of auto-resuscitation and resuscitation of neurological function with
the use of certain organ preservation techniques. A ‘standoff’ time, which varies between centers,
is therefore usually observed between confirmation of death and commencement of organ
procurement.

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Furthermore, minimization of warm ischaemic time (from circulatory dysfunction/failure to
commencement of cold perfusion) is essential in preserving the quality of allografts from NHBD.
This requires a highly integrated team including laboratory personnel; transplant coordinators, and
procurement team, which is a challenge even in well-resourced countries.

The Maastricht criteria

The first 2 are uncontrolled circumstances and unsuitable for solid organ retrieval.
Categories 3 and 4 can be controlled situations that lend themselves to organ procurement.
Category 1: Dead upon arrival at hospital
Category 2: Unsuccessfully resuscitated
Category 3: Awaiting cardiac arrest
Category 4: Cardiac arrest while brain dead

Deceased Donation and consent rates in South Africa(21)

Deceased donation rates in South Africa remain less than 5 million per population most likely
linked to lack of transplant co-ordinators, poor support from government and lack of public
understanding of deceased donation practices. Every potential deceased donor gets referred to a
transplant co-ordinator who then facilitates discussion with the family about organ donation and
arrange logistics for organ procurement. Unfortnately there are only 8 transplant co-ordinators
employed by the state. Of significance there is no overseeing body for transplant coordinators and
educational standardization is lacking. The current deceased donation model in South Africa is
based on consent by the deceased donors next of kin and there is no formal donor registry. Of note
the donors wish is not always known to the family thus frequently resulting in refusal of consent.
Better organizational structuring and funding is required to improve transplantation in this country.

ORGAN PRESERVATION(10,11)

The technology of organ preservation has improved considerably. Several organ-preservation

solutions are available, and these are being constantly modified to provide improved organ storage
and outcomes.

Euro-Collins solutions
The development of solutions of intracellular electrolyte composition allowed for organ
preservation to be attempted. These early solutions, called Collins solutions, contained high
concentrations of potassium, magnesium, phosphate, sulphate, and glucose. Organ preservation
improved with the use of Euro-Collins solution. When it was used for kidney preservation, delayed
renal function after implantation was significantly reduced. The solution was adequate for use in
preserving the heart, liver, and lung.

Bretschneider histidine tryptophan ketoglutarate solution

Initially developed as a cardioplegia solution for the use in open heart surgery, Bretschneider
histidine tryptophan ketoglutarate (HTK) solution was found to be effective in liver and kidney
preservation.

University of Wisconsin solution

University of Wisconsin (UW) solution was developed for liver, kidney, and pancreas preservation.
It has been considered the standard for renal and hepatic preservation, effectively extending the
ischemic time for kidneys and livers and allowing them to be transported considerable distances to
waiting recipients. UW solution has also been successfully applied to small-bowel and heart
preservation.

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Celsior solution
Celsior is a recently developed extracellular-type, low-viscosity (due to the absence of HES)
preservation solution. The solution was specifically designed for heart transplantation. It is being
currently used in clinical lung, liver, and kidney transplantations and it is under investigation for
pancreas transplantation

Hypothermic preservation:
Two techniques of hypothermic preservation are used: simple cold storage and continuous
hypothermic perfusion. With simple cold storage, the organ is flushed with cold preservative
solution and placed in a sterile bag immersed in the solution. The sterile bag is placed inside another
bag that contains crushed ice. Advantages of simple cold storage include universal availability and
ease of transport. With continuous hypothermic perfusion, which Belzer developed in 1967, a
machine is used to continuously pump perfusion fluid through the organ. In this way, oxygen and
substrates are continuously delivered to the organ, which maintains ion-pump activity and
metabolism, including the synthesis of ATP and other molecules. There has been renewed interest
in this method especially for liver preservation following DCD donation.

