B-lymphocyte alloantigens in Caucasians.

Human B lymphocytes have been shown to have at least five polymorphic specificities defined by 32 antisera. The antisera were produced by absorption with pooled platelets to remove HLA activity and were selected out of over 400 tested sera. The sera that defined the five specificities had high correlation coefficients within a group (generally in the range of 0.6-0.9). As shown by the fit in the Hardy-Weinberg equilibrium, the five specificities appear to be determined by alleles at one genetic locus. No association between these specificities and HLA was noted.

Prolonged survival of second human kidney transplants.

Rejection of kidney transplants in 264 patients, followed by retransplantation from cadaver donors, resulted in a 1-year survival rate of 51 +/- 3 percent (rate +/- standard error) as compared to 51 +/- 1 percent for first transplants. If the first transplant immunizes the patient or is rejected by immunologically responsive patients, second grafts into the same patients would be expected to be rejected at a higher rate. Only those reject who reject first grafts hyperacutely or between 1 to 3 months were found to have low second graft survival rates. Patients who rejected transplants after 3 months tended to have second transplant survival rates which were higher than their first graft survival rates.

Interaction analysis of selective and nonselective cell-mediated cytotoxicity.

The coexistence of selective and nonselective cytotoxic cells in effector suspensions required a method of separating the two effects before specificities in cell-mediated cytotoxicity could be investigated. A method of analysis was derived which used the average cytotoxicity for each effector and target to estimate selective and nonselective cytotoxic effects. The analysis clearly detected specificity in tests of cell-mediated lympholysis, and application to tests of cell-mediated cytotoxicity on cultured human tumor cells showed that selective reactions were found.

Specificities in human cell-mediated cytotoxicity.

Specificity of natural cell-mediated cytotoxicity was investigated through selective reactions detected by direct cell-mediated cytotoxicity and by inhibition of cytotoxicity through competition. Assuming that target cells reacting alike in direct cytotoxicity shared common antigens, we classified 10 target cells into three groups by target antigens: TA (target antigen) 1, 2, and 3. Partial confirmation of the three groups was achieved in the cross-competition assay. The distinction of TA 1 as a group was clear but some cross-reactivity existed between TA 2 and TA 3 cells.

Defective monocyte function in patients with genitourinary carcinoma.

An assay allowing quantitation of monocyte function, i.e., chemotaxis, was used to study the activity of monocytes in patients with neoplasms of the urinary tract. Twenty-four subjects with various stages of renal carcinoma exhibited a mean chemotactic defect of 34% (P less than 0.005) as compared to normal controls and patients hospitalized with nonneoplastic diseases. Twelve persons with transitional cell carcinoma of the bladder had a 29.8% (P less than 0.01) mean chemotactic defect as compared to the controls. There was no correlation between tumor stage and degree of chemotactic defect;--J Natl Cancer Inst 55: 1047-1054, 1975.

Effect of water-soluble adjuvants on in vitro lymphocyte immunization.

Water-soluble adjuvants prepared from Mycobacteriim smegmatis and human mixed mycobacteria strains C, DT, and PN were found to increase lymphocyte response in one-way mixed-lymphocyte culture and in vitro immunization to cultured human tumor cells. Phytohemagglutinin-induced lymphocyte blastogenesis, however, was depressed by water-soluable adjuvants.

Natural and antibody-dependent cell-mediate cytotoxicity to cultured target cells superinfected with Epstein-Barr virus.

