BackgroundOne of the most common life-threatening injuries to trauma patients arriving in the emergency department (ED) is traumatic brain injury (TBI). Traditionally, intravenous medications have been given as seizure prophylaxis in patients demonstrating signs of increased intracranial pressure (ICP), as post-traumatic seizures in trauma patients are associated with higher morbidity and mortality. Medications traditionally given for this indication such as phenytoin have been established to reach therapeutic levels in the cerebrospinal fluid (CSF) quickly and are effective in preventing post-traumatic seizures but often have a large side-effect profile. A newer medication that is being used for seizure prophylaxis in patients with epilepsy is levetiracetam. Levetiracetam typically has a better side effect profile, but it has not been demonstrated that the drug reaches therapeutic levels in the CSF as quickly as phenytoin. Studies have shown levetiracetam and phenytoin to be equivocal in the prevention of post-TBI seizure prophylaxis.MethodsThis was a prospective, randomized, case-control study at a Level II trauma center of adult patients (age >/= 18 years) who suffered severe TBI (sTBI) requiring the placement of an external ventricular drain (EVD) from May 2017 to June 2018. Twelve patients were randomly placed into one of two groups for the administration of antiepileptic medication (either levetiracetam or phenytoin), allowing for the subsequent serial collection of CSF for the analysis of therapeutic levels of antiepileptic medications. Levetiracetam or phenytoin was administered at standardized fixed doses per our neurosurgical center standard protocol. CSF was collected before either drug was administered, 60 minutes after completion of administration and 360 minutes after completion of drug administration. Data analysis was performed to compare the time frame for which therapeutic levels of the medications were achieved in the CSF. The published steady-state and therapeutic CSF level of levetiracetam is 32 mcg/ml and phenytoin is 2 mcg/ml.ResultsA trend was observed in which the closer the fixed dosage approximated the weight-based dosing of phenytoin, the more their CSF phenytoin level increased (and approximated the therapeutic range) with an associated R-squared value of 0.6274. This trend was not found in patients receiving levetiracetam.ConclusionsLevetiracetam does not reach levels needed for seizure prophylaxis in human CSF when loaded at standard dosing regimens in the acute setting. Phenytoin does reach levels needed for seizure prophylaxis in human CSF with standardized regimen dosing when dosages approximate weight-based dosing. If needed, in the acute setting phenytoin should have additional doses given prior to six hours after the loading dose to achieve therapeutic CSF levels.  Traumatic brain injury (TBI) remains a major health problem in the United States, with more than one million injuries occurring per year, causing not only death but also long-term disability -2. For pPer the landmark paper by Temkin, the use of phenytoin in sTBI shows a reduction in early post-traumatic seizures when compared to placebo . An alteThis was a prospective, non-blinded, randomized study conducted as a collaborative effort by the neurosurgery department and the emergency department at a level II trauma center from May 2017 to June 2018.A total of 12 patients  were enrolled. Inclusion criteria included either male or female patients 18 years or older who presented with sTBI and required the placement of an EVD. Exclusion criteria included any patients under the age of 18 years old, patients with a known seizure disorder and who take antiepileptic medication regularly, patients with a known allergy to either levetiracetam or phenytoin, or those who were deemed to have a direct contraindication to either medication as established by the drug manufacturer. Patients were identified as having sTBI by a GCS of eight or less, requiring the placement of an EVD according to the guidelines for the management of severe head injury, and were randomly assigned to one of the two groups of the study. The levetiracetam group (six patients) were given only intravenous levetiracetam  and the phenytoin group (six patients) were given only intravenous phenytoin .Serial CSF samples were drawn at designated times, including prior to the administration of antiepileptic medication, which served as a baseline control, and then subsequently at one hour and six hours after the administration of antiepileptic medication. Samples were labeled with predetermined randomized numbers and stored in a -20 degree Celsius refrigerator and then was evaluated with high-performance liquid chromatography (HPLC).The HPLC method for the simultaneous quantification of levetiracetam and phenytoin was developed using a Hewlett-Packard 1050 HPLC system , consisting of a degasser, a quaternary pump, and an autosampler. The system also included a diode array detector and a computer running Chemstation software  for data acquisition and processing. Chromatographic separation was performed using a Waters Symmetry® C18 column . The analytes were quantified by ultraviolet (UV) detection at 220 nm. The mobile phase comprised water (A) and acetonitrile (B) and the flow rate was 1.0 ml/min. The elution began with 2% B followed by programmed elution: linear gradient to 25% B from zero to six min; linear gradient to 95% B from six to 12 min; linear gradient to 2% B from 12 to 13 min; and isocratic at 2% B from 13 to 15 min. The total run time was 15 min. Under these conditions, levetiracetam and phenytoin eluted from the column at 5.83 and 9.66 min, respectively. Samples were prepared using a protein precipitation procedure. Briefly, to a volume of 100 µl CSF sample in a microcentrifuge tube (1.7 ml) was added 10 µl 50% methanol, followed by 490 µl acetonitrile. The mixture was separated by centrifugation  at room temperature for 15 min. The supernatant (580 µl) was transferred to a borosilicate glass tube (12 x 75 mm) and evaporated to dryness with a stream of dry air. The residue was redissolved in 50% methanol (100 µl) and loaded into a plastic vial insert and 20 µl was injected into the HPLC system. Calibration curves were constructed from 0.5 to 20 µg/ml for both levetiracetam and phenytoin with good linearity (r > 0.99). Data analysis was completed using Microsoft Excel® .Twelve patients were included for analysis with HPLC. Of the 12, six patients received levetiracetam and six received phenytoin. HPLC results were tabulated to obtain CSF concentrations as listed in Tables Differences between actual dose and weight-based dosing of phenytoin and levetiracetam compared to goal six-hour CSF concentrations of levetiracetam and phenytoin are plotted below in Figures Figures The current literature demonstrates that levetiracetam, when recommended blood level doses are reached, can significantly increase the seizure-free time period following post-traumatic brain injury . RecommeA variety of laboratory methods have been utilized to measure levetiracetam levels in biological matrices, including but not limited to, immunoassays, HPLC with UV detection, gas chromatography with mass spectrometry detection, high-performance liquid chromatography-tandem mass spectrometry, capillary electrophoresis with UV detection, and ultra-performance liquid chromatography tandem-mass spectrometry . Some ofOur patient population consisted of two groups of six patients with sTBI who underwent EVD placement. For seizure prophylaxis, these two groups received levetiracetam and phenytoin, respectively. Studies have shown that seizures within the first-week post-traumatic brain injury can be decreased with AED administration . FurtherThe current approach to antiepileptic prophylaxis involves the administration of either intravenous or oral medications to produce high levels of the medications in the bloodstream. Regardless of the administration, the medication must travel from the bloodstream to the brain tissue. The largest obstacle with the administration of such medications is the blood-brain barrier (BBB), which is composed of tight junctions between endothelial cells, with an absence of fenestrations and strict regulation of molecules from the blood into the brain interstitial fluid. Given this challenge, there are several new approaches to increase the entry and persistence of antiepileptic medications in the brain, including strategies such as drug delivery systems, prodrugs, efflux pump inhibition, hyperosmolar BBB opening, and circumventing the BBB via direct drug delivery to the ventricle and cortex .Our study suggests that phenytoin reaches appropriate CSF concentration levels more predictably than those of levetiracetam when doses approximating weight-based calculations are used. As phenytoin levels approached weight-based dosing, CSF levels increased toward the therapeutic range. This relationship was not appreciated when plotting CSF levetiracetam levels against given and weight-based dosages Figures -2. AlthoSome of the limitations associated with this study have been identified. Data were collected from only one level II trauma center over a year-long period. We appreciate that, with just one center participating in the study, center-specific patient characteristics may contribute to the outcome. Furthermore, this study evaluated the CSF concentrations and pharmacodynamics of selected AED therapy but did not investigate the outcomes or incidence of post-traumatic seizure in this population. Further studies could be conducted to investigate this. Additionally, our study would benefit from larger sample sizes.The administration of AEDs are paramount to the prevention of seizure following TBI. Our study suggests that phenytoin reaches appropriate CSF concentration levels over that of levetiracetam when doses approximating weight-based calculations are used. Also, a correlation was found between the weight-based dosing of AED and higher concentration in CSF. More studies will be required in the future to determine the significance of this relationship.


