A single-center analysis of early readmission after renal transplantation.

BACKGROUND: Thirty-day readmission rates (early hospital readmission, EHR) are an important benchmark for quality improvement. Nationally, patients undergoing renal transplantation incur a 31% EHR rate. While national databases provide useful data, the impact of EHR on individual centers has received little attention. We proposed that an institutional review of EHR after renal transplantation may provide a benchmark for individual transplant programs and identify modifiable program-specific issues to reduce EHR. METHODS: We reviewed 269 consecutive kidney transplant recipients over a five-year period (2012-2016). Early hospital readmission was modeled using generalized linear modeling assuming a binary distribution. RESULTS: About 21% of patients were readmitted within 30 days. Deceased kidney donation (DD), delayed graft functioning (DGF), anti-thymocyte globulin (ATG) induction, diabetes, public insurance, weekend discharge, and low glomerular filtration rate (eGFR) at discharge were all identified as risk factors for readmission. Early hospital readmission was not correlated with risk of death (5.4% at 44 months: HR 2.2 (95% CI [0.7, 6.6]; P = 0.1473) or graft loss. CONCLUSIONS: EHR after renal transplantation is common. Certain factors may predict an increased risk for EHR. A multi-disciplinary approach to discharge planning may limit some EHR, but most complications and adverse events are unpredictable and require hospital-level of care.

Urinary iodine concentrations of pregnant women in Ukraine.

BACKGROUND: Iodine requirements increase during pregnancy and previous studies have reported the inadequate iodine status of pregnant women in areas that have achieved iodine sufficiency in the general population. We examined the urinary iodine (UI) concentrations of pregnant women in Ukraine, where the iodine status is showing improvement among the general population. METHODS: We enrolled 148 pregnant women<16 weeks pregnant and 80 healthy women as a control group living in Zhitomir, Ukraine. UI concentration, thyroid-stimulating hormone (TSH), antithyroglobulin antibodies (TGAb), and antithyroid peroxidase antibodies (TPOAb) were measured. RESULTS: The median UI concentrations were significantly lower in pregnant women than in control women [13.0 (ND­51.0) µg/L vs. 62.0 (35.3­108.5) µg/L, p<0.001]. TSH concentrations were significantly lower in pregnant women than in control women [1.7 (1.2­2.7) IU/L vs. 2.2 (1.4­3.1) IU/L, p=0.011], but this difference disappeared when adjusted for age (2.1±0.1 IU/L vs. 2.4±0.2 IU/L, p=0.097). The frequency of TSH over 6.2 IU/L and the frequency of positive TGAb and/or TPOAb were not statistically different between groups (p=0.70 and p=0.48, respectively). The UI concentrations of 142 pregnant women (95.9%) were <150 µg/L indicating insufficient iodine intake. CONCLUSIONS: The UI concentration of pregnant women in Ukraine revealed severe iodine deficiency. Regular monitoring and appropriate nutrition education are essential because iodine deficiency can be easily prevented by adequate iodine intake. The risk of iodine deprivation during pregnancy needs to be assessed locally over time because it may occur in areas that are not globally recognized as being iodine-deficient.

A comparison of Jurkat cell-reactive anti-T lymphocyte globulin and fetal anti-thymocyte globulin preparations in the treatment of aplastic anemia.

OBJECTIVE: The aim of this study was to investigate the success rate and effects on survival of different anti-thymocyte globulin (ATG) preparations in patients diagnosed with aplastic anemia. SUBJECTS AND METHODS: Of the total 24 patients included in the study, 12 were male and 12 female with a median age of 44 years (range 16-72). Nine patients received Lymphoglobulin®, 7 Thymoglobulin® and ATG-Fresenius® (ATG-F). There was no significant difference between the three treatment groups in terms of severity of aplastic anemia. RESULTS: The estimated 6-month survival rates for ATG-F, Lymphoglobulin and Thymoglobulin groups were 42.9, 77.8 and 71.4%, respectively. The difference in overall survival rates between groups was not significant, most likely due to the low number of patients. The most striking result was that none of the patients in the ATG-F preparation group showed any response to treatment. The ATG-F group was found to have a significantly inferior response rate (p = 0.07). CONCLUSION: Our data showed that none of the patients responded to ATG-F treatment. Hence, despite the small number of the patients, we recommend that ATG-F should not be used for treatment of severe aplastic anemia.