RENAL TRANSPLANTATION(12,13,14)

Renal transplantation has become the treatment of choice for most patients with end-stage renal
disease (ESRD). It offers better quality of life and confers greater longevity than long term dialysis

Indications for renal transplant:

In selected patients, virtually all causes of chronic renal failure can be treated by transplantation

Contra-indications to renal transplant:

Contra-indications to surgery
Contra-indications to
immunosuppression
Other
• Cardiopulmonary insufficiency / Irreversible IHD
• Hepatic insufficiency
• Morbid obesity
• Unsuitable vascular anatomy
• Acute infections (Hepatitis; See HIV section)
• Malignancy (if not in remission)
• Psychosocial problems
• Active systemic disease (i.e. oxalosis)
• Inability to adequately perform rehabilitation post-
transplantation.

Histocompatibility testing
The purpose of tissue typing is to assess donor-recipient compatibility for HLA, ABO and the
presence of lymphocytotoxic antibodies. Successful transplantation depends on the recipient’s
immunological acceptance of the foreign tissue. Optimal donor-recipient matching for the HLA-
haplotype has a great impact on reducing graft rejection and the need for extensive
immunosuppression.

In kidney transplantation, current criteria for HLA matching consider 3 loci:

HLA-A, HLA-B and HLA-DR. Each donor and recipient can type for up to 6 different HLA
antigens, and HLA compatibility is usually assessed by the number of HLA mismatches (or
matches) of the donor. Survival statistics have shown the best survival rates of cadaveric transplants

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Living unrelated transplants are superior to all but the best-matched cadaver transplants, although
the results are slightly poorer than the HLA identical and half identical living donor transplants.

Immunosuppression:
Current immunosuppressive therapy can be divided into 2 phases: induction and maintenance.
The induction phase occurs during and immediately following transplantation and is divided into
antibody and non-antibody regimens.
Antibody-based induction immunosuppression uses either mono- or polyclonal antibody
preparations directed at T lymphocytes in combination with calcineurin inhibitors (viz. Cyclosporin
and tacrolimus), antiproliferative agents (viz. AZA, MMF), and steroids.
In the case of non-antibody induction therapy and most forms of maintenance therapy, various
combinations of calcineurin inhibitors, antiproliferative agents and steroids are used.
Calcineurin inhibitors (Tacrolimus) have been the mainstay of clinical immunosuppression. Due to
significant dose-related nephrotoxicity, ongoing monitoring of drug levels to avoid toxicities is
necessary.
The Symphony trial(6) using TAC, MMF and steroids, has demonstrated a definite improvement in
graft survival and reduction in rejection episodes. In addition, the better side-effect profile of the
latter protocol has led to its widespread acceptance. It is currently the standard protocol.
Steroids play an important role in immunosuppression and form the mainstay of most maintenance
protocols. Their side-effect profile, especially their contribution to coronary artery disease and
cardiac-related deaths however make them a double-edged sword.

Living Donor Surgery

Surgical options for donor nephrectomy have evolved significantly. They include:
Open Surgical Approach
Flank (with or without rib resection)
Mini-Incision - retroperitoneal
Transperitoneal
Laparoscopic/ Retroperitoneoscopic Approach
Pure
Hand-assisted
Robotic assisted

Laparoscopic Vs Open donor nephrectomy(22)

A study by Dolce et al. revealed that laparoscopic DN resulted in less blood loss, reduced operative
time, and shorter hospital stay than open DN. Hand-assisted laparoscopic DN has the potential to
decrease warm ischemia time for renal allografts. Donors managed laparoscopically had fewer
complications, significantly less wound-related morbidity, and less delayed graft function than
patients who underwent open DN.

Post transplantation complications

• Delayed graft function (DGF): = primary non-function of kidneys up to 1 week. This varies
based on donor, recipient and transplants characteristics.
• Vascular-related
- Arterial stenosis: Management includes angioplasty and stent placement.
- Venous thrombosis: Once suspected, an urgent duplex scan and immediate
exporation is mandatory. Nephrectomy is often the final outcome.
- Renal artery thrombosis: Usually involves small-caliber arteries. Management once
suspected, is immediate exploration.