Scenedesmus is a common green algae genus with high biomass productivity, and has been widely used in biofuel production and waste water management. However, the suitability and metabolic consequences of using Scenedesmus as an animal feed ingredient have not been examined in detail. In this study, the influences of consuming Scenedesmus on the metabolic status of young mice were investigated through growth performance, blood chemistry, and liquid chromatography-mass spectrometry (LC-MS)-based metabolomics. Compared to the control diet, feeding a diet containing 5% Scenedesmus improved growth performance while the diet containing 20% Scenedesmus suppressed it. Among common macronutrients-derived blood biochemicals, serum triacylglycerols and cholesterol levels were dramatically decreased by feeding the 20% Scenedesmus diet. Metabolomic analysis of liver, serum, feces, and urine samples indicated that Scenedesmus feeding greatly affected the metabolites associated with amino acid, lipid, purine, microbial metabolism, and the endogenous antioxidant system. The growth promotion effect of feeding the 5% Scenedesmus diet was associated with elevated concentrations of antioxidants, an expanded purine nucleotide cycle, and modified microbial metabolism, while the growth suppression effect of feeding the 20% Scenedesmus diet was correlated to oxidative stress, disrupted urea cycle, upregulated fatty acid oxidation, and an imbalanced lipidome. These correlations among Scenedesmus dietary inclusion rate, individual metabolite markers, and growth performance suggest the need to define the dietary inclusion rate threshold for using Scenedesmus and other microalgae supplements as feed ingredients, and also warrant further mechanistic investigations on the biological processes connecting specific constituents of Scenedesmus with the metabolic effects observed in this study. Microalgae are more efficient than many agricultural crops in harvesting solar energy and fixing carbon dioxide for nutrient production. This outstanding autotrophic property has led to extensive exploration of microalgae as a staple source of human food in the 1940s and 1950s . DespiteScenedesmus is a large genus of green microalgae that contains many common freshwater species + = m/z 556.2771 or [M + H]− = m/z 554.2615). Mass chromatograms and mass spectral data were acquired and processed by MassLynxTM software  in centroided format. Additional structural information was obtained by tandem MS (MS/MS) fragmentation with collision energies ranging from 15 to 45 eV.A 5 µL aliquot of diluted urine, fecal, serum, or liver aqueous fraction samples was injected into an Acquity ultra-performance liquid chromatography (UPLC) system  and separated in a BEH C18 column with a gradient of mobile phase ranging from water to 95% aqueous acetonitrile consisting of 0.1% formic acid in a 10 min run. The LC eluate was directly introduced into a Xevo-G2-S QTOF mass spectrometer for the accurate mass measurement and ion counting. Capillary voltage and cone voltage for electrospray ionization (ESI) was maintained at 3 kV and 30 V for positive-mode detection, or at −3 kV and −35 V for negative-mode detection, respectively. Nitrogen was used as both cone gas (50 L/h) and desolvation gas (600 L/h) and argon as collision gas. For accurate mass measurement, the mass spectrometer was calibrated with sodium formate solution (range m/z), and ion abundance was generated through centroiding, deisotoping, filtering, peak recognition, and integration. The intensity of each ion was calculated by normalizing the single ion counts (SIC) versus the total ion counts (TIC) in the whole chromatogram. The data matrix and sample list were further exported into SIMCA-P+ software . Principal components analysis (PCA) and projection to latent structures-discriminant analysis (PLS-DA) were generated after data were transformed by mean-centering and Pareto optimization to analyze the data from control and Scenedesmus-treated C57BL/6 mice. Major latent variables in the data matrix were described in a scores scatter plot of multivariate model. The potential metabolites after Scenedesmus feeding were identified by analyzing ions contributing to the principal components and to the separation of sample groups in the loadings scatter plot.Chromatographic and spectral data of samples were analyzed using MarkerLynx software (Waters). A multivariate data matrix containing information on sample identity, ion identity (retention time (RT) and http://www.hmdb.ca/, Lipid Maps: http://www.lipidmaps.org/, Metlin: https://metlin.scripps.edu/), MSMS fragmentation, and comparisons with authentic standard if available. The concentrations of selected metabolites were determined by calculating the ratio between the peak area of metabolite and the peak area of internal standard, and fitting with a standard curve using QuanLynxTM software (Waters). The distribution of metabolite markers in sample groups was present in relative levels or in heatmaps. The relative level of individual metabolite (fold) was calculated as the ratio between its mean abundance in a specific sample group and its highest mean abundance in all sample groups. The heatmap of selected metabolite markers was generated by the heatmap.2 package in R program after the Z score transformation of relative abundances (http://www.R-project.org), and the correlations among these metabolite markers were defined by hierarchical clustering analysis (HCA).The chemical identities of compounds of interest were determined by accurate mass measurement, elemental composition analysis, database search (Human Metabolome Database: Acot1), carnitine palmitoyltransferase 1 (Cpt1), phosphatidylethanolamine N-methyltransferase (Pemt), glutamate-cysteine ligase modifier subunit (Gclm), glutamate-cysteine ligase catalytic subunit (Gclc) were designed using the NCBI/Primer-BLAST tool . The sequences of the primers used for the quantitative real-time polymerase chain reaction (qPCR) analysis of targeted genes, including acyl-CoA thioesterase 1 . Data are presented as mean ± SEM. Homogeneity of variance for ANOVA was assessed by Bartlett’s test. The one-way ANOVA using dietary treatment as the fixed factor was performed. For metabolomics data, one-way ANOVA was conducted on the original abundances of individual metabolite instead of the relatives to highest level values. The Tukey post hoc test was performed if the one-way ANOVA was significant. Differences were considered significant if Scenedesmus, and 20% Scenedesmus experimental diets. After 28 days of feeding, significant differences in growth performance were observed among the three treatment groups of mice. Compared to the control group, feeding the 5% Scenedesmus diet increased the ADG, whereas feeding the 20% Scenedesmus diet decreased it  was only increased by feeding the 20% Scenedesmus diet , riboflavin (B2), and pantothenic acid (B5), as prominent urinary metabolites increased by nedesmus F. Among mus diet A–C. To d feeding , suggestt manner D. OveralScenedesmus protein could affect the homeostasis of amino acids (AA) in mice, the concentrations of free amino acids (FAAs) in the liver and serum were quantified. The results indicated that protein enrichment in Scenedesmus diets was not translated into the increases of FAAs because total concentrations of FAAs in serum and the liver were comparable among the three dietary treatment groups of mice  and lyso-phospholipids (lyso-PL) species in the liver and serum were identified in the PLS-DA models of the liver and serum metabolomes (Scenedesmus diet increased the abundance of phosphatidylcholine (PC) and lyso-PC species containing ω-3 PUFA, including α-linolenic acid (18:3), eicosapentaenoic acid , and docosahexaenoic acid , but reduced the distribution of saturated and monounsaturated fatty acids (FAs), including palmitic acid (16:0), palmitoleic acid (16:1), stearic acid (18:0), and oleic acid (18:1) (Scenedesmus increased the relative abundance of many phosphatidylethanolamine (PE) species in the liver, while decreased that of PC species, leading to a clear shift in the profile of hepatic PL  C. Moreovpatic PL D. Cholin feeding E. Subseqmus diet F.Scenedesmus diet, while oxidized glutathione (GSSG) was positively correlated with feeding the 20% Scenedesmus diet , the rate limiting enzyme in glutathione biosynthesis showed that feeding the 20% Scenedesmus diet induced Gclm gene expression, while Gclc expression was not affected  was positively correlated with feeding the 5% mus diet B. Subseqntration . Examiniaffected B. Moreovion rate C,D. All Scenedesmus feeding on microbial metabolism were reflected by the metabolite markers contributing to the separation of three dietary treatments in the PLS-DA models of fecal and urine metabolomes  was decreased by the 20%  [Scenedesmus were likely utilized to compensate for the decrease of carbohydrates in the diet for use in energy metabolism. This shift in macronutrient metabolism requires the deamination of amino acids and may increases the volume of nitrogen metabolism  , the addtabolism . The chatabolism  indicatearginase . InteresScenedesmus diet, suggests an association of enhanced PNC activity and elevated energy production with the improved growth performance. Interestingly, hepatic MTA, a sulfur-containing nucleoside that is produced during the biosynthesis of polyamines, was increased by feeding the 20% Scenedesmus diet  . Becausemus diet E. The coutrients , the macScenedesmus sp. in this study contains elevated levels of PUFAs, especially EPA [Scenedesmus diet, resulting in the decreases of serum and hepatic TAG and the increases of dicarboxylic acids in urine and serum  diet was effective in improving the incorporation of PUFAs into PC and Lyso-PC content of egg yolk [In addition to TAG and cholesterol, feeding the 20% ficiency . However in rats . Decreas in rats . Further in rats , the bioegg yolk .Scenedesmus feeding in a dose-dependent pattern. The disruption of the thiol antioxidant system in the 20% Scenedesmus dietary treatment was also supported by other two lines of evidence: (1) The imbalance between methionine and taurine suggests a disruption of the metabolic pathways between them because methionine is the precursor of thiol antioxidants, while taurine is the end product of transsulfuration and cysteine oxidation. (2) The induction of Gclm expression by the 20% Scenedesmus diet, which is a rate-limiting enzyme in GSH biosynthesis [Scenedesmus diet  are formed by the deconjugation of taurine or glycine moieties from primary bile salts , and are then subsequently converted to secondary bile acids (DCA and LCA) through dehydroxylation . Based ole acids . This meormation . OverallScenedesmus offers a combination of protein, lipids, vitamins, fiber, and bioactive constituents that are significantly different from common plant or animal feed ingredients. These compositional differences in nutrients and non-nutrients led to diverse and dramatic changes in the mouse metabolome observed in this study. The growth promotion effect from feeding the 5% Scenedesmus diet was associated with elevated antioxidants, an expanded purine nucleotide cycle, and modified microbial metabolism, while the growth suppression effect observed when feeding the 20% Scenedesmus diet was correlated to oxidative stress, disrupted urea cycle, upregulated fatty acid oxidation, and an imbalanced lipidome. These dose-dependent effects clearly suggest the existence of an inclusion threshold for the dietary addition of Scenedesmus as an animal feed ingredient. Further studies on the metabolic fates of individual algal constituents, as well as their influences on specific metabolic routes, such as purine, methionine, PUFA, and SCFA metabolism, will provide useful insights on the chemical signals and biological pathways contributing to dose-dependent beneficial and adverse effects, and guide the uses of Scenedesmus and also other microalgae as animal feed ingredients.Overall,