Outcomes of kidney transplantation over a 16-year period in Korea: An analysis of the National Health Information Database.

BACKGROUND: This study investigated the outcomes of kidney transplantation (KT) over a 16-year period in Korea and identified risk factors for graft failure using a nationwide population-based cohort. METHODS: We investigated the Korean National Health Insurance Service-National Health Information Database. Health insurance claims for patients who underwent KT between 2002 and 2017 were analyzed. RESULTS: The data from 18,331 patients who underwent their first KT were reviewed. The percentage of antithymocyte globulin (ATG) induction continuously increased from 2.0% in 2002 to 23.5% in 2017. Rituximab began to be used in 2008 and had increased to 141 patients (9.6%) in 2013. Acute rejection occurred in 17.3% of all patients in 2002 but decreased to 6.3% in 2017. The rejection-free survival rates were 78.8% at 6 months after KT, 76.1% after 1 year, 67.5% after 5 years, 61.7% after 10 years, and 56.7% after 15 years. The graft survival rates remained over 80% until 12 years after KT, and then rapidly decreased to 50.5% at 16 years after KT. In Cox's multivariate analysis, risk factors for graft failure included being male, more recent KT, KT from deceased donor, use of ATG, basiliximab, or rituximab, tacrolimus use as an initial calcineurin inhibitor, acute rejection history, and cytomegalovirus infection. CONCLUSIONS: ATG and rituximab use has gradually increased in Korea and more recent KT is associated with an increased risk of graft failure. Therefore, meticulous preoperative evaluation and postoperative management are necessary in the case of recent KT with high risk of graft failure.

Spontaneous release of the Leu-2 (T8) molecule from human T cells.

Sensitive enzyme-linked immunosorbent assays (ELISA) for the detection of human T cell antigens in soluble form have been developed. The assays use mouse monoclonal antibodies and specific anti-Leu sera prepared in rabbits by immunizing with Leu antigens absorbed to monoclonal antibody affinity columns. With these assays, Leu-1, -2, and -3 antigen signals from extracts of as few as 5 X 10(3) cells could be detected. When culture supernatants from various cell lines were tested, Leu-2 antigen, but not Leu-1 or Leu-3, was found to be present. Leu-2 antigen was present only in supernatants from T cell lines that expressed Leu-2 on their cell surface. Leu-2 antigen accumulated progressively in the supernatant of low density culture and its presence did not depend on cell proliferation or on fetal calf serum in the culture medium. The Leu-2 antigen in the supernatant was found to have only one Leu-2a determinant, whereas Leu-2 antigen from cell extracts had at least two determinants. The Leu-2 molecule was effectively purified from supernatant with an anti-Leu-2a affinity column. The purified Leu-2 antigen from supernatant of HPB-ALL cells was a single polypeptide chain of 27,000 mol wt, whereas Leu-2 antigen present on HPB-ALL cell surface was composed of two or more identical polypeptide chains of 33,000 mol wt linked by disulfide bonds. Normal human sera and sera from leukemia patients were also examined for the presence of the Leu-2 antigen. Normal human sera contained low levels of Leu-2 antigen but sera from Leu-2-positive leukemia patients had high levels. These results indicate that Leu-2 antigen is released from human T cells under physiological conditions.

Preleukemic expression of TL antigens in x-irradiated C57BL/6 mice.