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 • Ureter-related
o Urine leak or urinoma
o Ureteric obstruction
Early: As a result of a clot, oedema or anastomotic site (ureteroneocystostomy).
Management is by stenting and bladder decompression. If unresolved, surgical
revision may be necessary.
Late: Due to fibrosis and nephrolithiasis. Management is by stent placement and
stricture dilatation.
o Vesico-ureteric reflux: Usually occurs years later. It’s only treated if there is
deterioration in renal function, in the presence of severe reflux (Gr 3 or 4) or
recurrent urinary tract infections. Management is by ureteric re-implantation,
injection of Teflon/ microplastique at cystoscopy.
• Lymphocele: Collection of lymph due to leakage from perivascular lymphatic vessels. The
current management is internal drainage of the lymphocele into the abdominal cavity.
• Infections: The risk of opportunistic infections is increased. These infections are typically
caused by commonly encountered bacteria, viruses and fungi. Routine prophylaxis for TB
(INH) and pneumocystis carinii (Bactrim) is given. CMV is the other common infection
treated with gancyclovir.
• Acute rejection: In the first year, acute rejection is observed in approximately 15-25% of
patients. Rejection is usually asymptomatic, and presents as an unexplained rise in serum
creatinine levels. This is confirmed by biopsy revealing lymphoplasmacytic infiltration of
the renal interstitial areas with occasional penetration of the tubular epithelium by these
cells. Usually treated by high dose (1g) and short pulse (3 days) of methylprednisolone.
Monoclonal antibody (OKT3) can be use if no response.
• Post transplant Diabetis Mellitus ( PTDM )
With improvements in transplantation and immunosuppressive medications, there has been a
substantial increase in 1-year allograft survival rates. PTDM is an undesirable consequence
of transplantation because of its associated morbidity and impairment of both patient and
graft survival. Although some controversy exists, it is likely that glucose intolerance after
transplantation results in both macrovascular and microvascular disease, and there is an
increasing risk for infectious and cardiovascular diseases, to which transplant recipients are
already at increased susceptibility. Both experimental and clinical observations have shown
that immunosuppressive agents currently used in transplantation account for a large degree
of the increased risk for PTDM.
Cardiac
The incidence of cardiac complications posttransplant depends on the recipient’s underlying
disease, cardiac history and the level of graft function. Recipients with diabetes,
hypertension or coronary artery disease are more likely to develop cardiac complications.
Correction of uremia by immediate functioning of the transplanted kidney improves the
cardiac index, stroke volume and ejection fraction.
•
Post-transplantation malignancy
The chronic use of immunosuppressive agents to prevent allograft rejection increases the
long-term risk of malignancy, compared with that of the general population. Many types of
post-transplant cancers display a more malignant course than the same type of cancer in
non-transplant patients. This aggressive behaviour of post-transplant malignancy contributes
to the associated mortality causing 26 percent of deaths in patients surviving transplantation
for at least 10 years

13
 LIVER TRANSPLANTATION(15)
Liver transplantation has become a widely accepted therapy for the management of the
complications of cirrhosis and liver failure. Each year approximately 5000-6000 people in the USA
with ESLD receive new livers with a 1-year, 3-year and 5-year patient survival of 87, 78, and 73%
respectively.

Common Indications for Liver Transplantation

Acute liver failure: Toxin or drug induced liver injury, viral hepatitis, autoimmune hepatitis,
Wilson’s disease
Chronic liver disease: Cirrhosis- Hepatitis C virus
- Hepatocellular carcinoma
- Alcoholic cirrhosis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Non alcoholic steatohepatitis
Hemochromatosis, Alpha-1 antitrypsin defiecieny, biliary atresia, HBV

Hepatocellular carcinoma:
Liver transplantation is indicated in patients with HCC within the Milan criteria (a single lesion
<5cm in diameter or three or fewer lesions, the largest of which is <3cm in diameter). There has
been a suggestion that these criteria are too restrictive. Therefore some transplant centres may
consider using expanded criteria.

