Relationship between HL-A antigens and beta-2-microglobulin as studied by immunofluorescence on the lymphocyte membrane.

The antibody-induced redistribution of beta2-microglobulin (beta2-micro) and HL-A antigens on the surface of living lymphocytes was studied by immunofluorescence. When all beta2-micro was redistributed on the lymphocyte membrane by specific rabbit antibodies and goat antirabbit Ig conjugates, the HL-A antigens were no more detectable with anti-HL-A conjugates outside the beta2-micro caps already formed. However, the redistribution of HL-A antigens fails to provoke the redistribution of all detectable beta2-micro molecules. These results suggest that HL-A antigens may be associated with beta2-micro at the cell surface, but that all beta2-micro molecules are not bound to HL-A antigens.

Reinfection of liver graft by hepatitis C virus after liver transplantation.

We have investigated hepatitis C virus (HCV) viremia before and after orthotopic liver transplantation (OLT). 38 patients were examined; 16 were anti-HCV positive and 22 anti-HCV negative pre-OLT in a RIBA-2 test (Ortho Diagnostic Systems Inc., Westwood, MA). HCV-RNA was detected using a modified nested polymerase chain reaction in 14/38 and 10/38 patients before and after OLT, respectively. 7 of these 14 subjects who were HCV-RNA positive before OLT were also positive for serum hepatitis B surface antigen. After OLT, six patients became HCV-RNA positive, likely as a result of transfusions, while four developed a probable recurrence of HCV infection. Infection of the liver graft by the same strain of HCV was indeed demonstrated by sequence analysis of a hypervariable domain (in the envelope region) in two cases. This establishes the possibility of HCV recurrence and shows the usefulness of polymerase chain reaction as the only assay currently capable of identifying HCV infection after OLT.

The use of ABO-incompatible grafts in liver transplantation: a life-saving procedure in highly selected patients.

The aim of this study was to assess the long term results of 43 ABO-incompatible liver transplantations performed in 40 patients. The 5-year patient and graft survival rates were 50 and 20%, respectively. In the group of patients transplanted in emergency for fulminant or subfulminant liver failure, ABO incompatibility had no significant impact on patient survival (P = 0.09). Graft survival, however, was significantly impaired (P = 0.0002) through a greater incidence of hyperacute rejection (20%), vascular thrombosis, and biliary injury (56%). Increasing the magnitude of immunosuppression and postoperatively reducing the titer of anti A/B antibodies by plasmapheresis had little influence on the incidence of these complications and were associated with a greater incidence of septic complications. These results indicate that the use of ABO-incompatible liver grafts is a life-saving procedure in patients with life-threatening acute liver failure, but at a high price. Justification for accepting or not accepting an ABO-incompatible graft in these emergency situations depends on the personal choice in giving priority to saving the patient in an acute life-threatening condition or to giving the graft the best chance of success. To avoid this difficult choice, efforts should aim at expanding the pool of grafts available in emergency, at developing artificial support devices that could allow to safely delay transplantation, or at more efficiently controlling the humoral response.

Persistent hepatitis B virus infection of mononuclear blood cells without concomitant liver infection. The liver transplantation model.

We have investigated the recurrence of Hepatitis B virus (HBV) in 30 patients treated by orthotopic liver transplantation and given high doses of anti-HBs immunoglobulin. The polymerase chain reaction (PCR) assay showed no evidence of HBV DNA sequences in the liver of 23/24 patients who remained serum HBsAg-negative during a mean follow-up of 13 months (2-24 months) after OLT. However, the liver scored positive in all the 6 individuals in whom HBsAG reappeared. The PCR assay identified HBV DNA sequences in the peripheral blood mononuclear cells of 7 of 11 subjects who were serum HBsAG-negative and liver HBV DNA-negative by PCR. Therefore, this application of the sensitive PCR assay demonstrates persistent infection of PBMC in the absence of liver HBV--thus OLT provides a model for studying the interaction between HBV, PBMC, and the liver.

How to deal with the hyperimmunized potential recipients.

End-stage renal disease (ESRD) patients with high levels of anti-HLA panel reactive antibodies (PRA) represent an increasing group in which sensitization, induced by pregnancies, previous transplants, and blood transfusions, considerably delay the opportunity to receive a graft. Currently, more than 50% of the 4700 patients awaiting transplantation in France are sensitized, of which 33% are defined as hyperimmunized (PRA greater than = 80%), and only 9.5% of the total number of transplants have been done in highly sensitized recipients. The magnitude of this problem, similar in Europe and North America, explains why more active strategies for managing hyperimmunized patients have been introduced during the past decade. Clearly, the simplest is finding of a well-matched organ that does not carry the HLA antigens against which the recipient has generated antibody, but that is limited by the number of shared grafts. The second is the development of a new cross-matching technique prior to transplantation. Attempts at immunoregulation of secreting B cell clones have been carried out using either hypertransfusions or injection of polyclonal Ig. Finally, removal and prevention of the resynthesis of HLA antibodies is a most attractive approach using immunoadsorption (IA) system with sepharose-bound protein-A columns. In our unit, fifteen ESRD patients with high levels of PRA were treated with IA. Infectious complications were not observed after IA and transplantation, and the procedure was well tolerated. In spite of the use of adjunctive immunosuppressive treatment with cyclophosphamide and prednisolone, this method produced only variable effects in lowering PRA levels, and was hampered by high de novo resynthesis of anti-HLA antibodies.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful management of a patient with an acquired factor VIII inhibitor.