The relationship between natural cell-mediated cytotoxicity (NCMC) and antibody-dependent cell-mediated cytotoxicity (ADCC) was examined in an Epstein-Barr virus-infected target cell system. The total ADCC reactivity to Epstein-Barr virus-infected target cells varied considerably with different effector cells, indicating contributions to specificity by the effector cells as well as by antibodies in the sera. To investigate the role of each reactant, the effector cells, sera, and target cells were tested according to a three-dimensional experimental design and examined for selectivity with the two- and three-way interaction analysis. The two-way analysis was applied to different planes from the experiment to examine special interactions involving two of the three reactants. Selective ADCC was examined through the results from sera versus target cells, selective NCMC was examined by effector cells versus target cells, and the relationship between NCMC and ADCC was examined through the final plane of effector cells versus sera. A three-way interaction analysis applied to the same results supported the conclusions from the two-way analysis and allowed further inquiry into the concurrent role of three reactants. The design and analysis used in the study allowed detection of selective ADCC and NCMC for Epstein-Barr virus-infected target cells and variations in the efficiency of ADCC by different effector cells and in the modulation of NCMC by different sera.

Correlation of clinical and immunologic states in multiple sclerosis.

Cyclophosphamide was administered to 14 patients with chronic progressive multiple sclerosis on an intermittent escalating dosage schedule adjusted to maintain numbers of peripheral blood B lymphocytes and helper/inducer (CD4) T cells below the fifth percentile of the normal population. Peripheral blood B cells, T cells, suppressor/cytotoxic (CD8) T cells, CD4 cells, and FcR+-bearing cell numbers and percentages were monitored at one-week to two-week intervals. Clinical status was assessed by neurologic examinations at approximately four-week intervals. Regression analysis revealed a statistically significant correlation between changes in immunologic status and changes in clinical state. The immunologic changes preceded the neurologic changes. Increases in percent of CD8 cells and decreases in percent of CD4 cells forecast improved clinical course. These findings, coupled with other studies, strongly suggest a pathogenetic role for helper and suppressor T cells in the production of clinical signs of multiple sclerosis.

Cyclophosphamide 'pulses' in chronic progressive multiple sclerosis. A preliminary clinical trial.

To our knowledge, this is the first clinical trial in multiple sclerosis (MS) demonstrating the feasibility of directing immunomodulating therapy by monitoring immunologic results. Cyclophosphamide was administered at monthly intervals, escalating the dose until there was a significant reduction in both the number of blood B lymphocytes and helper/inducer (CD4) T cells of 14 patients with chronic progressive MS. The frequency and severity of adverse effects led us to conclude that the regimen is too toxic for the long-term treatment of patients with MS.

Alternatives to randomized clinical trials.

Data bases describing the natural history of patients with multiple sclerosis or the clinical course of patients treated with placebos might serve as "historical controls" in future clinical therapeutic trials. The results of clinical trials with such controls can be misleading. There is a strong tendency for the new treatment to appear efficacious when historical controls are the comparison group. Therefore, claims of efficacy deduced from trials using such controls should be closely questioned. Thus, such comparison groups probably would be useful for preliminary and early phase II (pilot) trials rather than in more definitive phase III (full) trials.

An illness severity score for multiple sclerosis.

A single score is desirable for evaluating progression in clinical trials of MS therapy. Our objective was to develop a more sensitive scoring that would reflect clinical assessment of relative severity of disability. An Illness Severity Score (ISS) was developed as a sum of weights corresponding to ratings of Kurtzke Disability Status Scale and Functional Systems Scales and phase of illness. Weights were computed from clinical comparison of pairs of patients. The score was standardized to have mean 50 and standard deviation 10 in a single clinic population. Score reproducibility (correlation = 0.93) was evaluated by two independent scorings of several patients. The ISS was satisfactory as the primary assessment in a small-scale clinical trial.

Clinical experience with azathioprine: the pros.

We performed a randomized, placebo-controlled, double-blind, comparative clinical trial of 36 weeks of methylprednisolone and 3 years of azathioprine in 98 patients in the chronic progression phase of multiple sclerosis (MS). We demonstrated a trend in favor of the combination therapy for limiting progression. The relapse rate in the azathioprine recipients was half that of the control group, and visual evoked potential latencies were stabilized in those who received the combination. We think that a therapeutic trial of continuous use of the combination of adrenal steroids with azathioprine would be worthwhile if administered early in the course of the disease.

A placebo-controlled, randomized, double-masked, variable dosage, clinical trial of azathioprine with and without methylprednisolone in multiple sclerosis.