Anomalous appearance of TL (thymus-leukemia) antigens is a characteristic feature of radiation-induced leukemias of C57bl/6 mice. We now report that thymocytes of irradiated C57BL/6 mice express TL antigens long before the development of overt leukemia. Thus, TL is a marker for preleukemic changes occurring during radiation leukemogenesis. Low levels of murine leukemia virus (MuLV)-related antigens are also detected on preleukemic thymocytes. Comparative tests on individual mice show no direct correlation between TL and MuLV antigen expression.

Suppression of in vitro monoclonal human rheumatoid factor synthesis by antiidiotypic antibody. Target cells and molecular requirements.

Previous studies have indicated that antiidiotypic antibody can modulate expression of idiotype both in vivo and in vitro. Although the precise mechanisms underlying modulation of idiotype expression by antiidiotype remains unclear, a requirement for intact IgG antiidiotypic antibody has been suggested and T cells appear to play a role in some systems. We have studied peripheral blood mononuclear leukocytes (MNL) from a patient with a B cell lymphoma and a circulating IgMK rheumatoid factor (RF) paraprotein in an effort to delineate mechanisms involved in regulation of idiotype expression by antiidiotypic antibody. 1-10% of MNL from this patient could be cytoplasmically stained with specific F(ab')2 antiidiotypic antibody. MNL from the patient spontaneously synthesized IgM RF in culture that possessed the same idiotype as the circulating IgM RF paraprotein. Production of RF by MNL was suppressed by pretreatment with either intact IgG or the F(ab')2 fragments of antiidiotypic antibody (50% inhibitory concentration was 0.2 and 1.1 micrograms/culture, respectively). In contrast, the Fab' fragment of antiidiotypic antibody was not inhibitory (up to 57 micrograms/culture) despite retaining demonstrable antiidiotype activity. Suppression of RF production was not observed over the same concentration range with the IgG or F(ab')2 fractions of a non-cross-reactive antiidiotypic antibody prepared against another monoclonal IgMK RF paraprotein or with IgG or F(ab')2 fractions prepared from normal rabbit serum. Inhibition of RF production by antiidiotypic antibody did not require T cells. Antiidiotypic antibody decreased intracellular and extracellular levels of idiotype indicating diminished synthesis of idiotype by the patient's B cells. Synthesis of IgM RF by MNL obtained from unrelated donors was not suppressed by the antiidiotypic antibody specific for the patient's paraprotein. The results indicate that (a) antiidiotypic antibody is capable of directly suppressing human B cell release of idiotype, (b) the bivalent antigen-binding fragment (F[ab']2) of antiidiotypic antibody is sufficient for mediating such suppression, (c) an intact Fc portion of antiidiotypic antibody enhances suppression of idiotype, and (d) antiidiotypic antibody inhibits idiotype expression by suppressing synthesis of idiotype.

Murine antiidiotypic monoclonal antibodies that bear the internal image of HLA-DR allospecificities.

Hybridization of murine myeloma cells P3-X63-Ag8.653 with splenocytes from a BALB/c mouse immunized with the syngeneic anti HLA-DR1,4,w6,w8,w9 MAb AC1.59 resulted in the development of 108 hybridomas secreting antiidiotypic antibodies. 100 of them inhibited the binding of MAb AC1.59 to target cells. Detailed analysis of the antiidiotypic MAb F5-444, F5-830, F5-963, F5-1126, F5-1336, and F5-1419 showed that all of them recognize idiotopes within or spatially close to the antigen combining site of MAb AC1.59. In cross-blocking experiments, the six antiidiotypic MAbs cross-blocked each other. It is likely that the six MAbs recognize spatially close, but not identical idiotopes because they elicited antiantiidiotypic antibodies of different or similar, but not identical specificity and differ in their ability to elicit anti-HLA class II antibodies. The latter, which were found only in sera from BALB/c mice immunized with antiidiotypic MAb F5-444 and F5-830, mimic the specificity of MAb AC1.59 and express the idiotope defined by the immunizing antiidiotypic MAb. These results indicate that the MAb F5-444 and F5-830 are antiidiotypes beta and the remaining four are antiidiotypes gamma.

