Prevention of cytomegalovirus infection by prophylaxis with an intravenous, hyperimmune, native, unmodified cytomegalovirus globulin. Randomized trial in bone marrow transplant recipients.

We have completed a randomized trial to evaluate the safety and effectiveness of hyperimmune cytomegalovirus intravenous human globulin in prevention of cytomegalovirus infection and related problems in bone marrow transplant recipients. Prophylactic intravenous administration of this native, intact, hyperimmune, cytomegalovirus IgG, at a dose of 200 mg/kg 25, 50, and 75 days following transplant resulted in complete protection against cytomegalovirus infection during the 120 days covered by the treatment (p = 0.009). There was no interstitial pneumonia or mortality in the group receiving the hyperimmune IgG. This is significant at the p = 0.014 when compared with the supporting treatment control group. In bone marrow transplant recipients, prophylaxis with a total dosage of 0.6 g/kg of an intravenous hyperimmune cytomegalovirus globulin was safe and afforded effective protection against cytomegalovirus infection and interstitial pneumonia in this high-risk population.

115 patients with first cadaver kidney transplants followed two to seven and a half years. A multifactorial analysis.

One hundred fifteen consecutive patients received first transplants from cadaver donors at the University of Minnesota between January 1, 1968, and May 31, 1973. All patients have been followed for at least two years. The two-year survival rate is 70 per cent and the two-year transplant function rate is 58 per cent. Considerable improvement in both patient survival and transplant function has been noted since 1971. The success of transplantation appears to depend to a large degree on the age of the transplant recipient, the number of HLA antigens matched between donor and recipient, and the dose of antilymphoblast globulin (ALG) administered to the recipient during the first two weeks after transplantation. Each of these factors appears to be important even when the other factors are controlled, and when patients with diabetes, suffering technical failure or hyperacute rejection, are excluded. The results utilizing well-matched cadaver kidneys plus large doses of ALG appear to be equivalent to those obtained with the use of mismatched kidneys from relatives, but further analysis will be required to draw a definite conclusion. Patients receiving poorly-matched cadaver kidneys do far less well than patients receiving mismatched related grafts, however, even when ALG is utilized.

Comparison of sacks and a new colloid hyperosmolar solution for hypothermic renal storage.

A new colloid hyperosmolar solution with high concentrations of proteins, potassium, and glucose has been favorably compared with a crystalloid, intracellular, and hyperosmolar solution (Sacks II) for 24-hr hypothermic storage of ischemic and nonischemic canine kidneys. Sixty minutes of warm ischemia was overcome by all kidneys flushed with the colloid hyperosmolar solution. In four of six ischemic kidneys flushed with Sacks' solution the function returned to normal limits. Hypothermic storage (24 hr) without warm ischemia did not cause any deleterious effects on either one of the flushed group of kidneys. Thirty minutes of warm ischemia followed by 24-hr hypothermic storage was tolerated by most of the kidneys (83%) flushed with the colloid hyperosmolar solution and one-half of the kidneys flushed with the crystalloid hyperosmolar solution. Sixty minutes of warm ischemia and 24-hr hypothermic storage was detrimental to 50% of the kidneys flushed with the colloid hyperosmolar solution.

The use of antilymphoblast globulin in the treatment of renal allograft rejection: a double-blind, randomized study.

A randomized, double-blind study comparing horse antilymphoblast globulin (ALG) (25 patients) with human IgG (20 patients) in addition to standard antirejection therapy was performed in recipients of first kidney transplants having their first rejection episodes. Patients received ALG (20 mg/kg/day) for 10 days, and a control group was given human IgG (20 mg/kg/day) for 10 days in addition to standard therapy. The groups were comparable with respect to HLA matching, age, time to onset of first rejection episode, and number of diabetics. The number of patients requiring transplant nephrectomy and/or dialysis, having a second rejection episode, having good late function, or dying did not differ in recipients of related kidneys receiving either ALG or human IgG. Recipients of cadaver kidney grafts had fewer (0.05 less than P less than 0.06) second rejection episodes if they received ALG during their first rejection episode. However, the number of patients requiring transplant nephrectomy and/or dialysis, having late good function, and dying did not differ significantly for recipients of cadaver kidneys. We conclude that ALG does not add significantly to standard antirejection therapy for the treatment of first rejection episodes.