An otherwise healthy 42-year-old man had hematuria and hematomas in both legs associated with a spontaneous inhibitor to factor VIII. The patient was treated with repeated plasma exchange, factor VIII concentrates, and steroids. Rapid clinical improvement with rapid recovery of circulating factor VIII occurred. Disappearance of the inhibitor was observed within 1 month. The patient remains well with no evidence of an inhibitor. It is unlikely that steroids were responsible for the disappearance of the inhibitor. Therefore, plasma exchange associated with factor VIII concentrate administration may be considered an effective tool for the management of patients with spontaneous idiopathic inhibitor to factor VIII.

[Approach to cochleovestibular tolerability of aminoglycosides in man. Demonstration of a methodology apropos of a controlled comparative trial of dibekacin versus gentamicin]. / Abord de la tolérance cochléo-vestibulaire des aminosides chez l'homme. Mise au point d'une méthodologie à propos d'un essai contrôlé comparatif dibékacine versus gentamicine.

A controlled trial comparing the effects of dibekacin and gentamicin in 30 patients has enabled us to standardise the most commonly used vestibulocochlear tests. None of the patients treated with dibekacin showed any auditory disturbance. The only abnormality detected was on vocal audiometry in 7 patients treated with gentamicin. Could vocal audiometry be the first paraclinical test capable of detecting aminoglycoside ototoxicity?

[Immunoadsorption of anti-HLA antibodies on protein A-sepharose columns in hyperimmunized recipients waiting for transplantation]. / Immunoadsorption d'anticorps anti-HLA chez les receveurs hyperimmunisés en attente de transplantation sur colonnes de protéine A-sépharose.

In an attempt to reduce anti-HLA immunization in 15 patients awaiting for renal grafts and who were immunized against 65% of a panel of lymphocytes (titre 1/8 to 1/128), were given 5 to 7 sessions of immunoadsorption on protein A columns, immunosuppressor drugs (corticosteroids: 1 mg/kg/day + cyclophosphamid: 2 mg/kg/day) and intravenous polyclonal immunoglobulins. The antibody titres decreased in all patients, but this protocol did not sufficiently block resynthesis of antibodies. Among the 12 patients who were transplanted, the graft functioned correctly in 8 after a follow-up of 3 months to 3 years. Three early graft failures occurred in the group of 5 patients whose had had a positive cross-match before treatment. This treatment did not appear to increase the frequency of infectious complications immediately after transplantation.

Immunoadsorption of anti-HLA antibodies for highly sensitized patients awaiting renal transplantation.

Fifteen end-stage renal disease patients with high titres of panel reactive (PRA) antibodies were treated with immunoadsorption (IA) on sepharose-bound protein A columns in order to remove anti-HLA antibodies and facilitate transplantation. Infectious complications were not observed after IA and transplantation, and the procedure was well tolerated. In spite of the use of adjunctive immunosuppressive treatment with cyclophosphamide and prednisolone, this method produced only variable effects in lowering panel reaction antibodies, and was hampered by high de novo resynthesis of anti-HLA antibodies. Patients whose pre-IA antibody titre was greater than or equal to 1:64 clearly did not benefit from the procedure, but other immunological criteria were not predictive of efficacy. Twelve patients were transplanted on the basis of a negative cross-match with current serum, historical sera being retrospectively tested. Surprisingly, seven patients received a well-matched graft with both pre- and post-IA negative cross-matching. Graft survival was 86% in this group. Conversely, in the group of five transplants which were performed in recipients having a positive historical cross-match with the donor, graft survival was only 40%. One patient died with a functional graft, and two grafts failed due to hyperacute humoral rejection. Humoral rejection in a third patient was successfully treated by a second IA course and administration of polyclonal IgG. We conclude that IA is a safe procedure for managing hyperimmunized transplant candidates. However, its efficacy remains variable, and a better definition of patients who should benefit from IA needs to be found.

Genetic control of sensitivity to Moloney leukemia virus in mice. III. The three H-2 linked Rmv genes are immune response genes controlling the antiviral antibody response.