To better understand its role in cardiac function, we studied mechanical and electrophysiological effects in transgenic mice that overexpress the human A2A-AR in cardiomyocytes (A2A-TG). We used isolated preparations from the left atrium, the right atrium, isolated perfused hearts with surface electrocardiogram (ECG) recording, and surface body ECG recordings of living mice. The hypothesized arrhythmogenic effects of transgenicity per se and A2A-AR stimulation were studied. We noted an increase in the incidence of supraventricular and ventricular arrhythmias under these conditions in A2A-TG. Moreover, we noted that the A2A-AR agonist CGS 21680 exerted positive inotropic effect in isolated human electrically driven (1 Hz) right atrial trabeculae carneae. We conclude that A2A-ARs are functional not only in A2A-TG but also in isolated human atrial preparations. A2A-ARs in A2A-TG per se and their stimulation can lead to cardiac arrhythmias not only in isolated cardiac preparations from A2A-TG but also in living A2A-TG.Adenosine can be released from the heart and may stimulate four different cardiac adenosine receptors. A receptor subtype that couples to the generation of cyclic adenosine monophosphate (cAMP) is the A Typically, A1- and A3-AR inhibit and A2A- and A2B-AR stimulate adenylyl cyclase activities  expressed in the mammalian heart is controversially discussed. Species- or method-dependent differences may exist: in some publications, no cardiac effects of adenosine were reported , the precursor of adenosine, are useful to treat supraventricular tachyarrhythmias. Hence, in the human heart, the actions of adenosine are of clinical relevance and merit further investigation. If Ated rat: , whereasted rat: .2A-ARs have been detected on the protein level (2A-ARs (A2A-AR-KO mouse), the functional expression of A2A-ARs in the wild-type (WT) mouse heart could be demonstrated  phosphorylation, and this was suggested to lead to an altered flow of Ca2+ through the sarcolemmal sodium calcium exchanger (NCX) and thus arrhythmias  and NCX stimulation might increase Ca2+ inflow into the cell. This increase of Ca2+ content in the SR may lead to increased release of Ca2+ from the SR, leading to delayed afterdepolarization and thus to atrial arrhythmias like atrial fibrillation  and hypoxia in mammalian cardiac preparations. Progress reports of this work have appeared in abstract form , and PCR amplification was performed using the Ampliqon Taq DNA polymerase  according to the manufacturer’s instructions. All experiments presented here were performed on 12- to 30-week-old A2A-TG mice and WT littermates of both sexes.The polymerase chain reaction (PCR)-generated human A3 and 100 µl 20% SDS (sodium dodecyl sulfate). Mixtures were kept at 25°C for 30 min before centrifugation to remove debris. Thereafter, supernatants  were kept at −20°C until further analysis. Western blot analysis was performed as reported . All secondary antibodies were conjugated with an alkaline phosphatase . Bands were detected using enhanced chemifluorescence , and fluorescent bands were visualized in a Typhoon 9410 PhosphorImager and quantified using the ImageQuaNT software . Enhanced chemifluorescence detection was carried out according to the manufacturer’s instructions .Cardiac homogenates were prepared in 300 µl of 10 mM NaHCOreported . Aliquot2A-TG and WT mice, measurement of Ca2+ transients, and measurement of cell shortening were performed as described previously (−1) was present under all experimental conditions. In order to get an insight into the signaling via A2A-AR, we used the following highly selective antagonists for pre-incubation: DPCPX (A1-AR antagonist) or ZM 241385 (A2A-AR antagonist). Isolated cardiomyocytes were stimulated either by 1 µM CGS 21680 (A2A-AR agonist) or by 1 µM isoproterenol (β-adrenergic stimulation as positive control) each for 10 min at 37°C.Isolation of ventricular cardiomyocytes from Aeviously . To avoi2A-AR agonist CGS 21680 (40 µg kg−1). Before injection, ECGs were recorded for 1 h to preserve basal conditions. ECGs were analyzed for heart rate and arrhythmias.Adult (9 months old) mice were instrumented with a telemetric ECG transmitter  as described previously . After a−1).Echocardiography in spontaneously breathing mice was performed under anesthesia with 1.5% isofluorane as described previously . We asse−1) and hearts were excised. Pentobarbital was used here in order to provide direct comparability with our previous work  was cumulatively applied for 20 min for each compound. Contraction experiments were performed after addition of ADA (1 µg ml−1) and DPCPX (1 µM) to avoid interference from endogenous adenosine or A1-AR activation. For comparison, right atrial preparations were obtained from patients undergoing bypass surgery due to coronary heart disease and handled in the same way as left atrial preparations from mice .Contractile function was studied as reported . In brieork e.g.  and follork e.g.  with eac−1 body weight urethane and treated with 1.5 units of heparin. This was done to provide direct comparability with our previous work . Hearts were stimulated at 8 Hz. Heart rate, aortic pressure, and LV pressure were measured and monitored continuously. The first derivative of LV pressure (+dP/dt and −dP/dt) was calculated . In order to achieve global ischemia, the perfusion was stopped for 20 min and thereafter the hearts were perfused for 60 min. In an additional set of experiments, electrophysiological studies  were performed in isolated, Langendorff-perfused hearts as described previously (Heart preparations were utilized as described previously . Mice weork e.g.  and folleviously .Right atrium (RA) samples were obtained from patients undergoing open-heart surgery with coronary artery bypass grafts and electrically stimulated in organ baths as described previously . Patient2-test as appropriate. A p-value < 0.05 was considered as significant.Data shown are means ± SEM. Statistical significance was estimated by analysis of variance followed by Bonferroni´s t-test or using the χADA (produced by Roche) was purchased from Sigma-Aldrich (#10102121001), CGS 21680 (2-p-(2-carboxyethyl)phenethylamino-5′-N-ethylcarboxamidoadenosine hydrochloride hydrate) was purchased from Sigma-Aldrich (#C141), DPCPX  was purchased from TOCRIS (#0439), and ZM 241385 (4-(2-triazolotriazin-5-ylamino]ethyl)phenol) was purchased from TOCRIS (#1036). All other chemicals were of analytical grade. Deionized water was used throughout the experiments. Stock solutions were freshly prepared daily.2A-ARs was similar in RA as in left atrium (LA) of A2A-TG. However, expression in the ventricle of A2A-TG was about double to that of transgenic atria . For lack of sufficient amount of tissue, we could not perform Western blots in atrial preparations; however, we could present functional data on the presence of A2A-AR in atrial samples  was lacking in left atrial preparations from WT  in ventricular cardiomyocytes from A2A-TG but not WT  and in isolated right atrial preparations . Moreover, even under basal conditions, an increased incidence of arrhythmias was noted in isolated spontaneously beating right atrial preparations from A2A-TG compared to WT, and also after β-adrenergic stimulation by addition of isoproterenol to these preparations from A2A-TG, the incidence of arrhythmias was higher than in WT  in the cardiac perfusate. Indeed, the activity of AST was higher in samples from WT than in samples from A2A-TG, and this difference vanished after application of the A2A-AR antagonist ZM 241385 . Here, the duration of the monophasic action potential was shortened by CGS 21680 in WT . These arrhythmias manifested as non-sustained atrial fibrillation or atrial tachycardia , as this underscores the functionality of this receptor in the human heart and more specifically a similarity (and comparability) of our atrial preparations from transgenic mice with overexpression of the A2A-TG but not in WT. Here, we extended the functional relevance of phospholamban phosphorylation  was increased to a higher extent during reperfusion in hearts from A2A-TG than in WT. A role of active AKT and/or ERK1/2 in cardiac protection but also generation of arrhythmias has been reported by others before -physiological relevance. For example, Apatients . Hence, on waves . Spontanmyocytes .2A-ARs is increased in arrhythmias, but likewise, the expression of angiotensin II-receptor, IP3-receptors, opioid receptors, and 5-HT4-receptors was reported by others to be elevated .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


For diagnosing glioma, this approach has unfortunately proven to be of limited use since glioma contribute minimal ctDNA to the blood circulation. A more promising avenue may therefore be to hunt for ctDNA in cerebrospinal fluid (CSF). The study by Mouliere  Each year, more than 200,000 individuals are diagnosed with glioma worldwide  in the blood circulation have shown exciting promise . The presence of tumor DNA in CSF was first reported in 1995 by Harker Rhodes l, et al  used botl  in CSF‐sWGS data. SCNAs were detected in the CSF of five out of 13 glioma patients as focal events confined to individual genes and as large events spanning entire chromosomes. Similar SCNAs were not seen identified in matched plasma samples, confirming earlier reports that cfDNA in CSF better represents the genomic alterations of brain tumors than cfDNA in plasma (Bettegowda et al, To study structural features in CSF‐cfDNA on molecular scales, the authors implemented paired‐end DNA sequencing, which provides sequence information from both ends of the molecules, and obtained the size distribution of cfDNA fragments in CSF. This analysis revealed a shortening of fragments in the CSF of patients with primary brain tumors. A similar shortening has been observed for ctDNA in plasma (Underhill et al,et al,et al,et al is an important early step in the creation of diagnostic protocols that take advantage of low‐cost screening via CSF‐cfDNA to identify samples where more expensive, confirmatory testing is needed. First however, further study is necessary to validate the concepts put forward in this paper in a larger cohort of patients.Cell‐free DNA in CSF provides a compelling, information‐rich window into the genetic makeup and biology of brain cancers (Harker Rhodes The authors declare that they have no conflict of interest.