Improved survival of heart transplants. Graft and/or donor pretreatment with antilymphoblast globulin, cyclophosphamide, or methylprednisolone.

Survival of heart allografts flushed with antilymphoblast globulin (ALG) was significantly prolonged when the grafts were transplanted into minimally immunosuppressed recipients. When no immunosuppression was given, there was no prolongation of survival of ALG-flushed grafts. Donor pretreatment with cyclophosphamide, methylprednisolone, or ALG had no influence in the prolongation of survival of cardiac allografts. We do not have a clear explanation for the prolonged survival of ALG-flushed grafts transplanted into minimally immunosuppressed recipients.

Lung transplantation. Hypothermic storage for 24 hours in a colloid hyperosmolar solution.

We studied the effects of a colloid hypersomolar solution in perservation of lungs for transplantation in dogs. Fresh allografts were compared to lungs stored (4 to 7 degrees C), in Ringer's lactate for 3 hours and in modified silica gel function (MSGF) for 8, 16, and 24 hours before transplantation. Lungs preserved in Ringer's lactate for 3 hours were significantly damaged, and there were no long-term survivors in recipient dogs (1.2 +/- 0.4) (mean +/- S.E.). In contrast, the recipients of lungs preserved in MSGF for periods of up to 24 hours stored MSGF grafts = 10.5 +/- 3.1 days, survival, mean +/- S.E. Fresh Ringer's lactate grafts = 8.5 +/- 2.3 days, mean +/- S.E.; Fresh MSGF grafts = 13.6 +/- 3.8 days, mean +/- S.E.). Arterial blood gas measurements and chest roentgenograms were good methods of assessting the condition of preserved lung allografts. No significant differences were observed between the fresh and MSGF-preserved grafts. Pneumonia and rejection were the most frequent causes of death for both the fresh and MSGF-preserved allograft recipients. We demonstrate that a calloid hyperosmolar solution (MGSF) is a good method for 24 hours hypothermic storage of lung allografts for transplantation.

Preservation of canine hearts after warm ischemia (zero to thirty minutes) and one to two days of hypothermic storage. A comparative analysis of crystalloid and colloid solutions with different osmolarity and ion composition.

The effect of extracellular crystalloid (Ringer's) and colloid (silica gel fraction [SGF]) solutions, and intracellular crystalloid (Sacks) and colloid (modified silica gel fraction [MSGF]) solutions for canine heart preservation in a 24 to 48 hour model of hypothermic storage and zero to 30 minutes of warm ischemia was compared. Canine hearts flushed with an intracellular colloid solution (MSGF) had better survival rates after transplantation than did the hearts flushed with intracellular crystalloid solutions (Sacks). Better survival results also were observed in the group of hearts flushed with extracellular colloid (SGF) solutions than extracellular crystalloid (Ringer's) solutions. The most important theoretical factor in heart preservation appears to be hyperosmolarity and elevated concentration of potassium, proteins, and glucose.

Prevention of graft rejection in allogeneic bone marrow transplantation: I. Preclinical studies with antithymocyte globulins.

Heterologous horse antithymocyte globulins (ATG) were investigated in vitro as potential immunotherapeutic reagents in the prevention of bone marrow graft rejection by allogeneic recipients. Different lots and concentrations of ATG were evaluated for their ability to inactivate natural killer (NK) cells, IL-2 cultured 'augmented' NK cells, and/or cytotoxic T cells (CTL) using the 51Cr-release assay for measurement of cytotoxic activity. In vitro incubation of peripheral blood mononuclear cells (PBMC) with a prototype non-myelotoxic ATG (ATGP12) at 0.1 mg/ml (a concentration which can be achieved with an i.v. infusion of approximately 30 mg ATG/kg daily) variously inhibited NK activity (0-100%); whereas treatment with the same concentration of ATGP12 and autologous human complement completely inhibited NK, as well as 'augmented' NK function from all normal individuals tested. Incubation of T cytotoxic effector cells with ATGP12 alone also significantly abrogated primed T cell cytotoxicity. These studies demonstrate that lots of ATG can be easily prescreened and titered in vitro in order to identify immunosuppressive reagents capable of inhibiting the MHC restricted and non-restricted cytotoxic cells, which can survive chemotherapy and radiation, and may play a critical role in resistance to engraftment of T cell-depleted marrow.

