A phospholipid derivative of cytosine arabinoside and its conversion to phosphatidylinositol by animal tissue.

We have synthesized an analog (ara-CDP-DL-dipalmitin) of cytidine diphosphate diglyceride (CDP-diglyceride) in which the antitumor drug, cytosine arabinoside, is substituted for the cytidine moiety. Enzymes in rat and human liver convert this analog to phosphatidylinositol, thereby releasing cytosine arabinoside-5'-monophosphate, an obligatory intermediate in the activation of cytosine arabinoside. Unlike cytidine diphosphate diglyceride, however, ara-CDP-DL-diapalmitin is not an efficient substrate for phosphatidylglycerophosphate synthesis in liver or phosphatidylserine in Escherichia coli. The antitumor activity of ara-CDP-DL-dipalmitin in mice bearing L5178Y leukemia is described.

Effects of organ motion on IMRT treatments with segments of few monitor units.

Interplay between organ (breathing) motion and leaf motion has been shown in the literature to have a small dosimetric impact for clinical conditions (over a 30 fraction treatment). However, previous studies did not consider the case of treatment beams made up of many few-monitor-unit (MU) segments, where the segment delivery time (1-2 s) is of the order of the breathing period (3-5 s). In this study we assess if breathing compromises the radiotherapy treatment with IMRT segments of low number of MUs. We assess (i) how delivered dose varies, from patient to patient, with the number of MU per segment, (ii) if this delivered dose is identical to the average dose calculated without motion over the path of the motion, and (iii) the impact of the daily variation of the delivered dose as a function of MU per segment. The organ motion was studied along two orthogonal directions, representing the left-right and cranial-caudal directions of organ movement for a patient setup in the supine position. Breathing motion was modeled as sin(x), sin4(x), and sin6(x), based on functions used in the literature to represent organ motion. Measurements were performed with an ionization chamber and films. For a systematic study of motion effects, a MATLAB simulation was written to model organ movement and dose delivery. In the case of a single beam made up of one single segment, the dose delivered to point in a moving target over 30 fractions can vary up to 20% and 10% for segments of 10 MU and 20 MU, respectively. This dose error occurs because the tumor spends most of the time near the edges of the radiation beam. In the case of a single beam made of multiple segments with low MU, we observed 2.4%, 3.3%, and 4.3% differences, respectively, for sin(x), sin4(x), and sin6(x) motion, between delivered dose and motion-averaged dose for points in the penumbra region of the beam and over 30 fractions. In approximately 5-10% of the cases, differences between the motion-averaged dose and the delivered 30-fraction dose could reach 6%, 8% and 10-12%, respectively for sin(x), sin4(x), and sin6(x) motion. To analyze a clinical IMRT beam, two patient plans were randomly selected. For one of the patients, the beams showed a likelihood of up to 25.6% that the delivered dose would deviate from the motion-averaged dose by more than 1%. For the second patient, there was a likelihood of up to 62.8% of delivering a dose that differs by more than 1% from the motion-averaged dose and a likelihood of up to approximately 30% for a 2% dose error. For the entire five-beam IMRT plan, statistical averaging over the beams reduces the overall dose error between the delivered dose and the motion-averaged dose. For both patients there was a likelihood of up to 7.0% and 33.9% that the dose error was greater than 1%, respectively. For one of the patients, there was a 12.6% likelihood of a 2% dose error. Daily intrafraction variation of the delivered dose of more than 10% is non-negligible and can potentially lead to biological effects. We observed [for sin(x), sin4(x), and sin6(x)] that below 10-15 MU leads to large daily variations of the order of 15-35%. Therefore, for small MU segments, non-negligible biological effects can be incurred. We conclude that for most clinical cases the effects may be small because of the use of many beams, it is desirable to avoid low-MU segments when treating moving targets. In addition, dose averaging may not work well for hypo-fractionation, where fewer fractions are used. For hypo-fractionation, PDF modeling of the tumor motion in IMRT optimization may not be adequate.