Varicella-zoster virus (VZV) is a common viral agent causing central nervous system (CNS) infections including encephalitis, meningitis, and Ramsay Hunt syndrome. Neurological complications occur frequently despite antiviral treatment. Matrix metalloproteinases (MMPs) and cytokines are involved in the neuroinflammatory response during CNS infection. Their role in VZV CNS infections and how they differ between different CNS entities caused by VZV are poorly investigated.n = 24).We analyzed the levels of 30 chemokines and 9 MMPs in cerebrospinal fluid (CSF) and serum from 66 patients with VZV CNS infections diagnosed by detection of VZV DNA in CSF and concomitant neurological symptoms and compared with a control group  and MMPs , indicating that different location of the virus gives rise to qualitative differences in the ensuing inflammatory response. In addition, the pronounced increase of MMPs in CSF of the patients with encephalitis suggests an association to the severity of this manifestation, compared to VZV meningitis and Ramsay Hunt syndrome. The role of MMPs in association to chemokines should be further investigated to evaluate their significance in the neuropathogenesis of VZV CNS infections and as a potential target for new treatment alternatives. Varicella-zoster virus (VZV) is recognized as one of the most common viral agents causing central nervous system (CNS) infections and includes a wide spectrum of CNS manifestations such as encephalitis, meningitis, Ramsay Hunt syndrome with facial paralysis, and vasculitis with stroke-like syndromes. Serious neurological complications are reported despite antiviral treatment. Encephalitis caused by VZV is associated with severe neurological sequels with primarily cognitive deficits whereas meningitis and Ramsay Hunt syndrome are considered more benign. The neuropathogenesis of VZV CNS infections is only partly elucidated. After primary infection, VZV establishes latency in sensory ganglia. When VZV reactivates and causes herpes zoster, it is suggested that the virus propagates to CNS primarily from afferent fibers from trigeminal and other ganglia via trans-axonal transport . In the The CNS is considered an immune-privileged site. Leukocyte entry into the CNS is restricted by the blood-brain barrier (BBB) and/or the blood-cerebrospinal fluid barrier (BCSFB). However, immune surveillance continuously takes place in the CNS during steady state indicating that leukocyte trafficking over these barriers takes place also in the absence of CNS inflammation –9. DurinThe second step in the process, the BBB breakdown, may be due to direct trauma or mediated by inflammatory modulators –9 such aOur aim was to investigate the concentrations of 30 chemokines and 9 MMPs in the CSF and serum of patients with VZV CNS infections diagnosed by VZV DNA by PCR in the CSF and to correlate the amount of these chemokines and MMPs to clinical entities and parameters. We found that CXCL8, CXCL9, CXCL10, CXCL11, and CCL19 were significantly increased in CSF to levels above those found in serum. In addition, CSF levels of MMP-2, MMP-3, MMP-8, MMP-9, and MMP-12 reached high to very high levels in patients with VZV CNS infections compared to controls. Most pronounced were the increased levels of MMPs in patients with encephalitis, indicating an association to the severity of this manifestation, compared to VZV meningitis and Ramsay Hunt syndrome.Patients from the region of Västra Götaland in Sweden, with VZV DNA detected in the CSF by real-time PCR between 2004 and 2015, were retrospectively identified at the Laboratory of Virology at Sahlgrenska University Hospital, Gothenburg, Sweden. The inclusion criteria were contemporary acute CNS symptoms in patients categorized as encephalitis, meningitis, or Ramsay Hunt syndrome, based on previously presented criteria , and avaCSF and serum samples from 24 non-infectious persons that had sought care for headaches were included. All control subjects had normal neurological status at examination, normal CSF cell count, and normal CSF albumin concentration. None of them were diagnosed with any neurological or other diseases that could be presumed to affect the CNS, within 1 year after sampling.The CSF samples were analyzed for VZV DNA by a quantitative in-house TaqMan PCR method as described previously  at the tChemokines  and MMPs  were detected and quantified using a human magnetic Luminex assay  according to the manufacturer’s instructions and analyzed using Bio-Plex 200 system (Bio-Rad) with five-parameter logistic standard curves which were used for interpolation of chemokine and MMP levels.U test was used for comparisons between two groups, and Kruskal Wallis non-parametric test with Dunn’s post-test was used for multi-group comparisons. Non-parametric Spearman’s correlation coefficient test was used for correlations. Statistical analyses were performed using GraphPad Prism version 7 (GraphPad Software). One patient with VZV meningitis and vasculitis as a result of systemic lupus erythematosus showed extremely deviating results, that is why she was regarded as an outlier and was not included in further statistical analysis to avoid misleading data.Mann-Whitney n = 29), meningitis (n = 21), and Ramsay Hunt syndrome (n = 17). In 34 of these 67 patients, paired CSF and serum samples were analyzed , meningitis (n = 14), Ramsay Hunt syndrome (n = 9)). Thirty of 34 serum samples were drawn the same day as the CSF and the other four were drawn within 3 days. Lumbar punctures were performed median 4 days (range 0–90) after onset of neurological symptoms. Four patients with encephalitis had changes at computer tomography (CT) and/or at magnetic resonance imaging (MRI) of the brain compatible with acute ischemic stroke, which were regarded as VZV manifestations. One other patient with encephalitis had concomitant symptoms of polyneuropathy. Clinical data are presented in Table n = 1), rheumatoid arthritis (n = 1), prostate malignancy (n = 1), systemic lupus erythematosus (n = 1), vasculitis (n = 1), and ulcerous colitis (n = 1)). All received immunosuppressive treatment. Antiviral treatment was administered median 0 day (range 5–6) after lumbar puncture.Seventy-two patients with VZV DNA detected in the CSF were included. In 67 patients, sufficient amount of frozen CSF was available for further analysis. These 67 patients were categorized into the following diagnostic entities: encephalitis . However, when we adjusted these data to the levels found in serum from the VZV patients, we identified five chemokines that were not only increased in the CSF of VZV patients but also reached levels in the CSF surpassing those found in serum, thus creating a chemotactic gradient towards the CNS. CCL19, CXCL8, CXCL9, and CXCL10 were significantly increased compared to CSF from control patients and compared to levels in serum in patients with encephalitis, meningitis, and Ramsay Hunt syndrome  and to the number of infiltrating PMN (p = 0.002) which is consistent with the fact that virus levels, PMN, and CXCL8 were all enhanced in VZV encephalitis patients. There was a strong correlation between the CSF levels of CCL19 and the number of MNC in the CNS (p = 0.0003). Weak associations were found between CXCL9 and numbers of MNC (p = 0.020) and CXCL11 and PMN (p = 0.046).The CSF levels of CXCL8 correlated both to the viral load in the CSF (p = 0.034 and p = 0.031 respectively).We analyzed the levels of nine different MMPs  in CSF and, when available in serum, from 67 VZV patients and 24 control patients. MMP-2-levels increased 10,000-fold in CSF from patients with encephalitis, meningitis, and Ramsay Hunt syndrome and was the only MMP to be increased in all disease entities and also in CSF from all 67 patients . No other correlations were shown between the number of MNC and the CSF levels of the other MMPs. The number of PMN in CSF was highly associated with the increased levels of MMP-8 in CSF (p = 0.0001) and to a minor extent with the levels of MMP-3 (p = 0.002) and MMP-9 (p = 0.032). A moderate correlation between viral load in CSF and the levels of MMP-3 in CSF in the VZV patients was shown (p = 0.007) which was slightly more pronounced in the patients with meningitis (p = 0.002). No other correlations were found between viral load in CSF and concentrations of MMPs.When analyzing cell numbers in the CSF, there was a very strong correlation between the CSF levels of MMP-9 and the number of MNC in the CNS .n = 44) and without blisters (n = 21) in the VZV patients, an inverse relation was revealed with moderate higher concentrations of MMP-9 in CSF of patients lacking blisters compared to patients with blisters (p = 0.008). In serum, there were no significant differences in MMP levels or chemokine levels  depending on if the patients had blisters or not.When comparing patients with blisters (p < 0.0001) and Ramsay Hunt syndrome (p = 0.022) and also a modest difference between VZV patients as a whole group compared to controls (p = 0.025), we also correlated age to the levels of MMPs and chemokines. In CSF, only MMP-12 of the five increased MMPs in CSF  correlated with age (p < 0.001). In serum, levels of MMP-3 and MMP-12 correlated with age (p = 0.046 and p < 0.001 respectively). However, the associations to age disappeared when the patients were subgrouped. No correlations were shown between age and chemokine levels  in CSF.As there were differences in age between the subgroups (see Table n = 60) compared to the immunocompromised patients (n = 5) (p = 0.009); otherwise, there were no significant differences in MMP levels or chemokine levels  in CSF depending on immune status.Modest increased concentrations of MMP-8 in CSF were expressed in the immunocompetent patients  in CSF or MMPs in CSF or serum and numbers of days between onset of symptoms and CSF sampling (not shown). Taken together, the analyzed possible confounding variables can only have influenced the results in very minor extent.This is to our knowledge the first study that investigates chemokines and MMPs in patients with various CNS manifestations caused by VZV infection. We demonstrate that CNS complications caused by VZV virus are associated with highly elevated CSF levels of the chemokines CCL19, CXCL8, CXCL9, CXCL10, and the matrix metalloproteinase MMP-2 in patients with different CNS manifestations such as encephalitis, meningitis, and Ramsay Hunt syndrome. In addition, patients with encephalitis had pronounced increased levels of MMP-3, MMP-8, and MMP-12 in their CSF compared to controls, suggesting an association to the severity of this manifestation.Prior to this study, little was known regarding the chemokine responses during VZV infection in humans neither in the systemic compartment nor in the CNS. We found that VZV CNS complications led to significantly increased CSF levels of 26 out of 30 examined chemokines. Elevated levels of CXCL13 have previously been identified in CSF fluid from two patients with VZV meningitis , which wVZV can induce CXCL8 production in a variety of different cell types in vitro , 25. We CCL19 binds the CCR7 receptor expressed on T cells and B cells and is one of several chemokines that are constitutively expressed in the CNS , 30. DurWe found high levels of CXCL9 and CXCL10 in CSF from patients with VZV CNS complications. VZV infection leads to CXCL10 production in a variety of cell types , 25 inclThe increase of the constitutively produced MMP-2 may disrupt basal lamina and tight junctions between endothelial cells, leading to BBB disruption. We found a 10,000-fold increase of MMP-2 in CSF from patients with encephalitis, meningitis, and Ramsay Hunt syndrome which supports a previous study of VZV patients with CNS vasculopathies that also showed high levels of MMP-2 in CSF . Animal Only the patients with VZV meningitis demonstrated increased levels of MMP-9 in CSF. In humans, high levels of MMP-9 have been found in the CSF in both viral and bacterial meningitis , 42. In Also, MMP-2 and MMP-3 were increased in serum of the VZV patients. As for MMP-9, we cannot exclude that a portion of these MMPs in CSF may be derived from serum.The patients with VZV encephalitis had elevated levels of MMP-3, MMP-8, and MMP-12 in CSF compared to controls, which may reflect a more intense neuroinflammatory response in these patients compared to the other groups. MMP-3 is an intercellular signaling molecule that modulates neuroinflammatory responses . Both stBoth MMP-8 and MMP-12 have been reported as critical factors for brain damage in cerebral ischemia in animal studies , 46. MMPThe present study demonstrates that patients with VZV CNS infections have a high CSF production of CXCL8 which attracts neutrophils, CCL19, CXCL9, and CXCL10, which attracts virus-specific T cells, and MMP-2 that facilitates the breakdown of the BBB and thus cell infiltration into the parenchyma. In addition, patients with encephalitis showed pronounced increased levels of MMP-3, MMP-8, and MMP 12 in their CSF compared to controls, indicating an association to the severity of this manifestation. The role of MMPs in association to chemokines should be further investigated to evaluate their role in the neuropathogenesis of VZV CNS infections and as a potential target for new treatment alternatives.