Mechanisms of the adjuvant effect of hemoglobin in experimental peritonitis. VI. Effects of stroma-free hemoglobin and red blood cell stroma on mortality and neutrophil function.

Hemoglobin is known to increase the lethality of experimental E. coli peritonitis, but its mechanism of action has not been defined. Some evidence from this laboratory previously suggested that hemoglobin could interfere with local leukocyte function in the peritoneal cavity. In the present study we compared the effect of impure bovine hemoglobin, highly purified stroma-free hemoglobin, and red blood cell stroma on the mortality rate of rats with Escherichia coli peritonitis, as well as on human neutrophil function in vitro. Both hemoglobin preparations markedly increased the mortality rate at low bacterial concentrations. Red blood cell stromal elements increased the rate to a minimal degree and only at high bacterial concentrations. The character of the E. coli-induced peritoneal leukocytosis was not significantly affected by concomitant administration of either stroma-free hemoglobin or red blood cell stroma. Although crystalline bovine hemoglobin inhibited in vitro leukocyte chemotaxis, centrifugation of this preparation to remove debris abrogated this effect. Stroma-free hemoglobin had no effect on in vitro leukocyte chemotaxis. Red blood cell stromal elements in high concentration diminished phagocytosis and bacterial killing by human neutrophils, but stroma-free hemoglobin had no effect on these neutrophil functions. The results confirm that hemoglobin is a potent adjuvant in experimental E. coli peritonitis, but contrary to our previous conclusion does not owe this effect to direct interference either with neutrophil influx into the peritoneal cavity during bacterial peritonitis or with human leukocyte function in vitro. Such prior conclusions appear to have been based on insoluble material including stromal elements in the hemoglobin preparations used. Red cell stromal elements derived from as little as 1 ml of packed red cells can significantly interfere with the phagocytosis and killing of E. coli.

Anticore endotoxin F(ab')2 equine immunoglobulin fragments protect against lethal effects of gram-negative bacterial sepsis.

Gram-negative bacterial sepsis and shock remain a cause of substantial morbidity and mortality in hospitalized patients despite appropriate antimicrobial therapy, fluid resuscitation, and monitoring. We sought to test the ability of equine antibody directed against core endotoxin, a portion of bacterial outer membrane lipopolysaccharide common to many gram-negative microorganisms, to bind to various gram-negative bacteria in vitro, to promote bacterial phagocytosis by leukocytes, and to protect against lethal gram-negative bacteremia in mice. The importance of the IgG Fc leukocyte attachment site was examined by comparing the ability of intact IgG and IgG F(ab')2 fragments to protect against lethality during murine sepsis. A single horse was immunized with Escherichia coli J5, an organism that expresses a portion of core endotoxin extensively on the cell surface. Preimmunization IgG and F(ab')2 possessed no titer as determined by enzyme-linked immunosorbent assay, did not promote in vitro phagocytosis, and did not protect in vivo. Postimmunization IgG and F(ab')2 possessed a significant titer to E. coli J5 whole cell and lipopolysaccharide antigens and provided significant (p less than 0.05) protection in vivo during lethal intravenous sepsis caused by either E. coli J5, E. coli 0111:B4, Klebsiella pneumoniae, or Pseudomonas aeruginosa. Only postimmunization IgG, but not F(ab')2, promoted in vitro phagocytosis of these same organisms. We therefore hypothesized that protection occurred as a result of antitoxin activity rather than opsonization and phagocytosis, as F(ab')2 fragments were as active as the intact molecule. Further studies must be done to determine the role of anticore endotoxin antibody in conjunction with antibiotics so that appropriate clinical studies may be undertaken.

Mechanisms of the adjuvant effect of hemoglobin in experimental peritonitis. VII. Hemoglobin does not inhibit clearance of Escherichia coli from the peritoneal cavity.