Physical properties of arabinofuranosylcytosine diphosphate diacylglycerol, an antitumor liponucleotide.

Dispersed from a dry film into buffer (5 mM phosphate, 0.15 M NaCl, pH 7.4), the liponucleotide 1-beta-D-arabinofuranosylcytosine 5'-diphosphate L-1,2-diacylglycerol (ara-CDPdiacylglycerol) spontaneously forms vesicles which are several microns in diameter and probably unilamellar. Their average size immediately begins to decrease, and after 2 h none can be seen in the light microscope. During 1-2 days in unstirred solutions at 25 degrees C, the vesicles are transformed to spherical or nearly spherical micelles having an apparent partial specific volume of 0.835 ml . g-1, a maximum possible aggregation number of about 150, and an anhydrous radius of about 37 A. The critical micelle concentration (CMC) is about 10 microM in buffer and 20 microM in distilled water, but micelle-monomer equilibration requires at least 1 week at a total concentration of 66 microM. This exceedingly slow equilibration is unique among reported detergents. The standard enthalpy and entropy of micellization are - 13 kJ . mol-1 and 87 J . mol-1 . K-1, respectively. These values are within the range reported for other detergents. Sonication accelerates the vesicle-micelle transformation to 30 min.

Biophysical properties of cytidine diphosphate diacylglycerol in solution.

The physical properties of CDP diacylglycerol derived from egg phosphatidylcholine are very different from those of the common glycerophospholipids, such as phosphatidylcholine. Gently dispersed in buffer (5 mM phosphate, 0.15 M NaCl, pH 7.4), the liponucleotide initially forms an opalescent suspension of spherical vesicles, up to 50 micron in diameter, which appear to be unilamellar. These large vesicles are unstable and, independently of initial concentration, unstirred suspensions are no longer turbid after being incubated for about 1 h at room temperature. The passage of samples through Sepharose and Sephadex at increasing time intervals after the first hour reveals a continuing but slow diminution in size until, at about two days, a final peak is obtained which remains invariant for longer times. Chromatography of these ultimate stable micelles on Sephadex G-200 gives a Stokes radius of 4.2 nm. Their sedimentation coefficient extrapolated to zero concentration is 6.1 S. These numbers, combined with a partial specific volume of 0.835 ml X g-1, give an anhydrous mass of 155 000 Da and an aggregation number of 158. Although the data suggest the particles to be spherical, other compact forms cannot be excluded. Proton NMR at 220 MHz shows time-dependent spectral changes which are consistent with the slow structural transformation observed by gel-filtration chromatography, and indicate that the sugar and cytosine groups in the ultimate micelles apparently are motionally restricted. The critical micelle concentration is near 6 microM, but micelle-free molecule equilibration requires at least 7 days at a total concentration of 89 microM. Sonication considerably decreases the time required for the vesicle-micelle transformation and the micelle-free molecule equilibration. Some implications for enzymology are discussed.

Cytotoxic liponucleotide analogs. I. Chemical synthesis of CDP-diacylglycerol analogs containing the cytosine arabinoside moiety.

Cytidine and deoxycytidine diphosphate diacylglycerol are metabolic liponucleotides which are substrates for the biosynthesis of several classes of cellular phosphoglycerides. In addition to their essential biochemical function, liponucleotides can be considered unique from the point of view of molecular structure (lipid, phosphorus, sugar, heterocyclic moieties) and biophysical properties. Liponucleotides, therefore, have been investigated as possible models for anticancer drug design and development. The chemical synthesis of several liponucleotide analogs of cytidine diphosphate diacylglycerol (CDPdiacylglycerol/dCDPdiacylglycerol) containing the 1-beta-D-arabinofuranosyl moiety was undertaken for the purpose of evaluation of the antitumor activity of these compounds. The analogs were synthesized by reaction of 1-beta-D-arabinofuranosylcytosine-5'-(hydrogen morpholinophosphonate):N,N'-dicyclohexyl-4-morpholine carboxamide (1 : 1) in pyridine with either egg lecithin-derived phosphatidic acid, synthetic phosphatidic acid, or synthetic analogs of phosphatidic acid. The yields of liponucleotide analogs after purification were approx. 25-40%. Although reaction yields were not optimized, the condensation of phosphatidic acids and nucleotides represents an expedient laboratory-scale synthetic approach to liponucleotides, especially when phosphatidic acids are obtained from natural sources or by semisynthetic methods, and when 5'-nucleotides can be synthesized directly (i.e., without use of protecting groups) from precursor nucleosides.