A novel analytical ELISA-based methodology for pharmacologically active saikosaponins.

A competitive enzyme-linked immunosorbent assay (ELISA) for saikosaponins was established using monoclonal antibody (MAb) 3G10. Hybridoma 3G10 prepared by fusing splenocytes immunized with saikosaponin a-BSA (SSa-BSA) conjugate and a hypoxanthine-aminopterin-thymidine (HAT)-sensitive mouse myeloma cell line, P3-X63-Ag8-U1, secreted monoclonal antibodies with wide cross-reactivity to saikosaponins including saikosaponin b(2) (SSb(2)), c (SSc) and d (SSd), which are stereo and/or regio isomers of SSa. The method, at an effective measuring range of 0.6 mug /ml to 2.3 mug/ml of SSa, successfully detected total saikosaponins in Bupleuri radix and Kampo medicines prescribed with Bupleuri radix. Good correlation between ELISA and HPLC analyses of total saikosaponin in a crude extract of Bupleuri radix was obtained after hydrolysis of acyl saikosaponins by treatment with a mild alkaline solution.

Lymphocytotoxic antibodies and histocompatibility antigens in juvenile-onset diabetes mellitus.

Cold-reacting serum lymphocytotoxic antibodies (LCAs) were measured in sera from 230 insulin-dependent juvenile-onset diabetes mellitus (IDDM) patients and from 116 control subjects. LCAs were present in only 4% of control sera compared with 19% in IDDM patients. The most significant determinant of LCAs was time since onset of diabetes; within the first 12 mo, 55% of IDDM sera had LCAs, compared with 25% after one year and 15% after five years of diabetes. LCAs were absent in sera from patients with IDDM for 10 yr or more. Genetic factors were also implicated in susceptibility toi occurrence of LCAs. HLA antigen B8 and B18 were associated with an increased risk for LCAs, whereas HLA-B7 was associated with a decreased risk. The relative risk for LCAs in patients positive for HLA-B8 but not B7 was 2.3, compared with 0.0 in HLA-B7/B8 heterozygotes. In contrast, B7 did not provide protection from LCAs in B18/B7 IDDM patients. Properdin factor B (Bf) alleles, which are in linkage disequilibrium with alleles of the HLA-B locus, were also associated with LCAs, IDDM patients with alleles BfS1 or BfF hd a prevalence of LCAs of 7%, significantly less than the 39% in Bf-F1S or -F1 patients. LCAs were not identical or closely correlated to pancreatic islet cell antibodies. Our findings indicate genetic heterogeneity in, yet, another autoimmune process in IDDM.

Presence and prognostic significance of antilymphocyte antibodies in symptomatic and asymptomatic human immunodeficiency virus infection.

The presence of antilymphocyte antibody (ALA) in patients with the acquired immunodeficiency syndrome (AIDS), identified in a previous study, was confirmed by testing a population of 200 patients with AIDS. Of these, 88% had significant levels of ALA vs only 8% of a control group of patients with non-AIDS-related diseases. In a prospective study, the levels of ALA were determined in 61 patients with AIDS-related complex who were followed up for 18 to 30 months. During this interval, 31 (67%) of 46 patients with significant elevation of ALA levels developed AIDS, while none of 15 patients without elevation of ALA levels progressed to AIDS. In a group of 85 apparently healthy homosexual men, also followed up for 18 to 30 months, a significant number of those with high levels of ALA developed clinically apparent disease, while those with low levels did not. These results show that the amount of ALA correlates with the present clinical status as well as the future risk of developing immune deficiency.

Antilymphocytic antibodies and marrow transplantation. VII. Two of nine monoclonal anti-Thy-1 antibodies used for pretreatment of donor marrow suppressed graft-versus-host reactions without added complement.