Hemoglobin has been shown to be a potent adjuvant in experimental Escherichia coli peritonitis, although a satisfactory mechanistic rationale is still obscure. Hemoglobin has been thought to impair intraperitoneal neutrophil function, delay clearance of bacteria from the peritoneal cavity by the normal absorptive mechanisms, or directly enhance bacterial growth. Using highly purified stroma-free hemoglobin (SFHgb), we have largely discounted any direct effect of hemoglobin on peritoneal white blood cell function. In the present study, we confirmed that uncontrolled proliferation of bacteria takes place in the presence of hemoglobin in the peritoneal cavity. Nonviable 5-iododeoxyuridine 125I-labelled bacteria were then used to directly study peritoneal clearance kinetics, eliminating the problem of bacterial growth. SFHgb had no influence on the removal of intraperitoneal bacteria. The rate of bloodstream appearance of radiolabel was similar with or without intraperitoneal SFHgb. Thus, SFHgb does not prevent clearance of bacteria from the peritoneal cavity by interfering with normal host clearance mechanisms. SFHgb may act as a bacterial growth adjuvant, either by serving as a bacterial nutrient or by suitably modifying the environment so that extensive bacterial proliferation can occur. The latter hypothesis appears to be an area in which investigation concerning the adjuvant effect of hemoglobin may prove most fruitful.

Protective capacity of polyclonal and monoclonal antibodies directed against endotoxin during experimental sepsis.

Both monoclonal antibody (MAb) and polyclonal antibody (PAb) directed against the shared core/lipid A region of lipopolysaccharide (LPS) (endotoxin) provide protection during experimental gram-negative bacterial sepsis. Although these preparations have not been compared, clinical trials administering either preparation to septic patients have been instituted. The core/lipid A region of LPS represents an antigenic domain common to many, if not all, gram-negative microbes, and thus represents an ideal target site for antibody binding. We sought to determine (1) the protective capacity of similarly reactive IgG anti-core LPS/lipid A MAbs and PAbs, (2) whether the timing of administration was important, and (3) whether either would act additively with antimicrobial agents. Antibody was administered intravenously to outbred mice, and Escherichia coli 0111:B4 was then administered intravenously or intraperitoneally with hemoglobin. Monoclonal antibodies and PAbs were equally protective, and protection was maximized by pretreatment, although the effect extended to four hours after bacterial challenge. Both MAbs and PAbs acted in concert with gentamicin hydrochloride to further reduce lethality. We concluded that MAbs and PAbs were equally protective and that clinical utility may eventually be dictated by ease and cost of antibody production.

The use of allogeneic stimulation and exogenous interleukin for syngeneic tumor rejection.

Increased survival in the syngeneic tumor-challenged host was accomplished by the addition of exogenous IL-2 with syngeneic tumor and by simultaneous administration of allogeneic plus syngeneic tumor cells. Whether the mechanisms responsible for this increased longevity are due to the same type of modulation of the immune system is undetermined. These results, however, suggest a therapeutic method of manipulating tumor and IL administration to trigger a sluggish or nonreactive immune system to respond in situations in which it otherwise would not be programmed to react.

Examination of the role of the colloids hydroxyethylstarch, dextran, human albumin, and plasma proteins in a modified UW solution.

The delayed contralateral nephrectomy procedure (three-step) produced inconsistent results, indicating that the preserved autotransplanted kidney tends to remain unfunctional and to regenerate incompletely unless the demand for work is placed upon it. Omission of HES in UW (UW-plain) did not affect preservation success, but resulted in increased graft edema. Substitution of HES in UW with plasma (SGF-V) or albumin (MAlb) gave significantly worse results than UW-like solutions with or without synthetic colloids. Replacement of HES in UW with UMdex-70 or UMdex-500 gave nonsignificantly worse results than UW-like solutions with or without synthetic colloids. The use of UMdex-40 as the main colloid in UW cheapened the solution, equalled the preservation success of UW and UW-plain but surpassed UW-plain in edema prevention, and exceeded UW concerning recovery of graft microcirculation.

Treatment of life-threatening infections in renal transplant recipients with high-dose intravenous human IgG.

This study demonstrates that large doses of human IgG can, if prepared by appropriate methods, be safely given intravenously. Antibody titers to CMV can be significantly elevated by administration of MIVIgG. While this is not a controlled trial, IgG therapy appears to be beneficial in renal transplant patients presenting with life-threatening infections.