Cytotoxic liponucleotide analogs. II. Antitumor activity of CDP-diacylglycerol analogs containing the cytosine arabinoside moiety.

Among events limiting the effectiveness of cancer chemotherapy are the general lack of preferential uptake of anticancer drugs by tumor cells and the occurrence of drug resistance. An approach has been undertaken to explore whether or not such events can be favorably altered or circumvented therapeutically by development of a new class of anticancer molecules, cytotoxic liponucleotide analogs. The design of cytotoxic liponucleotide analogs encompasses both biochemical and biophysical aspects of liponucleotide and glycerophospholipid structure and metabolism. Several cytotoxic liponucleotide analogs of cytidine diphosphate diacylglycerol (CDPdiacylglycerol/dCDPdiacylglycerol), containing the 1-beta-D-arabinofuranosyl moiety, were tested for antitumor activity. Multispecies ara-CDPdiacylglycerol (1-beta-D-arabinofuranosylcytosine 5'-diphosphate diacylglycerol), which contains egg lecithin-derived mixed fatty acyl chains, was more active than 1-beta-D-arabinofuranosylcytosine (ara-C), a clinically used anticancer drug, against leukemia L5178Y and P388 ascites cells in mice. At identical single doses (50 mg/kg per day times 4) administered intraperitoneally, ara-CDPdiacylglycerol prolonged the life spans of L5178Y tumor-bearing mice 93%, while ara-C prolonged life by 18%. Ara-CDPdiacylglycerol increased life spans of P388 tumor-bearing mice by 357% at doses of 50 mg/kg per day times 4; the maximum increase with ara-C was 159% (85 mg/kg per day times 4). Against a P388 ara-C-resistant cell line (P/Ara-C, kinase deficient) in mice, ara-CDPdiacylglycerol prolonged survival times by 34% at a dose of 50 mg/kg per day times 4 and by 55% at 75 mg/kg per day times 4; the drug was not active against two other ara-C-resistant murine leukemia mutants (CA 55, CA5b). With cell line-derived human colon carcinoma HCT-15 grown in mice immunosuppressed with anti-thymocyte serum, ara-CDPdiacylglycerol at a single daily dose of 50 mg/kg per day times 4 significantly reduced tumor weights to 21% of the controls; the same dose schedule of ara-C caused no observable reduction of tumor weights. Results of these preliminary antitumor evaluations indicate that cytotoxic liponucleotide analogs should be investigated further to determine their potential as antineoplastic molecules.

Chemical synthesis and surface activity of lung surfactant phospholipid analogs. II. Racemic N-substituted diether phosphonolipids.