Eleven monoclonal antibodies of rat or mouse origin against the mouse pan T antigen Thy-1 were compared for their ability to reduce mortality from graft-versus-host disease (GVHD) when incubated with donor marrow. Spleen and bone marrow cells were transferred to F1 hybrids or to fully allogeneic (H-2 I-A incompatible) mice. Particular attention was paid to whether complement (rabbit) enhanced the anti-GVHD effect of the antibodies in homozygous histoincompatible chimeras: without complement, 5 IgM anti-Thy-1 and 2 IgG2a anti-Thy-1 did not reduce GVHD. With complement, acute GVHD was completely suppressed. Two of two rat IgG2b anti-Thy-1, however, suppressed acute GVHD without the need for added complement. One of the two also prevented chronic mortality following two haplotype-unmatched transplantation. This antibody, in contrast to other complement-fixing anti-Thy-1 antibodies, had previously been shown to delay rejection of skin allografts. Its specificity did not differ from other complement-dependent Thy-1 antibodies when tested in a cross-blocking radioimmunoassay, and it also had the lower affinity for Thy-1. It seems therefore that only a minority of the antibodies were able to fully exploit the marrow recipients' opsonizing capacity for suppression of GVHD. The important clinical implications of the remarkable difference in immunosuppression of various monoclonal antibodies with comparable specificity and capacity to fix complement in vitro are discussed.

Two monoclonal antibodies (DLy-1 and DLy-6) directed against canine lymphocytes.

Two murine monoclonal antibodies directed against canine lymphocytes are described. DLy-1, raised against puppy thymocytes, and DLy-6, raised against bronchoalveolar lymphocytes, both react with most lymphocytes in peripheral blood, thoracic duct lymph, and bronchoalveolar lavage fluids. DLy-1 also recognizes monocytes and granulocytes. However, it is not reactive with erythrocytes, megakaryocytes, or platelets. Expression of DLy-1 antigen on thymocytes ranged from 5--30%. The distribution of DLy-6 antigens seems to be confined to lymphoid cells. Ten to 60% puppy thymocytes were positive. Interestingly, lymphoblasts formed in response to stimulation with mitogens or alloantigens lacked DLy-6 in contrast to DLy-1 cell surface antigen expression.

Partial purification and characterization of a lymphotoxic factor from multiple sclerosis serum.

A factor found in the serums of some patients with multiple sclerosis has been shown to have a toxic effect on the normal, mature lymphocyte. This lymphotoxic factor is a protein that is stable to heating at 56 degrees C for 3 hours. It is a nondialyzable material, with recovery of lymphotoxic activity following 30 days of dialysis. Elution of lymphotoxic serum through Sepadex G-100 demonstrates toxic activity closely associated with albumin. Purification by elution through DEAE-cellulose yielded lymphotoxic activity. The lymphotoxic factor was inactivated by standard ammonium sulfate precipitation. Analysis of the effect on distinctive cell types within the total lymphocyte population demonstrated that the T lymphocyte was particularly sensitive.

Circulating immune complexes in multiple sclerosis: relation with disease activity.

Two hundred fifty-four MS patients were studied for circulating immune complexes (CIC) by three different assays: Raji-RIA, Clq-PEG, and Conglutinin-BA. Thirty-five percent of the sera were positive by one or more of these tests; Raji-RIA had the highest sensitivity (29.4%). Incidence of CIC in acute relapse, progressive, remission, and stable state of MS was 33.3%, 30.2%, 26.1%, and 23.1%, respectively, by Raji-RIA, compared with 7.75% and 8.82% among normal and neurologic controls. The incidence of CIC in neurologic controls differed significantly from both acute relapse and progressive disease, and almost significantly from patients in remission. There was no significant difference between patients with stable MS and neurologic controls, and there was no association of CIC with HLA-B7.

Lymphocytes in multiple sclerosis: correlation with CSF immunoglobulins and cold-reactive lymphocytotoxic antibodies.