In delphinium and Arabidopsis, p-hydroxybenzoylglucose and sinapoylglucose are used in vivo as bi-functional donor molecules by vacuolar GT and AT, respectively. The evolution of these enzymes has allowed delphinium and Arabidopsis to utilize unique donor molecules for production of highly modified anthocyanins.Higher plants can produce a wide variety of anthocyanin molecules through modification of the six common anthocyanin aglycons that they present. Thus, hydrophilic anthocyanin molecules can be formed and stabilized by glycosylation and acylation. Two types of glycosyltransferase (GT) and acyltransferase (AT) have been identified, namely cytoplasmic GT and AT and vacuolar GT and AT. Cytoplasmic GT and AT utilize UDP-sugar and acyl-CoA as donor molecules, respectively, whereas both vacuolar GT and AT use acyl-glucoses as donor molecules. In carnation plants, vacuolar GT uses aromatic acyl-glucoses as the glucose donor Angiosperms display a wide range of flower colors and many species are exploited for horticultural purposes because of this characteristic. Flower colors commonly depend on three major plant pigments, namely, flavonoids/anthocyanins, betalains and carotenoids . Of thesSome plant species can produce complicated molecular anthocyanin structures, termed polyacylated anthocyanins, by attachment of multiple sugar and organic acid moieties see . As eachbenzoylalcohol acetyl transferase, anthocyanin-O-hydroxycinnamoyltransferase, anthoranilate-N-hydroxybenzoyl/benzoyltransferase and deacetyl-vindoline acetyltransferase activities .,12.O- has been discovered . SurprisN-terminal end for translocation into the vacuole . Analyses using a crude protein extract prepared from delphinium sepals showed that these modification steps are carried out in a step-by-step sequence in the order p-hydroxybenzoylation, a second glucosylation, and then a second p-hydroxybenzoylation . Un. UnAtSATsylation . AtBGLU1position  25]. Ev. EvAtSATer donor ,19,26,46This review has mainly focused on the roles of acyl-glucoses as substrates for anthocyanin biosynthesis. Although the vacuole was initially regarded simply as a storage organ that accumulated a wide range of substances, recent studies show that it is also the location of diverse enzymatic reactions. The modification reactions mediated by vacuolar enzymes are not limited to anthocyanins ,41,42,43Recent studies indicate the dynamic function of the vacuole as an active site of synthesis of plant metabolites. In future work, it will be important to verify that these enzymatic reactions truly occur in the vacuole as opposed to other organelles such as the pre-vacuole . The que


Borrelia antibodies in the cerebrospinal fluid (CSF) are required for definite diagnosis of Lyme neuroborreliosis (LNB). However, children often present with early LNB, and antibody production in the CSF may not be demonstrated. Recent studies have suggested the chemokine CXCL13 to be an early marker for LNB. The aim of the study was to evaluate CXCL13 for laboratory diagnosis in pediatric LNB patients and to evaluate the association with pleocytosis in CSF, clinical features, and recovery. CSF samples were collected from LNB patients, classified as definite LNB (n = 44) or possible LNB (n = 22), and controls classified as non-LNB (n = 102) or other specific diagnoses (n = 23). CSF samples were analyzed with the recomBead CXCL13 assay , cut-off 160 pg/mL. CXCL13 was significantly higher in LNB patients compared to controls (p < 0.001). Among LNB patients, 58/66 had elevated CXCL13, and among controls, 111/125 had CXCL13 levels under cut-off . In LNB patients with pleocytosis but no detectable anti-Borrelia antibodies in CSF (possible LNB), CXCL13 was elevated in 16/22 (73%). A weak correlation between CXCL13 and pleocytosis in CSF was found in LNB patients , but no differences in CXCL13 levels in relation to specific clinical features. In conclusion, CXCL13 is elevated in CSF in children with LNB, showing acceptable sensitivity and specificity. In patients with possible LNB, CXCL13 was elevated in a majority of cases (73%) and is suggested as a complementary diagnostic tool in pediatric LNB patients. CXCL13 was not associated with specific clinical features or recovery.Anti- Borrelia burgdorferi sensu lato complex [Borrelia (B.) garinii, B. afzelii, and B. burgdorferi sensu stricto [Borrelia spirochetes are invasive and motile, easily disseminating through different tissues in the body. These bacteria do not produce any toxins but they activate the host’s immune defense, causing numerous inflammatory responses that in turn generate the symptoms of the disease [Lyme borreliosis (LB) is a tick-borne infection caused by spirochetes belonging to the  complex . The mai stricto . The Bor disease , 4.B. garinii) into the central nervous system (CNS), leading to inflammation in the CNS (meningitis) and affection of cranial or peripheral nerves [Lyme neuroborreliosis (LNB) is caused by dissemination of the spirochetes  neurological symptoms attributable to LNB, (ii) pleocytosis in cerebrospinal fluid (CSF), and (iii) intrathecally produced anti-tibodies . However disease . Childrepatients , 13.The chemokine CXC motif ligand 13 (CXCL13) is known primarily for its function as a B cell- and follicular T-helper cell-attractant in lymphoid tissues , but CXCBorrelia-induced inflammation, and it has been shown in several studies that the CXCL13 concentration is high during active inflammation and decreases rapidly after successful antibiotic treatment of LNB [CXCL13 also seems to be a valid clinical marker for active t of LNB , 20, 21.t of LNB , 22–25, Borrelia antibodies may not yet be present in the CSF, it is of importance to evaluate the usefulness of complementary methods for diagnostic purposes in this group of patients, and CXCL13 has been a promising candidate [Since children often present with early LNB, and anti-andidate , 22. Furandidate , 19.The aim of the study was to evaluate the usefulness of CXCL13 for laboratory diagnosis in well-characterized pediatric LNB patients and controls, and to evaluate the association to pleocytosis in CSF, clinical features, and recovery.Children with suspected LNB were recruited from seven pediatric clinics in a Lyme endemic area in southeast Sweden during the period 2010 to 2014. Patients were clinically evaluated on admission and underwent a lumbar puncture as part of the routine investigation. Additional blood and CSF samples were taken at the same occasion for research purposes. A questionnaire was completed by children and parents/guardians, including questions regarding clinical symptoms, observed tick bites or erythema migrans, previous antibiotic treatment, and the overall health of the child. All children in the study were followed clinically for 2 months, and a questionnaire for self-reported symptoms was employed.Borrelia antibodies. Possible LNB was defined as (i) symptoms attributable to LNB, (ii) pleocytosis in CSF, or (iii) intrathecally produced anti-Borrelia antibodies. All children in the possible LNB group in this study had pleocytosis in CSF but no detectable intrathecally produced anti-Borrelia antibodies, and no clinical signs or laboratory evidence for other infection.Classification of LNB patients was made according to European guidelines . DefinitAll patients classified as definite LNB and possible LNB received antibiotics according to national guidelines . All patients responded well to treatment.n = 44) and possible LNB (n = 22) patients are, in this study, referred to as LNB patients (n = 66).Definite LNB . These patients presented with neurological symptoms attributable to LNB but with no pleocytosis in CSF and no intrathecally produced anti-Borrelia antibodies. Non-LNB patients were mainly patients with idiopathic facial nerve palsy or headache of unknown origin. No patient in the non-LNB group received any other specific neurological diagnosis.Two control groups were included in the present study. The first control group consisted of patients classified as non-LNB cases (n = 23), such as viral meningitis (n = 4), epilepsy (n = 4), idiopathic intracranial hypertension (n = 3), post infectious encephalitis (n = 2), infantile spasm (n = 2), migraine (n = 2), head trauma (n = 1), stroke (n = 1), attention deficit hyperactivity disorder (ADHD) (n = 1), neurofibromatosis type 1 (n = 1), and Guillain-Barre syndrome (n = 1).The second control group consisted of children with other specific diagnoses . They all had specific clinical symptoms associated to either viral meningitis  or post infectious encephalitis , but only one patient with viral meningitis had a specific causative agent (enterovirus) confirmed by PCR. All patients with other specific diagnoses were negative for intrathecally produced anti-Borrelia antibodies, including the six patients with pleocytosis. Patients classified as non-LNB cases (n = 102) and other specific diagnoses (n = 23) are being referred to in this study as controls (n = 125).Some patients in the group of other specific diagnoses presented with pleocytosis in CSF  as part of the clinical routine evaluation on admission at each pediatric department, all using the flagella antigen-based enzyme-linked immunosorbent assay (ELISA), IDEIA Lyme Neuroborreliosis Kit  [Borrelia antibodies according to the manufacturer’s instructions. Data from anti-Borrelia antibodies in serum was not separately available for patients with positive index with the IDEIA assay, noted as NA (not available) in Table 6 cells/L [All patients were analyzed for intrathecal anti-ire, UK) . An inde cells/L .CSF and blood samples for CXCL13 analyses were taken before the start of antibiotic treatment and stored at − 70° until analyses were performed at the Laboratory of Clinical Microbiology, Division of Laboratory Medicine, and Region Jönköping County, Sweden. The CXCL13 analyses in CSF were performed with the recomBead CXCL13 assay , a multiplex bead array, using Luminex xMAP technology. The software Xponent version 33.1.971.0  was used. The platform was applied according to the manufacturer’s instructions for evaluation of CXCL13 in CSF and 9 pg/mL was set as the lowest detection level. The cut-off level of 160 pg/mL was chosen according to previous studies , 21.IBM SPSS Statistics, version 21  and Microsoft Excel 2016  were used for statistical analyses and illustrations.U test was used when comparing continuous data between groups. Correlations were calculated using the Spearman’s rank-sum test using the correlation coefficient Rho when needed. A p value < 0.05 was considered statistically significant.Chi-squared test and Fisher’s exact test were used for non-continuous data. For non-parametric