Cholangiocarcinoma:
Patients with CCA were once thought to be poor candidates for transplantation because of nearly
universal recurrent disease and poor survival. The Mayo clinic developed a novel therapeutic
protocol for patients for patients with uresectable hilar CCA or CCA arising in the setting of PSC.
This protocol combines neoadjuvant chemoradiation and liver transplantation and has shown
excellent 1-year survival rate of 82%.

Other liver tumors:

Neuroendocrine tumors are slow growing neoplasms, frequently presenting with multifocal liver
metastases. Liver transplant should be considered in selected patients without evidence of
extrahepatic tumor spread. Other liver tumors such as large or multifocal adenomas, epithelioid
hemangioendothelioma or very select cases of fibrolammelar HCC, may be considered for
transplant.

Contraindications to liver transplantation:

Relative Absolute
Age > 65 years Severe cardiopulmonary disease/cerebral injury
Severe malnutrition Sepsis/ Active infection (HIV/AIDS)
Other organ failure (Ischaemic heart disease) Extrahepatic mlignancy
Previous upper abdominal surgery Vascular abnormalities
Poor functional status Active alcohol or drug usage
Poor medical compliance Psycosocial issues

14
Evaluation of patients for liver transplant:
Referral for liver transplant evaluation is made once liver failure develops, ideally, early enough to
allow time for a thorough assessment for candidacy. When the decision is made to proceed to
transplant an extensive patient evaluation is performed:

• Laboratory tests:

Liver function tests, total protein, albumin

Hepatitis screen (A, B, C)

Serologies - Cytomegalovirus (CMV), herpes simplex virus (HSV), Epstein-
Barr virus (EBV), HIV

Tumor markers

Alpha-fetoprotein, cholinesterase

Arterial blood gases

Others (selective) - Carbohydrate antigen 19-9, cancer antigen 125

• Assessment of severity according to the Child-Turcotte-Pugh and MELD (model for end-
stage liver disease) scoring system, PELD in children
• Imaging (CXR, u/sound, ECG, lung function tests: as indicated)
• Upper and lower GI endoscopies to assess for presence of oesophageal varices

Model for end stage liver disease (MELD):

Initially patients were transplated on a first come first serve basis. The growth of the waiting list far
out-paced the growth of donor organs, therefore death on the waiting list continued to increase. The
MELD was developed to predict 3-month survival following trans-jugular intra hepatic
portosystemic shunting. This evidence based prospectively derived model was subsequently
validated to accurately predict short term mortality for patients with chorinc liver disease. UNOS
adopted the MELD in 2002 and following its adoption, sicker patients were given priority and
waiting time was minimized. Despite the improvements in listing outcomes the MELD has been
criticized. The MELD score tends to under-prioritize patients with HCC and cirrhotic patients with
encephalopathy, ascites and bacterial peritonitis. Several alterations have been proposed to the
current MELD score, with none being prospectively validated. In addition to mortality predictors,
poor quality of life, in the form of recurrent cholangitis requiring intervention or intractable pruritus
are also considered.
The American Association for the study of Liver diseases (AASLD) guidelines recommend that a
patient with a Child-Pugh score ≥ 7 and /or a MELD score 10 or higher be referred for transplant.

Surgical options:
• Orthoptic graft : The donor organ replaces the liver in its native position.
• Auxillary: a split graft is transplanted as a bridge till the native liver, which is left in
its original position, recovers its function. May occur in the following forms:
o Heterotopic auxillary liver transplant- graft is placed in an ectopic site
o Auxillary partial orthotopic liver transplantation- the graft replaces the
resected native right or left hemi-liver.