Ninety-eight patients with multiple sclerosis (MS) in the chronic progression phase entered a 3-year clinical trial to determine if azathioprine (AZ) alone or with adrenal cortical steroids stabilizes the course of MS. In group AM, the patients took AZ throughout and methylprednisolone (MP) for the first 36 weeks. Group AP received AZ and placebo instead of MP. Group PP took placebos for both drugs. We adjusted the AZ to maintain the total white blood cell count within 3,000 to 4,000/mm3; we gave the MP in a fixed dose "pulse" and alternate-day regimen. The "intent-to-treat" groups had no statistically significant differences in the rates of progression among the 3 treatments. Subgroup analysis suggests that patients in the AM group who completed treatment exactly according to protocol did statistically significantly better than the placebo recipients using the sum of Standard Neurological Examination scores, slightly better using the quantitative neuro-performance tests, but no better using Mickey's Illness Severity Scores or Kurtzke's Disability Status Scale. Also, the AZ-treated groups had half the relapse rate of the placebo-treated group. Adverse reactions to AZ accounted for most withdrawals. Hematologic and hepatic abnormalities were significantly associated with AZ, but serious non-MS abnormalities were uncommon and were equally distributed among the 3 groups. Addition of MP to the AZ slightly improved the efficacy of the treatment, but also increased the adverse effects. The benefits of AZ with or without steroids did not outweigh the risks, and therefore we do not recommend this treatment for patients with chronic progressive MS.

A microassay for leukocyte migration: analysis of its reproducibility.

A reliable microassay for human leukocyte migration is described by which 50 to 100 assays can be performed each day in quadruplicate with the number of indicator cells obtainable from 10 to 20 ml of peripheral blood. The reproducibility of this method is demonstrated with respect to the variability among replicate test wells (including reading), the variability among different test readers, the variability among replicate cultures, and the variability of using indicator cells from different subjects. A microculture system is described that requires only 75,000 mononuclear cells to consistently produce detectable polymorphonuclear leukocyte migration inhibition factor in response to PPD. The reproducibility of this culture system is demonstrated with respect to the variability of lymphocyte responsiveness on repetitive testing in the same individuals.

The effect of zero HLA class I and II mismatching in cyclosporine-treated kidney transplant patients.

The effect of HLA matching on one-year first cadaver donor graft survival rates between best and worst matches was 6% (P less than 0.001) for A, B; 7% (P less than 0.001) for DR; 9% (P less than 0.001) for A, DR; 15% (P less than 0.001) for B, DR; and 17% (P less than 0.001) for A, B, DR. For second cadaver donor grafts, the differences were comparable. Analysis of the cyclosporine-treated patients separately yielded similar results: 5% (NS) for A, B; 7% (P less than 0.001) for DR; 13% (P less than 0.001) for A, DR; 16% (P less than 0.001) for B, DR; and 18% (P less than 0.001) for A, B, DR. The most significant effect of matching was achieved by zero mismatching B and DR antigens. The one-year graft survival for patients with zero A, B, DR mismatch was 88% with cyclosporine. Without cyclosporine, zero mismatched A, B, DR grafts survive at 84%; this difference is not statistically significant. Zero mismatching for class I and II antigens (that is, A, DR or B, DR with cyclosporine) gives one-year graft survivals of 84% and 87%, respectively. The zero mismatching HLA class I and II antigen effect is lost when even one antigen is mismatched. Transfusions improved the one-year graft survival 10% in cyclosporine-treated patients, but not in those who were not treated with cyclosporine. Seventy-one patients transfused with more than 4 units of blood, zero B, DR mismatched, and treated with cyclosporine had a 91% one-year graft survival. Recipient pool sizes for obtaining zero A, B, DR or B, DR mismatched donors are calculated. Zero A, B, DR mismatched patients can be transplanted at a 19% frequency with a 10,000 recipient pool. The success rate for zero mismatching of class I and class II antigens indicates that kidney sharing and large recipient pool sizes are a reasonable policy.