A series of racemic 16:0 disaturated N-substituted diether phosphonolipid analogs of glycerophospholipids have been synthesized and purified. Isosteric methylene substitution at three of the four ester sites (carboxyl, phosphate) of conventional glycerophospholipids enhanced the hydrophobicity of analog compounds compared with dipalmitoyl phosphatidylcholine (DPPC), the major glycerophospholipid component of lung surfactant. Further substitutions at the nitrogen headgroup also contributed to hydrophobicity/hydrophilicity characteristics, as well as allowing graded variations in headgroup size among the members of the diether phosphonolipid analog series. Interfacial property studies showed that these compounds had significant differences in surface activity characteristics compared with DPPC, including increased adsorption and respreading facility, plus an enhanced ability to generate low surface tension (less than 1 to 4 mN/m) on an oscillating bubble apparatus at 37 degrees C. In addition, pressure-volume mechanical studies in surfactant-deficient excised rat lungs showed that the diether phosphonate analog of DPPC could partially restore pressure-volume characteristics toward normal, both as a pure component and in binary mixtures with palmitoyl-oleoyl phosphatidylglycerol. These findings suggest that selected analog compounds, synthesized with relatively small structural modifications from biologic glycerophospholipids, may have eventual applications as components of synthetic exogenous lung surfactants. Of more immediate importance, analog molecules with defined structural variations are convenient molecular probes for developing structure-surface activity correlates for phospholipid-like surfactants and for investigating the specificity of interactions between glycerophospholipids and other compounds such as proteins.

Factors affecting the frequency infection in renal transplant recipients.

A retrospective review of 149 patients receiving 162 renal transplants showed that 83% of these patients developed one or more infections during a follow-up period averaging one year. In 32 (73%) of 44 deaths, infection was an important contributing cause. In only four (9%) of the deaths were the patients free of infection at the time of death. The Klebsiella-Enterobacter group was the most common agent causing pneumonitis and sepsis. Cryptococcus neoformans caused seven of 11 cases of meningitis. Pseudomonas was the most frequent agent associated with infections documented during postmortem examinations. In a short-term controlled study comparing daily and alternate daily therapy with prednisone, the alternate daily group had significantly (P less than .05) more infections per patient, especially in patients who had no evidence of rejection (P less than .025).

Estrogen receptors in dendrites and axon terminals in the guinea pig hypothalamus.

The ultrastructural localization of steroid hormone receptors has been made possible by the development of immunocytochemical procedures using monoclonal antibodies. Estrogen receptor-immunoreactivity (ER-IR) in the brain is present most abundantly in neuronal nuclei when observed with light microscopy. However, we have also observed ER-IR in the perikarya and cytoplasmic processes of neurons. To determine the organelles with which the cytoplasmic ER-IR is associated, we developed a technique for ultrastructural visualization of ER-IR. Ovariectomized guinea pigs were perfused, brains vibratome-sectioned, and estrogen receptors immunostained by either an immunoperoxidase-diaminobenzidine technique or by an immunogold-streptavidin procedure, each followed by silver intensification. Electron microscopic analysis confirmed distribution of ER-IR throughout cell nuclei, but ER-IR was also observed in proximal and distal dendrites and rough endoplasmic reticulum. Most surprisingly, however, ER-IR was found in many axon terminals containing predominantly round, and in some cases, flattened clear synaptic vesicles. Parallel experiments examining the distribution of progestin receptors confirmed the localization at the same subcellular sites as for estrogen receptors. The results of this experiment corroborate our earlier findings of extranuclear steroid receptor-immunoreactivity in the brain, and they suggest potential nongenomic sites of action for estradiol and progesterone in dendrites and axon terminals.

Role of renin-angiotensin system in chronic renal hypertensive rats.

The role of renin-angiotensin system has been examined in the maintenance of hypertension in acute and chronic two-kidney (36 weeks) and chronic one-kidney (12 weeks) Goldblatt hypertensive rats using three inhibitors of this system. The inhibitors used were URI-73A, a synthetic analog of lysophosphatidylethanolamine, which inhibits renin both in vivo and in vitro, SQ14,225, a potent converting enzyme inhibitor, and [Sar1, Thr8] angiotensin II, an angiotensin II antagonist. When the inhibitors were administered in acute (high renin) hypertensive rats, they all lowered blood pressure significantly. However, in the chronic (low renin) hypertensive phase, both renin and converting enzyme inhibitors lowered blood pressure, whereas, Sar1, Thr8 failed to lower blood pressure. The renin inhibitor lowered plasma renin activity (PRA), and SQ14,225 and [Sar1, Thr8] Ang II increased PRA. Further studies on water and electrolyte balance with one-kidney model hypertensive and uninephrectomized control rats showed no change in plasma volume. However, there was increased 24-hour urinary output and increased sodium excretion. This study indicates that in chronic renal hypertensive rats, blood pressure reduction is possible by either renin on converting enzyme inhibitor, but not by angiotensin antagonists. Since volume did not change either during the development or reversal of hypertension, volume did not appear to play a major role in the maintenance of hypertension.