Lymphocyte profiles were studied in patients with multiple sclerosis (MS) and normal controls. Apart from cold-reactive lymphocytotoxic antibodies (LCA), which were elevated in MS patients, there was no difference between MS patients and normal controls in terms of lymphocyte subpopulations, serum immunoglobulins, or responses to mitogens. There was no correlation between LCA and any of the immunologic characteristics measured. However, there was a correlation between immunoglobulin-bearing cells in the peripheral blood of MS patients and cerebrospinal fluid (CSF) levels of immunoglobulin and CSF viral antibodies. These results suggest that cold-reactive lymphocytotoxic antibodies do not affect lymphocyte function in patients with MS, that antigens stimulating "local" central nervous system (CNS) antibody production may be located outside the CNS and that locally produced CNS antibody may be made by immunoglobulin-bearing cells that migrate to the CSF from the periphery after exposure to antigen.

A rapid, objective method for the detection of lymphocytotoxic antibodies using flow cytometry.

Whilst several centres have reported lymphocytotoxic antibody detection using single and dual fluorescent stains with analysis of the fluorescence emitted from the cell population present in a well of a multiwell plate, problems are encountered with cell concentration and light emission overlap. A method we have developed using flow cytometry produces similar values of percentage cell death using single or double staining techniques (correlation coefficient = 0.9896). This method is not influenced by slight variation in cell number or light emission overlap. The effect of introducing red cell impurities into the normal lymphocyte preparation is described.

Assessment of anti-HLA antibodies in sera being tested for platelet reactivity by a platelet lymphocyte immunofluorescence test (PLIFT).

An indirect immunofluorescence test using a platelet mononuclear cell suspension is described. The test is a simple and sensitive method to assess the contamination by anti-HLA antibodies of sera being tested for platelet reactivity and eliminates the need to support two independent test systems such as lymphocytotoxicity and immunofluorescence testing. The test could be of value in routine platelet serology testing and platelet crossmatching.

Further improvement of dye-exclusion microcytotoxicity assay by introducing low melting point agarose into the medium.

We developed an improved method for the dye-exclusion microcytotoxicity test by introducing low melting point agarose (LMP-Aga) into the assay medium. The procedures in our method are made very feasible by such noble characteristics of LMP-Aga that once solubilized, the sol state is retained at 37 degrees C, while once gelated, the gelated state is retained even at 37 degrees C. The most important advantage of our method is that even distribution, without any accumulation, of the target cells on the bottom surface of the test wells and no dislodgement of the target cells from the wells by mechanical force inflicted during the assay, enable us to observe the target cells precisely and to obtain an accurate percentage of dead target cells. Another advantage of the present method is that in complement-mediated cytotoxicity tests, it is possible to use unabsorbed normal serum as complement source because naturally occurring cytotoxicity in normal serum is completely removed during the diffusion into the LMP-Aga medium. Thus it should be concluded that our method is excellent in all respects, e.g., accuracy and reproducibility in the results of the test, and feasibility of the procedures.

Quantitation of cytotoxic rat antibodies by post-assay labeling of mitogen-induced target blasts with [3H]thymidine.

Cytotoxic rat alloantibodies were quantitated using concanavalin-A induced blasts as target cells. [3H]thymidine incorporation by such cells was linearly related to their number. Serial dilutions of cytotoxic antisera were incubated with a small number of target cells in presence of rabbit, guinea pig or rat complement. Following a short incubation, cultures were pulsed with [3H]thymidine to estimate the number of live cells. Cytotoxicity titers were calculated according to conventional von Krogh analysis as the reciprocal of the dilution yielding 50% lysis. Such titers were virtually identical to titers obtained in assays in which the extent of cytolysis was determined by trypan blue or ethidium bromide exclusion. The assay, which is carried out in microtiter plates, is quantitative, economical, and objective. Furthermore, automatic harvesting of the cultures allows the rapid processing of large numbers of samples.