analysis, the Mann–Whitney p < 0.001).The concentrations of CXCL13 in CSF ranged between 29 and 54,266 pg/mL (median 7303) in the definite LNB group, whereas levels of CXCL13 ranged between 9 and 61,643 pg/mL (median 688) in the possible LNB group . Among LNB patients, 58 out of 66 had a positive test result, giving the CXCL13 recomBead test in CSF a sensitivity of 88%. Calculations from controls showed a negative test result in 111 out of 125, giving the CXCL13 recomBead test in CSF a specificity of 89%.When comparing CXCL13 concentrations over and under the cut-off 160 pg/mL  in LNB patients and controls, a statistically significant difference was found  and post-infectious encephalitis (n = 2). The CXCL13 concentrations in these two groups of children are shown in Fig. To be able to evaluate whether CXCL13 may be helpful in excluding LNB in children with neurological manifestations and pleocytosis caused by other etiologies, the two groups of children with these properties were examined more closely. Among LNB patients, all 22 children with possible LNB presented with neurological symptoms and pleocytosis in CSF, but no detectable intrathecally produced n = 22), and patients in the subgroup of controls with other specific diagnoses and pleocytosis (n = 6) (p < 0.01) . All patients in the subgroup of controls with other specific diagnoses and pleocytosis (n = 6) had CXCL13 levels under the cut-off .Based on the cut-off 160 pg/mL, 16 of the 22 patients (73%) with possible LNB were CXCL13 positive and six were CXCL13 negative. Laboratory findings of these six CXCL13 negative patients in the possible LNB group are shown in Table n = 102), seven children had CXCL13 concentrations over cut-off  .The CXCL13 concentrations of LNB patients were analyzed for correlation with the degree of pleocytosis in CSF . No differences in CXCL13 concentrations were found in relation to age, gender, observed tick bites, EM, or other clinical features. In addition, CXCL13 concentrations (on admission) were not more elevated in children who later reported persistent symptoms at the 2-month follow-up compared to children who were fully recovered at follow-up.The CXCL13 concentrations in CSF were analyzed for correlation with the duration of symptoms in LNB patients on admission Fig. . A very In this present study, the concentrations of CXCL13 in CSF were significantly higher in LNB patients compared to controls. These results are consistent with those observed in several previous studies , 28, 29,When looking at the definite LNB group exclusively in our study, the sensitivity of CXCL13 in CSF was excellent at 95%, which is in line with previous studies , 28, 29.Borrelia antibodies in serum and/or EM/ Borrelia lymphocytoma. No patient in the possible LNB group had clinical signs or laboratory evidence for other infections and all responded well to antibiotic treatment, which further supports the LNB diagnosis.One can always discuss whether patients classified as possible LNB according to European guidelines  are truen = 6)  possibly indicating two very early LNB patients with pleocytosis but with no intrathecally produced anti-Borrelia antibodies and no CXCL13 in CSF at the time of lumbar puncture. All six patients responded well to antibiotic treatment, but at follow-up, one patient had mild persistent facial nerve palsy and one reported persistent headache. Taken all together, results from our study clearly support the hypothesis that CXCL13 analysis can be useful as diagnostic tool in early LNB when intrathecally produced anti-Borrelia antibodies are not yet detectable [Among CXCL13 negative children in the possible LNB group (6) Table , pleocyttectable , 29, 30.Borrelia IgM in serum. Two patients had facial nerve palsy with a duration of 1–6 days on admission and CXCL13 concentrations in CSF above cut-off (236 and 330 pg/mL) but none of them had EM or anti-Borrelia IgM in serum to support a possible very early LNB diagnosis. No patient was later reinvestigated for prolonged symptoms. Thus, our current data does not support the hypothesis that non-LNB patients with elevated CXCL13 in CSF are patients with potential very early LNB, but this aspect should be further investigated.In addition, we wanted to investigate patients in the non-LNB group with CXCL13 concentrations in CSF over cut-off in order to understand whether they could possibly be overlooked patients with very early LNB , no patient had elevated CXCL13 in CSF. These findings are in line with previous studies on CXC13 and well defined controls with other inflammatory or infectious diagnoses [In the group of children with other specific diagnoses, seven children had elevated CXCL13 in CSF (cut-off 160 pg/mL) Table . Levels iagnoses , 19, 24.Borrelia antibodies. However, interpretation of CXCL13 results should always be made in concordance with other laboratory tests and the clinical picture of the specific patient [Our results suggest that CXCL13 could be used to support the LNB diagnosis in patients with clinical manifestations attributable to LNB and pleocytosis in CSF, but no intrathecally produced anti- patient , 22, 30.p < 0.01) was found in our study, but results are contradictory to previous studies where no significant correlation has been found [Borrelia antibodies [A moderate positive correlation between CXCL13 concentrations in CSF and the degree of pleocytosis in CSF . However, in a previous study on pediatric patients, we found no significant correlation between duration of symptoms on admission and levels of CXCL13 in CSF [Lastly, CXCL13 concentrations were analyzed for possible associations to specific clinical features. In a previous study performed on adult patients, a negative correlation was found between CXCL13 concentration in CSF, and duration of neurological symptoms reported on admission, with higher concentrations early in the course of the disease and lower concentrations later . In our 3 in CSF . Differe3 in CSF , 14. OurFinally, no differences in CXCL13 levels were found in relation to age, gender, observed tick bites, EM, or other clinical manifestations in the present study or in a previous study . FurtherBorrelia antibodies (possible LNB), the CXCL13 concentrations ware elevated in a majority of patients (73%) and CXCL13 is therefore suggested as a useful complementary diagnostic tool in pediatric patients. CXCL13 concentrations correlated moderately to the degree of pleocytosis in CSF and the duration of symptoms on admission but were not associated with other specific clinical features. CXCL13 could not be used as a prognostic marker for clinical recovery in pediatric LNB patients.The chemokine CXCL13 is elevated in CSF in children with LNB, showing a high sensitivity in the definite LNB group and an acceptable specificity. In patients with pleocytosis, but no intrathecally produced anti-


Background: Blood contamination due to traumatic lumbar puncture presents a diagnostic pitfall in cerebrospinal fluid (CSF) analysis. It is controversially discussed if phagocytosis of erythrocytes which can be found in the CSF after subarachnoid hemorrhage can also develop in vitro in the presence of artificial blood contamination. Furthermore, there is no consensus about the acceptable amount of artificial blood contamination on CSF protein results.Methods: Two measurement series were performed in order to investigate the role of artificial blood contamination on the possible development of erythrophages and siderophages in the CSF: (1) blood contamination was simulated in vitro by adding blood into the CSF. (2) CSF was investigated when blood contamination occurred during a traumatic lumbar puncture. In both types of experiments, CSF including blood was incubated for 24 h and for 72 h at room temperature or at 4°C. In the third measurement series, the effects of artificial blood contamination on CSF protein results were investigated. Blood contamination was simulated in vitro by adding different amounts of blood ending up with five different samples containing erythrocyte counts of 2,500, 5,000, 7,500, 10,000, and 20,000 per μl CSF.Results: Cytological examination revealed no evidence of erythrophages or siderophages in vitro. In contrast, already a low blood contamination  led to false pathological results of total protein and albumin. Along with increasing amounts of blood, the frequency of false pathological protein results increased. A blood contamination of 5,000 erythrocytes/μl CSF resulted in a false positive intrathecal IgM production in nearly every fifth patient. In contrast, blood contamination with 5,000 erythrocytes/μl CSF was the acceptable amount of blood which did not lead to a false positive intrathecal synthesis of IgG and IgA.Conclusion: Erythrophages and siderophages do not develop in vitro. An extensive diagnostic work up for the source of blood in the CSF should be performed when erythrophages or siderophages are found in the CSF. The contamination of CSF with increasing volume of blood resulted in falsely elevated CSF protein concentrations. Hence, the amount of blood contamination has to be taken into consideration when interpreting CSF protein measurement results. In 7% obleeding . Howeverin vitro .Another diagnostic problem is the analysis of CSF immunoglobulins  in patients with artificially contaminated CSF. The evaluation of intrathecal immunoglobulin synthesis is the result of IgM, IgA, and IgG CSF/serum quotients to albumin CSF/serum quotients as described previously .To date, there is no consensus about the acceptable amount of artificial blood contamination on CSF results. Therefore, we investigated the influence of artificial CSF contamination with different amounts of blood spiked into the CSF on the development of erythrophages and siderophages and on routine CSF results including total protein measurements, blood-CSF-barrier-function, intrathecal synthesis of immunoglobulins IgM, IgA, and IgG, and virus specific intrathecal antibody synthesis.in vitro by adding blood from the same patient into CSF samples after routine lumbar puncture. Before the blood was added, the CSF samples were cytological controlled to be free of erythrocytes. In the second experiment, CSF samples were investigated if blood contamination occurred by a traumatic lumbar puncture. Traumatic lumbar puncture was defined by the evidence of erythrocytes in cytological examination. In both experiments, CSF including blood was incubated for 24 and 72 h at room temperature and at 4°C with the aim to imitate the standard clinical practice.Two different measurement series were performed in order to investigate the role of artificial blood contamination on the possible development of erythrophages and