Immunocytochemical localization of midbrain estrogen receptor- and progestin receptor-containing cells in female guinea pigs.

In the guinea pig midbrain, a low concentration of progestin receptors is induced by estradiol. This is in contrast to the mediobasal hypothalamus which has a large number of estradiol-induced progestin receptors. Because the midbrain is an important site for the hormonal regulation of sexual behavior, we mapped the distribution of cells containing estrogen receptor- and estradiol-induced progestin receptor-immunoreactivity in that area. Estrogen receptor-immunoreactive cells are found in midbrain sites previously reported, including the midbrain central gray, the tegmentum lateral and ventral to the central gray, peripeduncular region, and parabrachial nuclei. While progestin receptor-immunoreactive cells were not detected without estradiol priming, estradiol-induced progestin receptors were found throughout the rostrocaudal extent of the midbrain central gray and adjacent tegmental area. Progestin receptor-immunoreactive cells were far fewer than estrogen receptor containing cells, had less cytoplasmic staining, and appeared restricted to the midbrain central gray, lateral and ventrolateral to the cerebral aqueduct and the adjacent tegmental area.

Staining of regenerated optic arbors in goldfish tectum: progressive changes in immature arbors and a comparison of mature regenerated arbors with normal arbors.

Individual optic arbors, normal and regenerated, were stained via anterograde transport of HRP and viewed in tectal whole mounts. Camera lucida drawings were made of 119 normal optic arbors and of 242 regenerated arbors from fish 2 weeks to 14 months postcrush. These arbors were analyzed for axonal trajectory, spatial extent in the horizontal plane, degree of branching, number of branch endings, average depth, and degree of stratification. Normal optic arbors ranged in size from roughly 100 to 400 microns across in a continuous distribution, had an average of 20 branch endings with average of fifth-order branching, and were highly stratified into one of three planes within the major optic lamina (SO-SFGS). Small arbors arising from fine-caliber axons terminated in the most superficial plane of SO-SFGS; large arbors from coarse axons terminated in the superficial and middle planes; and medium arbors from medium-caliber axons terminated in the middle and deep planes of SO-SFGS, as well as deeper in the central gray and deep white layers. Arbors from central tectum tended to be much more tightly stratified than those in the periphery. No other differences between central and peripheral arbors were noted. Mature regenerated arbors (five months or more postcrush) were normal in their number of branch endings, order of branching, and depth of termination. Their branches covered a wider area of tectum, partially because of their early branching and abnormal trajectories of branches. Axonal trajectories were often abnormal with U-turns and tortuos paths. Fine-, medium-, and coarse-caliber axons were again present and gave rise to small, medium, and large arbors at roughly the same depths as in the normals. There was frequently a lack of stratification in the medium and large arbors, which spanned much greater depths than normal. Overall, however, regenerates reestablished nearly normal morphology except for axonal trajectory and stratification. Early in regeneration, the arbors went through a series of changes. At 2 weeks postcrush, regenerated axons had grown branches over a wider-than-normal extent of tectum, though they were sparsely branched and often tipped with growth cones. At 3 weeks, the branches were more numerous and covered a still wider extent (average of five times normal), many covering more than half the tectal length or width. At 4-5 weeks smaller arbors predominated, although a few enlarged arbors were present for up to 8 weeks. Additional small changes occurred beyond 8 weeks as the arbors became progressively more normal in appearance.(ABSTRACT TRUNCATED AT 400 WORDS)

Assessment of the serotonin and norepinephrine reuptake blocking properties of duloxetine in healthy subjects.