Lymphocyte transformation induced by human granulocytes.

Contrary to previous reports, human granulocytes are capable of causing transformation of allogeneic lymphocytes. Pretreatment of granulocytes with mitomycin C results in nonstimulation, but untreated granulocytes are capable of stimulating lymphocytes. Nonstimulation with mitomycin C-treated granulocytes may result from the reduced viability of the cells. It is concluded that granulocytes possess alloantigens that stimulate lymphocytes in vitro.

Comparison of kidney transplant survival among transplant centers.

Human kidney transplant survival rates at 1 year were compared among centers according to the transplantation activity as measured by the number of renal transplants performed. Statistical methods are described by which a fair assessment can be made of the outcome when small numbers of grafts are involved. The method should also be useful in evaluating subsets of patients in any given center under different treatment protocols. No evidence was found that survival rates of cadaver donor transplants were lower at the smaller centers. Other factors besides size of centers are probably of greater importance in influencing transplant survival rates.

HLA matching and cadaver kidney transplant survival in North America: influence of center variation and presensitization.

In an analysis of 4,851 first cadaver kidney transplants, we found a statistically highly significant correlation between the number of HLA antigens mismatched and graft survival (P less than 0.0005 at 1 year). The difference in the survival rates of grafts with no HLA mismatch compared with grafts with four mismatches was 11 to 12%, similar to results of previous analyses. HLA-A locus antigens had a slightly stronger effect than B locus antigens. The correlation of HLA matching with graft survival was most significant at centers with poor overall transplant outcome, and there was no correlation at centers with very good overall results. Presensitization also had the strongest effect at centers with poor overall graft survival.

Blood transfusions and HLA matching--an either/or situation in cadaveric renal transplantation.

Cyclosporine-treated recipients of primary cadaver donor renal transplants had a one-year graft survival rate of 79% if they received pretransplant blood transfusions (n = 5308). The one-year survival rate for nontransfused recipients (n = 709) was significantly lower at 69% (P less than 0.001). The transfusion effect was larger in black recipients (a 17% difference) than in white recipients (5%). The effect was also larger in recipients of grafts poorly matched for HLA-A, B, -B, DR, or -DR antigens than in recipients of well-matched grafts. Transfusions did not significantly improve graft survival in recipients with zero or one HLA-A, B or -B, DR, or zero -DR-mismatched grafts. However, transfusions accounted for increases of 10%, 14%, and 17% in patients receiving grafts mismatched at 2, 3, or 4 HLA-B, DR antigens, respectively. Several factors including cyclosporine and HLA matching have contributed to improving graft survival rates in nontransfused recipients. Sensitization was noted in 20% of transfused patients awaiting primary renal transplants in Southern California, as compared with 10% in transplanted patients, suggesting a tendency to transplant nonsensitized patients. Of the sensitized patients, 75% were female. Based on these data, we suggest that high survival of primary kidney allografts in the cyclosporine era can best be maintained by the continued use of pretransplant transfusions for the majority of recipients--or, alternatively, by HLA matching for patients who are at higher risk of becoming sensitized.

Kidney transplantation trends from UCLA registry Data, 1975-1982.

A total of 23,607 cases transplanted in 1975-1982 were analyzed for proportion and survival trends within eleven classification variables. Increases of up to 2% of total cases per year in proportions of registered transplants over the eight years are found in the following subcategories (with corresponding decreases in complementary subcategories): first grafts, cadaver donors, recipients with diabetes mellitus, and kidneys shipped more than 50 miles. Larger proportional increases of 3-7% per year are found for HLA-DR matching, cold ischemia times greater than 24 hr, cold storage, and pretransplant transfusions. Recipient population cross-sections are unchanged for age, race, HLA-A,B matching, and cytotoxic antibodies at transplant. Only the pretransplant transfusion classification has no increased graft survival in any subcategory; all other variables have one or more categories with increasing graft survival. It appears likely that the marked shift in transfusion policy nationwide has been the primary factor in increasing graft survival rates overall.