siderophages in the CSF. In the first experiment, blood contamination was simulated in vitro by adding different amounts of blood into CSF samples after routine lumbar puncture.In a third measurement series, the effects of artificial blood contamination on CSF protein measurements were investigated. Blood contamination was imitated In this part of the study, CSF samples contaminated with blood were generated by adding patient's EDTA blood into the CSF. Three different blood concentrations were selected: (a) 2 μl blood was incubated with 2 ml CSF ; (b) 1 μl blood was incubated with 2 ml CSF ; (c) 1 μl blood was incubated with 3 ml CSF . The mean erythrocyte count for all three concentrations was 2,541 ± 1,306 erythrocytes per ml CSF,  and 4.6 ± 0.57 million erythrocytes per μl blood (range 2.9–5.6). The CSF sample was then divided in two 1 ml samples of which one sample was stored at room temperature and the other sample was incubated at 4°C for 24 h. Cytological examination for cell type distribution with special focus on erythrophages and siderophages was then performed by two independent experienced cytologists.n = 10), neurodegenerative diseases (n = 5), infectious diseases (n = 4), neoplastic diseases (n = 3), and idiopathic causes such as headache (n = 3).These samples originated from 25 adult patients who underwent lumbar puncture for routine diagnosis. The gender distribution was 48% females to 52% males. The median age was 49 years (range 23–81). Patients were diagnosed with autoimmune diseases (n = 6), neurodegenerative diseases (n = 2), infectious diseases (n = 2), and idiopathic causes .In order to investigate the effects of 72 h incubation additional experiments including new CSF samples were performed. CSF samples from 11 patients were spiked with different blood concentrations in analogy to samples that were incubated for 24 h: (a) 2 μl blood was incubated with 2 ml CSF ; (b) 1 μl blood was incubated with 2 ml CSF ; (c) 1 μl blood was incubated with 3 ml CSF . The mean erythrocyte count for all three concentrations in CSF was 3,287 ± 2,324  and 4.7 ± 0.90 million erythrocytes per μl blood (range 2.7–5.8). The CSF sample was then divided in two 1 ml samples of which one sample was stored at room temperature and the other sample incubated at 4°C for 72 h. The gender distribution was 45% females to 55% males. The median age was 45 years (range 24–69). Patients were diagnosed with autoimmune diseases  and 4.8 ± 0.51 million erythrocytes per μl blood (range: 3.5–5.6) was found. The CSF was again divided in two 1 ml samples of which one sample was stored at room temperature and the other sample was incubated at 4°C for 24 h. Cytological examination was then performed in analogy to the examination with artificial blood contamination n = 29), neurodegenerative diseases (n = 9), seizures (n = 4), an infectious disease (n = 1), neoplastic diseases (n = 2), and idiopathic causes such as headache (n = 5).This part of the study included 50 adult patients who underwent lumbar puncture for routine diagnosis. The gender distribution was 46% females and 54% males. The median age was 54 years (range 19–89). Patients were diagnosed with autoimmune diseases (n = 4), infectious diseases (n = 2), idiopathic causes such as headache (n = 2), neoplastic diseases (n = 1), and autoimmune diseases (n = 1).In order to investigate the effects of 72 h incubation additional experiments including new CSF samples were performed. CSF samples originated from 10 patients contaminated with blood by traumatic lumbar puncture were divided in two 1 ml samples and stored at room temperature and incubated at 4°C for 72 h. The mean erythrocyte count was 2,532 ± 5,750 /μl CSF  and 4.1 ± 0.75 million erythrocytes per μl blood (range 2.6–5.0). The gender distribution was 70% females and 30% males. The median age was 64 years (range 28–83). Patients were diagnosed with neurodegenerative diseases , neurodegenerative diseases (n = 10), peripheral neuropathy (n = 2), and a neoplastic disease (n = 1).This part of the study comprised 25 adult patients who underwent lumbar puncture for routine diagnosis. The gender distribution was 48% females to 52% males. The median age was 67 years (range 21–89). CSF was used from patients with no clinical or CSF evidence of an inflammatory CNS disease . Patients were diagnosed with idiopathic causes such as headache . Age and sex-adjusted upper reference limits for total protein in CSF were used according to recent studies , 18. BloMeaslevirus, rubellavirus, and varicella zoster virus IgG antibody ELISAs in serum and CSF as well as subsequent calculation of the virus specific antibody index (AI) were performed at the MHH Institute of Virology on a EUROIMMUN Analyzer I using the respective Euroimmun ELISA kits. The AI was calculated according to the formula (CSF virus-IgG/serum virus-IgG)/; AI values ≥ 1.5 were considered to indicate intrathecal production of virusspecific IgG .post-hoc test was used for group comparison and paired t-test for comparison of two groups. The level of statistical significance was set to 5%. Data are described by means, standard deviation, medians and ranges.GraphPad Prism version 5.02 was used for statistical analysis. Fisher's exact and chi-square tests were used when analyzing categorical data. Whether data were normally distributed was analyzed with D'Agostino-Pearson test. ANOVA with Bonferroni in vitro for 24 and 72 h did not induce the development of erythrophages or siderophages at two different storing conditions   . In addi and 4°C . Xanthocin vitro. The amount of lytic cells was between 6% (blood contaminated samples) and 15% (traumatic lumbar puncture at 4°C) of all cells after 24 h (p = 0.0046) and between 31% (blood contaminated samples) and 78% (traumatic lumbar puncture at 4°C) of all cells after 72 h (p < 0.0001). Moreover, the frequency of lytic cells after 24 h was similar between both incubation conditions , while more cells were lytic after 72 h than after 24 h (p < 0.0001). The amount of lymphocytes slightly decreased, while the amount of granulocytes slightly increased after addition of increasing amounts of blood in samples after 24 h incubation time . After 72 h, the amount of lytic cells and granulocytes was higher in samples which were incubated at 4°C than in samples incubated at room temperature .In addition, we investigated the cell distribution in all samples after 24 and 72 h of incubation p < 0.0001; p = 0.2347) before blood was added into CSF samples. The addition of blood resulted in a higher number of patients with pathological total protein results: 4/25 patients  in CSF containing 2,500 erythrocytes/μl, 4/25 patients  in CSF containing 5,000 erythrocytes/μl, 6/25 patients  in CSF containing 7,500 erythrocytes/μl CSF, 8/25 patients  in CSF containing 10,000 erythrocytes/μl CSF and 9/25 patients  in CSF containing 20,000 erythrocytes/μl CSF.Five different blood volumes including erythrocyte amounts between 2,500 and 20,000 per μl CSF were investigated in order to imitate daily clinical experience. The addition of blood into the CSF continuously increased the mean level of total protein in CSF , 7/25 patients (28%) in CSF containing 5,000 erythrocytes/μl (p = 0.0096), 7/25 patients (28%) in CSF containing 7,500 erythrocytes/μl (p = 0.0096), 7/25 patients (28%) in CSF containing 10,000 erythrocytes/μl (p = 0.0096), and 15/25 patients (60%) in CSF containing 20,000 erythrocytes/μl (p < 0.0001).The albumin quotient (QAlbumin) is generally accepted as the best indicator to describe a blood-CSF barrier dysfunction for blood derived proteins. The mean serum albumin level was 40.1 g/l ± 5.2. Four patients had serum albumin levels between 32.6 and 34.8 g/l. Before blood was added into CSF samples, 4/25 patients (16%) showed an elevated QAlbumin indicating a blood-CSF barrier dysfunction (p = 0.2347), in 3/25 patients (12%) in CSF containing 5,000 erythrocytes/μl (p = 0.2347), in 3/25 patients (12%) in CSF containing 7,500 erythrocytes/μl (p = 0.2347), in 3/25 patients (12%) in CSF containing 10,000 erythrocytes/μl (p = 0.2347), and in 6/25 patients (24%) containing 20,000 erythrocytes/μl (p = 0.0223).When using the formula 8 + (age in years/25), 3/25 patients (12%) had an elevated QAlbumin before blood was added. After addition of blood pathological QAlbumin was found in 3/25 patients (12%) in CSF containing 2,500 erythrocytes/μl  on results indicating intrathecal production of immunoglobulins as referred to Reiber-graphs, was investigated. The mean serum IgG level was 11.0 g/l ± 3.7, the IgA level was 2.5 g/l ± 1.3, and the IgM level was 1.0 g/l ± 0.5. Serum IgG concentration <7 g/dl was found in one patient, serum IgA <0.7 g/dl in three patients, and serum IgM <0.4 g/l in two patients. Before blood was added to the CSF, none of the selected patients exhibited an intrathecal synthesis of either IgG, or IgA, or IgM ; Table 3p > 0.9999), 3/25 patients (12.5%) in CSF containing 10,000 erythrocytes/μl (p = 0.2347) and 4/25 patients (16%) in CSF containing 20,000 erythrocytes/μl (p = 0.1099).The addition of blood containing 2,500 and 5,000 erythrocytes/ μl did not result in a false positive intrathecal synthesis of IgG. A false positive intrathecal synthesis of IgG was only detected with higher blood amounts: 1/25 patient (4%) in CSF containing 7,500 erythrocytes/μl (p > 0.9999). The addition of blood containing 10,000 erythrocytes/μl resulted in 3/25 patients  with a false positive intrathecal synthesis of IgA, while blood containing 20,000 erythrocytes/μl showed a false intrathecal IgA synthesis in 9/25 patients .Similar to IgG, a false positive intrathecal synthesis of IgA was first detected in CSF contaminated with blood containing 7,500 erythrocytes/μl  and further increased with higher blood amounts. The addition of blood containing 7,500 erythrocytes/μl resulted in 9/25 patients  with a false positive intrathecal synthesis of IgM, while blood containing 10,000 and 20,000 erythrocytes showed a false intrathecal IgM synthesis in 14/25 patients  and 20/25 patients , respectively.For intrathecal IgM synthesis, false positive results occurred already as consequence of blood addition containing 5,000 erythrocytes/μl  in the CSF artificially contaminated with blood. The concentrations of immunoglobulins are magnificent higher in serum than in CSF and thus blood contamination may pretend to a false positive evidence of an intrathecal production of immunoglobulins indicating inflammatory processes in the CSF. Due to the different molecular weight of immunoglobulins (IgM>IgA>IgG) only very low concentrations of IgM are usually found in CSF. Blood contamination of the CSF will therefore affect the above proteins exactly in