Duloxetine is a dual inhibitor of norepinephrine (NE) and serotonin (5-HT) uptake. Initial trials conducted in depressed patients using regimens of 20 mg/day or less did not convincingly demonstrate its efficacy as an antidepressant. The aim of this study was to assess the effects of duloxetine on the 5-HT and NE reuptake processes in healthy human volunteers. Twenty-seven healthy young males without a history of psychiatric disorder were randomly assigned to four groups, each group receiving one of the following daily drug regimens: placebo, clomipramine (a potent 5-HT/NE reuptake blocker) 100 mg/day, duloxetine 20 mg/day, or duloxetine 60 mg/day. In order to assess the NE reuptake process, the pressor response to intravenous tyramine (4 and 6 mg) was measured. Determination of the whole blood 5-HT content was used to evaluate the 5-HT reuptake blockade. These measurements were performed at baseline and repeated after 7 and 14 days of drug intake. Both duloxetine, at doses of 20 to 60 mg/day, and clomipramine significantly interfered with the 5-HT reuptake process, as demonstrated by marked decreases in blood 5-HT concentrations. However, the same doses of duloxetine, unlike clomipramine, failed to impede the usual increase in blood pressure that follows a tyramine intravenous infusion, indicating that clomipramine but not duloxetine blocked NE reuptake. At doses tested in a population of healthy volunteers, duloxetine acted as a selective 5-HT reuptake inhibitor, having no clear effect on the NE reuptake process. Nevertheless, given that the highest dose of duloxetine increased supine systolic blood pressure, it is possible that it represents the threshold regimen for NE reuptake inhibition.

Synthesis of lysophosphatidylethanolamine analogs that inhibit renin activity.

A series of lysophosphatidylethanolamine analogs containing saturated and methylene-interrupted cis-olefinic fatty chains was synthesized by phosphorylation and phosphonylation of respective fatty alcohols. Arachidonyl- and linolenylphosphorylethanolamines (12, 13), arachidonyl (2-phthalimidoethyl)phosphonate (17), and arachidonyl (2-aminoethyl)phosphonate (18) were found to be effective inhibitors of the renin-renin substrate reaction in vitro; lysophosphatidylethanolamine analogs 14-16 of lesser unsaturation were either weakly active or inactive. In a preliminary study, intramuscular administration of 25 mg/kg/day of arachidonyl (2-aminoethyl)phosphonate (18) to the hypertensive rat caused pronounced reduction (50 mm) in blood pressure within 3 days; upon continued dosage (15 mg/kg/day) of 18 for an additional 4 days, plasma renin activity was found to be 16 ng/0.1 ml/15 hr as compared with 69 ng/0.1 ml/15 hr before initial drug administration. Arachidonic acid (3), arachidonyl alcohol (8), and several corresponding tetraenoid ester, amide, mesylate, and glyceryl ether derivatives (4-7, 10, 11), that are not phosphate or phosphonate esters, were found to exhibit negligible or modest inhibition of renin activity in vitro.

The hepatic artery in liver transplantation.

Hepatic artery complications after liver transplantation are uncommon, but represent an important cause of morbidity and mortality. In addition, these complications tax an already limited supply of donor organs because of the frequent need for retransplantation in this group of patients. In this study, we examined the incidence of hepatic arterial anomalies in donors and recipients of orthotopic liver transplants, focusing on the techniques that are available for hepatic arterial reconstruction and on the occurrence of hepatic arterial complications. A total of 77 liver transplants were carried out in 68 patients. Standard recipient anatomy was present in 60 of 68 patients (88%). Anomalous vessels were identified in eight patients (12%), including six cases of replaced right hepatic artery (9%) and two cases of replaced left hepatic artery (3%). Donor liver arterial anatomy was standard in 62 cases (80%). Anomalous arterial supply was identified in 15 of 77 donor livers (20%), including replaced left hepatic artery in nine (12%) and replaced right hepatic artery in six (8%). A variety of methods were used to manage the anomalous vessels. There was one hepatic artery pseudoaneurysm, three cases of hepatic artery thrombosis (4%), and one patient developed a dissection of the native celiac axis. In primary transplants, utilization of the recipient's proper hepatic artery was associated with a significantly higher risk of hepatic artery thrombosis (P less than 0.04) when compared with the common hepatic artery or the branch patch technique. Use of a Carrel patch on the donor artery was associated with a significantly reduced incidence of hepatic artery thrombosis (P less than 0.0003). For retransplantation, it is recommended that a more proximal recipient anastomotic site be chosen. An innovative method is described that provides increased length of the donor arterial supply without the use of an arterial graft.