Liver procurement:
An important consideration in liver transplant is matching the size of the donor and the recipient. In
general the weight of the donor should be within 25kg of the recipient. Livers can be transplanted as
whole grafts or partial grafts (split and reduced size grafts) as in renal transplantation, both living
and cadaveric donors are used:

15
 1) Living donor hepatectomy:
This initially started with the use of segments II and III for paediatric transplants. Currently,
right hepatic lobectomies are used in adult recipients. The overall 3-year survival rate of
adults is 77%. Right lobe graft survival (79%) shows a better outcome than non-Right lobe
grafts (58%).
2) Cadaveric donors:
Still remain the largest source of livers for transplantation. A universal shortage of donors
has led to the split-liver technique. Although segments II and III are more easily split, it is
not ideal for adult recipients. Division of the liver based on the middle hepatic vein (Right
and Left hepatectomy) is required for use in adult recipients. One liver thus produces 2
functional grafts (Left: segments 2-4 and Right: segments 1+5-8).

Living donor liver transplantation (LDLT) : is performed all over the world today. The shortage
of cadaveric grafts makes it the only option for many end stage cirrhotics in many countries. Donor
hepatectomy was initially associated with significant morbidity and raised concerns about the safety
of this procedure. However, today donor hepatectomy is a safe operation with a low incidence of
complications. From the first living donor transplant performed in Brazil it has grown into a highly
successful operation performed in many centers. The amazing regenerative capacity of the liver
allows us to perform this operation with a good degree of safety. While increasing the donor pool
the quality of the graft is also better.

The Operation
Today donor hepatectomy is a standardized. The complication rates are low and the success rates
are high. The operation starts with a suitable incision and good exposure. The first step is a good
cholangiogram. The liver is mobilized and the outflow is looped. The inflow vessels and isolated
followed by parenchymal transection. Although the open method is the gold standard, there is an
increasing body of evidence suggesting that laparoscopy represents a safe means for donor
hepatectomy with equivalent if not better outcomes than open surgery. Advantages include reduced
need for analgesia, shorter hospital stay, improved cosmesis and early return to normal activities,
with no noted difference in post-procurement donor-related complications and equivalent early graft
function when compared to the open method.
Though, there are reports of a high incidence of complications in the initial years of LDLT the
incidence has decreased. The morbidity and mortality of this operations in high volume LDLT units
is extremely low. The most common complication are bile leaks (8%) with overall morbidity of 12–
16%.
Donor hepatectomy is a safe operation in high volume centers. It is a good option for end stage
cirrhotics who find it difficult to get a cadaveric graft.

PANCREAS AND ISLET CELL TRANSPLANTATION(16)

The goal of pancreas transplantation is to restore normoglycaemia in patients with labile diabetes,
and to ameliorate or prevent secondary diabetic complications. The results of this procedure
improved over the years. However, while pancreas transplantation is not considered experimental
anymore, there is often reluctance to recommend this procedure to patients because of its
complexity and risks, especially for solitary pancreas transplants.

The clinical practice recommendations of the American Diabetes Association state that a pancreas
transplant (Simultaneous Kidney and Pancreas Transplant [SPK] or Pancreas After Kidney
Transplant [PAK]is an acceptable surgical procedure in type 1 diabetic patients also undergoing
kidney transplantation. These must be in medically suitable type 1 diabetic patients who are also
renal transplant candidates or who have excellent function of a kidney transplant who are interested

16
in receiving a pancreas transplant. The vast majority of pancreas transplants are performed as an
SPK followed by PAK.
Pancreas transplantation alone ( PTA ) can be performed in type 1 diabetics who have preserved
native kidney function but suffer from glucose lability and frequent, acute and severe metabolic
complications including repeated episodes of ketoacidosis, have incapacitating clinical and
emotional problems related to insulin therapy, and have consistent failure of insulin therapy to
prevent acute diabetic complications. Significant hypoglycemic unawareness may also be an
indication as achieving an insulin-free state enhances their quality of life. PTA should be performed
before secondary complications of diabetes become irreversible and before the need for a kidney
transplant . A creatinine clearance above 60 to 70 mL/min is usually required as
immunsouppressants can cause accelerated deterioration of native renal function in patients with a
lower creatinine clearance. This type of transplant represents the smallest number of the three.