the same order with falsified IgM in the first place. The influence of blood contamination on CSF results should therefore be higher for IgM, followed by IgA and IgG. Our results are in line with these assumptions and conclusively show that false positive production of IgM was predominant in our experiments, followed by IgA, and IgG. A blood contamination of 5,000 erythrocytes/μl CSF resulted in a false positive intrathecal IgM production in nearly every fifth patient. In contrast, blood contamination with 5,000 erythrocytes/μl CSF did not induce a false positive intrathecal production of IgG and IgA. An artificial intrathecal synthesis of IgG and IgA occurred in every tenth patient after addition of blood containing 7,500 erythrocytes/μl CSF. We thus suggest a cut off of 5,000 erythrocytes/μl CSF for analyses of intrathecal IgG synthesis. In the case of a contaminated CSF with blood a falsely elevated intrathecal IgG synthesis will reliably be detected by the absence of oligoclonal bands in the CSF. This qualitative method to detect intrathecal IgG synthesis is less susceptible for blood contamination.Interestingly, CSF contamination with even higher amounts of blood  did not lead to false positive IgG antibody index against viruses. The cut-off of blood contamination for analyses of the IgG antibody index against viruses might be therefore higher than 20,000 erythrocytes/μl CSF. However, since blood contamination increased the mean IgG antibody index against rubella and measles for 0.1, false positive results could be the consequence in cases of borderline IgG antibody indices.in vitro and we thus suggest an extensive diagnostic work up for the source of blood when erythrophages and siderophages are found in the CSF. The contamination of CSF with blood resulted in false pathological CSF protein results in some patients. Contamination of the CSF with 5,000 erythrocytes/μl was the acceptable amount of blood which did not induce a false positive intrathecal synthesis of IgG.In conclusion, erythrophages and siderophages did not develop Data supporting the findings can be found in the tables. Additional data extracted may be shared upon request.The study was approved by the Ethic Committee of the Hannover Medical School, Carl-Neuberg-Str.1, 30625 Hannover . Only participants older than 18 years were included. All participants of this study gave written informed consent. The study is in accordance with the Declaration of Helsinki regarding ethical conduct of research involving human subjects.PS: participated in the design of the study, collected and analyzed the data and drafted the manuscript. TJ: collected the data, analyzed the data and drafted the manuscript. UW was responsible for CSF analysis, analyzed the data and contributed in drafting the manuscript. FK: collected and analyzed the data. AN, JA, WP, LB and KS contributed in drafting the manuscript. MS and TG analyzed the data and contributed in drafting the manuscript. TS: conceived the study, analyzed the data and drafted the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


There is a worldwide problem of waiting time and mortality rate associated with remaining on the waiting list for a liver transplant. However, some situations have been encouraging in terms of determining appropriate recipients and expanding the donor criteria. We herein report a case of useful liver donor with sickle cell anemia for liver transplantation. Here we described a case of liver transplantation from a donor with sickle cell anemia to a recipient with hepatocellular carcinoma who was deemed to be at risk of tumor growth and at risk of being dropped from the waiting list. The literature reveals the importance of using safe donors, and we describe the benefits of using a safe, deceased liver donor with sickle cell anemia who was an adequate option for liver transplantation. Nowadays, due to the great success of liver transplantation (LT) given advances in technologies and the quality of immunosuppressive drugs, the survival and quality of life have improved , 2. HoweThis situation has motivated revisions to the recipient-selection process and an expansion of donor criteria . The risThe purpose of this study is to show the possibility of enlarging use of organs. Moreover, we describe the special case report of a LT from a donor with sickle cell anemia (SCA) and hereditary hemoglobinopathy, with an atypical and inherited disorder of hemoglobin called hemoglobin S (HbS), to a hepatitis B virus (HBV) cirrhosis and hepatocellular carcinoma (HCC) patient who was adjudicated dropping out of the liver transplant waiting list.2. He was admitted to a general hospital with a subarachnoid hemorrhage and intracranial hematoma on the left side, and he suffered brain death. He had a previous pathological history of SCA and was treated for his anemia with several blood cell therapies and a splenectomy when he was 16 years old. He was receiving ceftriaxone, meropenem, and vancomycin when he was submitted to donor surgery, five days after the neurosurgery. He was under low doses of vasopressors: norepinephrine (0.18 mcg/kg/min) and vasopressin (0.02 mcg/kg/min). The best suitable recipient was chosen by balancing the risk of a hematological disease or thrombotic risk factors associated with the recipient remaining on the waiting list and either dying or dropping out of the list. All laboratory analysis and liver function of the donor were normal. After all analysis and arguments discussed with the transplant team , as risk of using SCA graft, probabilities of developing disease, and a few case reports in the literature, on the other hand, the benefits of being an excellent hepatic graft option, the recipient and her family were informed of all risks and probabilities, and a unanimous informed consent decision was made to receive the donor liver and follow with the transplant. The donor surgery was fine and was not associated with any complications. Both of the deceased patient's kidneys and liver were donated to three different recipients in different centers.The liver graft was from a young male patient, 20 years old, who weighed 57 kg, was 1.78 meters tall, and had a body mass index (BMI) of 18 kg/m2. She was diagnosed with hepatitis B virus (HBV) cirrhosis and hepatocellular carcinoma (HCC) according to the Milan criteria . Model for end-stage liver disease (MELD) score was 18 and Child-Pugh-Turcotte (CPT) classification was B7. The serum alpha-fetoprotein (AFP) value was increasing recently to the transplant (>200 ng/ml). In the waiting list for liver transplant, the patient performed 3 transarterial chemoembolization (TACE) sessions, initially with completely treated areas but afterwards showing partial treatment (progression). The liver allograft weighed 1.495 kg. The cold ischemia time was 8 hours and 30 minutes, and the warm ischemia time was 38 minutes. The transplantation was performed on September 27th, 2016. The patient received four units of red blood cells, three units of platelets, and eight units of plasma during the surgery. The liver biopsy protocol included preclamping and prerevascularization biopsy with mild siderosis and steatosis, hepatocyte ballooning, rare canalicular cholestasis, and moderate sinusoidal congestion with predominance of drepanocytes , including apoptosis of hepatocytes and a minor neutrophilic sinusoidal infiltrate. Kupffer cell erythrophagocytosis and scarce sickle cells were still seen in a biopsy performed on the following day , along wThe LT recipient also received antibiotics based on the medical profile of the liver donor: vancomycin and meropenem for seven days plus Amicacina for two days. Furthermore, she received hepatitis B immunoglobulin (HBIG) for seven days and then monthly for a year. She still receives entecavir (ETV) daily for preventing hepatitis B recurrence. As part of the LT protocol, she was submitted to a Doppler ultrasound of the vascular graft anastomosis investigation on the first postoperative day, and no abnormalities were noted. The follow-up of the vascular imaging examination will depend on clinical and laboratory data. Despite her good postoperative evolution, she developed acute kidney failure and she required hemodialysis for three weeks. The cause of acute renal failure and hemodialysis was due to liver transplantation procedure and the baseline renal function somewhat altered. Her recovery of renal function was complete, and she did not require renal replacement therapy anymore. She was discharged from hospital on the 37th postoperative day. Postoperative chemotherapy was not necessary due to good evolution and postoperative oncologic control image (CT) with absence of recurrence in the transplanted liver and decrease in the serum tumor marker (AFP <10 ng/ml). A long-term follow-up of 18 months revealed a good evolution, with normal liver blood tests.This study was approved by the Institutional Review Board and accomplished the entire requisite for studies in humans according to the guidelines of the 1975 Declaration of Helsinki.Sickle cell anemia (SCA) is a hereditary hemoglobinopathy and an atypical inherited disorder of hemoglobin called hemoglobin S (HbS). It is important due to its multifactorial components, diverse clinical manifestations, and impact on patient morbimortality . Sickle Some manifestations related to vascular damage have been associated with liver alterations due to acute hepatic crises to chronic liver disease accompanying intrahepatic cholestasis and iron overload. Regardless of this, intrahepatic cholestasis is possibly severe and clinical treatment is often inoperative . SCA or Regarding SCA and SCD liver histology, as one of the limiting factors to use these patients as donors , the livThere were few reported published cases of liver transplant in patients with SCD. Furthermore, a recent article review of the literature shows 10 adults and 5 children with SCD that underwent a liver transplant . OrthotoElsiesy H et al.  in 2017 We have highlighted a literature review and a successful LT case using SCA donor to a HBV cirrhosis and HCC patient with dropout risk from the waiting list for LT. The important objective of this work is to demonstrate this successful recipient and donor match that show that we can expand the donor criteria and share this successful option for liver transplantation. Furthermore, this present report is enhanced to promote to the transplant community this approach with this type of donor.In summary, we have reported that a deceased liver donor with sickle cell anemia is an adequate option for LT. The articles that we found demonstrate the importance of using a safe donor and the real benefits of expanding use of organs.