A prospective controlled trial of cold-storage versus machine-perfusion preservation in cadaveric renal transplantation.

A prospective controlled study was carried out in 60 consecutive cadaver renal donors comparing cold storage to pulsatile machine-perfusion preservation. Each donor served as its own control, by allocating one of the kidneys to each of the two preservation methods. There were 51 evaluable pairs of kidneys. Recipient age, panel-reactive antibody level, history of prior renal transplant, and immunosuppressive regimen were similar in the two preservation groups. Almost all recipients were treated with cyclosporine, and over 50% received antilymphoblast globulin. Total cold ischemic time was 1262 +/- 387 min in the machine-perfused group and 1309 +/- 426 min in the cold-storage group (P = NS). Prolonged ischemia (greater than 24 hr) occurred in 31% of machine-perfused and 22% of cold-stored kidneys (P = NS). Post-operative serum creatinine levels at 1, 7, and 30 days posttransplant were similar in both groups. Dialysis requirements were also similar, with 21 recipients of machine-perfused kidneys (41%) requiring at least one dialysis treatment compared to 16 patients (31%) in the cold-stored group (P = NS); the mean number of dialysis treatments required was 3.14 +/- 1.46 and 3.06 +/- 1.29, respectively (P = NS). Long ischemic time (greater than 24 hr) was associated with a higher rate of dialysis requirement in both groups, but in neither case did this achieve statistical significance. The distribution of graft losses within the first 30 days was similar in both groups, and the incidence of preservation-related graft failure was not significantly different. These results demonstrate that, in the cyclosporine era, machine perfusion offers no significant advantages over cold storage for cadaver renal preservation. Because machine perfusion is considerably more expensive and cold storage is simpler and facilitates the logistics of organ sharing, we recommend simple hypothermic storage of renal allografts as the preservation method of choice.

Extended treatment with antithymocyte globulin (ATGAM) in renal allograft recipients.

Twenty renal allograft recipients were treated with antithymocyte globulin (ATGAM; ATG) for up to 16 weeks in addition to azathioprine and prednisone, while 20 controls received no ATG. The ATG group showed a lower incidence of first rejection episodes during the first month after transplantation, and also a better functional graft survival rate up to 2 years after transplantation. The results in this early ATG trial were better than those in subsequent trials which used 14-day treatment regimens. Longer treatment deserves another look.

Immunosuppression with medroxyprogesterone acetate.

PIP: The immunosuppressive effects of MPA (medroxyprogesterone acetate) were tested in clinical studies with laboratory dogs and rabbits. The laboratory procedures employed in the studies are explained and results are tabulated and graphed. 2 microscopic photographs illustrate the observed effects. MPA significantly prolonged the survival of dogs with renal allografts. MPA was shown to enhance the immunosuppressive activity of azathioprine in dogs with renal allografts. In rabbits, MPA extended survival of rabbit skin allografts and suppressed the primary humoral antibody response. The influence of MPA on circulating leukocytes and on the histology of lymph nodes, spleen, thymus, liver, and kidney was also assessed. MPA is probably not as potent an immunosuppressive agent as azathioprine or corticosteroids. It is, however, useful in humans due to its low toxicity. It is possible that high local progesterone levels in the fetus and placenta during pregnancy help to prevent fetal rejection.^ieng

Amelioration of chronic renal allograft dysfunction in cyclosporine-treated patients by addition of azathioprine.