Surgical techniques
The surgical techniques for duct management changed from bladder drainage (BD) to enteric
drainage (ED) over time. ED is now used in the majority of transplants. In 2010, ED was used in
91% of SPK, 89% of PAK, and 85% of PTA patients. In the enteric drained transplants, systemic
venous drainage was performed in the majority of cases . The initial promise of portal drainage was
not fulfilled. In 2010, it accounted for only 18% in SPK and PAK, and for 10% in PTA. Bladder
drainage is typically utilized in the setting of solitary pancreas transplantation or where there are
concerns about the durability of the duodenal graft. It holds an immunosurveillance advantage;
where urinary amylase concentration is used as a sensitive marker of rejection, and graft biopsies
may be done via cystoscopy. Bladder drainage may be complicated by metabolic problems like
dehydration and hyperchloraemic metabolic acidosis, and urologic concerns such as haematuria,
recurrent urinary tract infections, urethritis and subsequent stricture formation.

Overall, the improvement in the field of pancreas transplantation is especially encouraging since the
spectrum of recipients accepted for transplants is widening.

Islet cell transplant

Pancreatic islet cell transplantation is a promising cellular-based therapy for type 1 diabetes mellitus.
This procedure involves portal venous injection of islet cells and affords 1-year insulin independence in
as many as 80% of recipients.
The current process used for human islet isolation is based on combined collagenase digestion and
mechanical dissociation of the donor pancreas. The digestion is stopped when the intact islets are
free from the surrounding exocrine tissue. The islets are then purified, washed, counted and assayed
to make sure it meets the product release criteria of the isolation facility.
The intraportal site for islet embolization was recognized to be the most efficient location for islet
implantation. Once the portal vein is cannulated, the islet cells are infused, were they then implant
in the liver and undergo angiogenesis. It appears that insulin independence is only obtained when at
least 9000 islet equivalents (IE)/kg are transplanted. Alternative implantation sites are being
investigated and include the native pancreas, omental pouch and immunopriviledged sites such as
brain, testes and thymus.

INTESTINAL TRANSPLANTATION(17,18)

Parenteral nutrition is a life-saving therapy for patients with intestinal failure. Intestinal
transplantation is now recognized as a treatment for patients who develop complications of
parenteral nutrition and in whom attempts at intestinal rehabilitation have failed. Patients with
parenteral nutrition related liver disease will require a liver graft typically part of a multivisceral
transplant. Isolated intestinal transplants are more commonly performed in adults while
multivisceral transplants are most commonly performed in infants. Isolated intestinal transplants

17
have the best short-term outcome, with over 80 % survival at 1 year. Patients requiring
multivisceral transplants have a high rate of attrition with a 1 year survival less than 70 %.
Prognostic factors for a poor outcome include patient hospitalization at the time of transplant and
donor age greater than 40 years while systemic sepsis and acute rejection are the major determinant
of early postoperative outcome. For patients surviving the first year the outcome of transplantation
of the liver in addition to intestine affords some survival advantage though long-term outcome does
not yet match other abdominal organs. Outcomes for intestinal retransplantation are poor as a result
of immunology and patient debility. Overall intestinal transplantation continues to develop and is a
clear indication with cost and quality of life advantages in patients with intestinal failure that do not
remain stable on parenteral nutrition.

PAEDIATRIC TRANSPLANTATION(9)

Renal transplantation
Pediatric kidney transplantation is the preferred treatment for children with end-stage renal disease.
The most common indications for transplantation in children are renal developmental anomalies,
obstructive uropathy, and focal segmental glomerulosclerosis. Living donor kidney transplants are
often performed pre-emptively and offer excellent graft function. Adequate pretransplant workup
along with evaluation of urologic abnormalities is imperative in achieving good outcomes. Overall,
patient and graft outcomes after kidney transplantation have improved, with five-year deceased
donor and living donor graft survivals of 78.8% and 84.3%, respectively. Improvements in
induction and maintenance immunosuppression have contributed to the gradual improvement in
outcomes. Unique challenges in pediatric recipients include increased graft thrombosis, adverse
growth, and abnormal development relating to immunosuppression, increased rejection due to
nonadherence, increased susceptibility to opportunistic infections, and post-transplant malignancy.