Management of chronic renal allograft dysfunction in cyclosporine-prednisone treated renal allograft recipients remains problematic. We therefore initiated a protocol of azathioprine addition (1.0-1.5 mg/kg/day) to ongoing CsA/Pred therapy. Three groups were treated. Group A (n = 21) had chronic progressive renal dysfunction (serum creatinine greater than or equal to 2.5 mg/dl or more than 15% above baseline) four or more months after transplantation. Group B (n = 8) had frequent or severe rejection episodes occurring despite adequate CsA levels. Group C (n = 7) had constitutional side effects of CsA with or without renal dysfunction persisting despite drug taper or financial difficulty in affording CsA. Aza was initiated 17.8 +/- 2.8 months after transplantation in group A, the mean serum creatinine having risen from 2.55 +/- 27 mg/dl to 3.04 +/- .20 mg/dl (P = .07) over the six months preceding Aza initiation, despite stable and low therapeutic range HPLC whole-blood CsA levels (118 +/- 10 ng/ml vs. 133 +/- 11 ng/ml, P = NS). Renal function declined at a rate of -0.20 +/- .06 Cr1/year in the six-month period before addition of Aza, and then improved at a rate of 0.09 +/- .04 Cr-1/year after addition of Aza (P = .002). These changes in renal function occurred without a decrease in CsA levels (118 +/- 10 six months before Aza vs. 126 +/- 26 six months after Aza, P = NS). In group B Aza was initiated at 58 +/- 8 days after transplantation when mean sCr was 3.56 +/- .29 mg/dl and mean CsA level was 222 +/- 17 ng/ml. At least follow-up 12.7 +/- 2.0 months after addition of Aza, all group B grafts were functioning, mean sCr was 2.69 +/- .31 mg/dl (P = .09 compared with baseline), and mean CsA level was 128 +/- 34 ng/ml (P = .07 compared with baseline). Group C patients had addition of Aza at 43 +/- 19 months after transplantation when mean sCr was 2.97 +/- .60 and mean CsA level was 125 +/- 30 ng/ml; addition of Aza had no influence on the rate of decline in renal function in this group. Of these 36 patients, 6 received therapy for acute rejection over the entire follow-up period of 12.3 +/- 1.4 months after addition of Aza; 4 of these retain graft function. Infectious complications consisted of 2 urinary tract infections, 1 bacterial pneumonia, and one case of otitis media.(ABSTRACT TRUNCATED AT 400 WORDS)

No improvement of pancreas transplant endocrine function by exogenous insulin infusion (islet rest) in the postoperative period.

The concept of islet exhaustion maintains that exposure of pancreatic islets to hyperglycemia and other stresses leads to islet dysfunction and irreparable damage. The process of pancreatic transplantation places many stresses on islets (e.g., counter-regulatory hormones, steroids, cyclosporine toxicity). As practiced by some centers, it may be important to administer exogenous insulin in the postoperative period to provide islet rest. Using a porcine pancreas transplant model that simulates clinical transplantation, we studied 2 groups: 1 group (n = 8) received constant insulin infusion for 7 days after transplantation; the control group (n = 5) received vehicle only. The islets in the insulin infusion group were rested as evidenced by a significantly decreased mean C-peptide level (0.27 +/- 0.04 ng/ml) as compared to the control group (0.66 +/- 0.08 ng/ml) (P less than 0.05). After insulin infusion was discontinued, intravenous glucose tolerance testing found insulin, C-peptide and glucagon responses were not different between groups. Glucose clearance was also comparable; K values were -1.79 and -1.60 in the insulin infusion and control groups, respectively. In conclusion, islet rest by insulin infusion for 7 postoperative days did not improve subsequent pancreas transplant endocrine function.