Liver transplantation
Liver transplantation is the accepted treatment for a wide variety of liver diseases in children. Over
the past 10 years a number of innovative surgical techniques have been developed to overcome the
shortage of size matched donors particularly in children less than 5 years of age. Graft and patient
survival at one year after liver transplantation has continued to improve, and is now over 85% and
higher for good risk cases. Complications are relatively common, but provided graft function is
satisfactory, long term survival for these children is to be expected. The need for retransplantation
has fallen significantly. Causes of early mortality include graft dysfunction and sepsis. Late
mortality is due to sepsis, post-transplant lymphoproliferative disease, and non-compliance. Long
term survival with good graft function and excellent quality of life is possible for the majority of
children undergoing liver transplantation.

HIV AND ORGAN TRANSPLANTATION(19,20,21)

HIV infection was previously an absolute contraindication to renal transplantation. However, with
the advent of highly active antiretroviral therapy (HAART), renal transplantation using HIV-
negative donor kidneys has successfully been employed for HIV-infected patients with end-stage
renal failure. In resource-limited countries, places on dialysis programmes are severely restricted;
HIV-infected patients, like many others with co-morbidity, are often denied treatment. Kidneys
(and other organs) from HIV-infected deceased donors are discarded. The transplantation of HIV-
positive donor kidneys to HIV-infected recipients is now a viable alternative to chronic dialysis or
transplantation of HIV-negative donor kidneys. This significantly increases the pool of donor
kidneys to the advantage of HIV-positive and -negative patients.

18
Inclusion criteria ( Adapted from UK guidelines ) :
• CD4> 200cells/microlitre for at least 6 months
• No history of opportunistic infection
• HIV RNA < 50copies/mL for at least 6 months
• Absence of AIDS defining illness following successful immune reconstitution after HAART
• Demonstrable adherence and stable HAART regimen > 6 months
• Available antiretroviral treatment options in the future
• No evidence of cirrhosis on liver biopsy if co-infected with HBV or HCV
• Negative β-HCG
• Ablity to give informed consent

All HIV-infected patients with ESRD should be considered candidates for renal transplantation if
they meet the HIV inclusion criteria. There is enough data to affirm that renal transplantation in
adequately selected HIV-infected patients is a safe procedure in the short and medium term, with
patient and graft survival rates similar to those of HIV-negative renal transplant recipients.
Immunosuppressive therapy does not have a negative impact on the course of HIV infection, with
no evidence of progression to AIDS and no further opportunistic infections or neoplasms. The best
immunosuppressive regimen in HIV-infected renal transplant recipients has not been completely
established. Until results from larger and controlled studies are available, immunosuppressive
therapy in the early post-transplant period should include induction therapy with anti-interleukin-2
receptor monoclonal antibodies (basiliximab) in combination with triple therapy based on
calcineurin inhibitors (cyclosporine or tacrolimus), mycophenolate mofetil, and corticosteroid

CONCLUSION

Many new programmes have been introduced to improve organ donor numbers. The use of ECD
and NHBD donors is being explored worldwide and, as a result, the threshold for using patients
with pre-existing medical conditions as organ donors is getting lower. South Africa has a huge HIV-
positive population and for this reason an HIV-positive-to-positive transplant programme was
started ( at Groote-Schuur Hospital ) for HIV-positive patients with end-stage renal failure. The
outcome of their study may guide future practice locally and even internationally. Ethical issues
have been associated with organ transplantation from the beginning and will continue to be a major
consideration in this field. Doctors practising in this field must be aware of all the issues and ensure
that they do not transgress any ethical principles. The burden rests on the medical fraternity to
empower itself and the general public with information to break barriers to organ transplantation
and refer potential organ donors appropriately. Further developments in the transplantation field
particularly the availability of new organs or tissue through genetic engineering or cloning, for
xeno-transplantation will pose new issues.

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