It has been shown previously that three different H-2-associated genes control the resistance to viremia and leukemia in Moloney virus-infected mice: Rmv. 1, mapping to the I-A or less probably K regions; Rmv. 2, mapping to the I-C, S or G regions and Rmv. 3, mapping to the D or T regions. Experiments have been performed to determine the role of these genes in the control of the antibody responses directed against Moloney murine leukemia virus (M. MuLV) virions and/or leukemic cells. The inoculation of infectious M.MuLV failed to provide conclusive responses due to unequal replication of the virus in different inbred strains resulting in variable antigenic stimulations and/or in vivo antibody absorptions. The use of inactivated M.MuLV as antigen allowed to avoid these problems. It showed that (2) the IgG-specific antiM.MuLV response is controlled by H-2 linked genes, (b) a clear correlation exists between high or low-responder phenotypes and the resistance or susceptibility to M.MuLV infection and (c) all three Rmv genes behave like immune response genes. These results were not surprising for Rmv. 1 and Rmv. 2 which map in the I region of the major histocompatibility complex. It was more puzzling for Rmv. 3. Further experiments are necessary to determine the exact mechanism by which this gene controls the immune response.

Incidence of rejection and infection after liver transplantation as a function of the primary disease: possible influence of alcohol and polyclonal immunoglobulins.

A retrospective analysis was undertaken to determine if the incidence, timing, and severity of acute and chronic rejection were influenced by the primary disease necessitating transplantation. Of the 875 liver transplantations performed between 1984 and 1992, 768 were primary transplantations and 107 were retransplantations. Among the former, 330 patients that were liver transplant recipients for a chronic liver disease without cancer in the native liver received an ABO-compatible and cross-match-negative graft and were given a cyclosporine- or tacrolimus-based immunosuppression. These included primary biliary cirrhosis (PBC, 66 patients), primary sclerosing cholangitis (PSC, 23 patients), alcoholic cirrhosis (ALC, 21 patients), autoimmune cirrhosis (AIC, 17 patients), hepatitis B virus-induced cirrhosis (HBV-C, 116 patients) and hepatitis C virus-induced cirrhosis (HCV-C, 87 patients). The incidence of acute (48% +/- 3% [SE] at 1 year) and chronic rejection (10% +/- 2% at 3 years) was comparable in patients who have undergone transplantation for PBC, PSC, AIC, and HCV-C. However, the incidence of acute (but not chronic) rejection was significantly lower in patients who have undergone transplantation for ALC (29% at 1 year). This reduced incidence of acute rejection was associated with an increased incidence of bacterial infections. In patients who have undergone transplantation for HBV-C (the majority of whom had received long-term anti-hepatitis B surface antigen [HBs] immunoglobulins), the incidence of both acute (21% at 1 year) and chronic rejection (0% at 3 years) was significantly lower, whereas the incidence of septic complications was comparable with that in the other groups. The incidence of acute rejection in patients who have undergone transplantation for nonviral disease receiving polyclonal human anti-cytomegalovirus (CMV) immunoglobulins was also significantly lower than that of patients who did not receive the immunoglobulins (19% vs. 48% at 3 months; P = .01), and this was identical to that of patients who have undergone transplantation for viral disease receiving polyclonal human anti-HBs immunoglobulins (19% at 3 months). These results show that the risk of rejection is unequal among patients, being lower in patients who have undergone transplantation for ALC (probably as a result of a state of nonspecific hyporesponsiveness) and in patients who have undergone transplantation for HBV-C (possibly as a result of long-term administration of polyclonal human immunoglobulins).

Incidence of hepatitis C in patients receiving different preparations of hepatitis B immunoglobulins after liver transplantation.

BACKGROUND: Recurrence of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection after liver transplantation is a clinical problem. Polyclonal immunoglobulins against hepatitis B surface antigen (HBIGs) prevent the recurrence of HBV infection, but no effective prophylaxis is available for HCV infection. Before screening of blood donors was introduced in France, HBIGs may have contained antibody to HCV (anti-HCV). OBJECTIVE: To determine the influence of HBIG on the occurrence of hepatitis C after liver transplantation before and after 1990. DESIGN: Retrospective cohort study. SETTING: Liver transplantation unit of a university hospital. PATIENTS: 428 consecutive patients who had liver transplantation because of cirrhosis between 1984 and 1994. MEASUREMENTS: Detection of serum HCV RNA before and 1 year after transplantation and findings on liver graft biopsy. RESULTS: Among the 218 patients who had HCV infection before transplantation, the incidence of HCV viremia after transplantation was lower in those receiving HBIG than in those not receiving HBIG (25 of 46 patients [54%] compared with 162 of 172 patients [94%]; P < 0.001). In patients receiving HBIG, the incidence of HCV viremia after transplantation was lower among those who had transplantation before March 1990 than among those who had transplantation after this date (15 of 33 patients [45%] compared with 10 of 13 patients [77%]; P = 0.05). Among the 210 patients without HCV infection before transplantation, acquired infection was significantly less frequent in those receiving HBIG than in those not receiving HBIG (18 of 68 patients [26%] compared with 40 of 86 patients [47%]; P < 0.001). Passively transmitted anti-HCV was transiently detected in patients receiving HBIG before March 1990. Multivariate analysis in patients with HCV infection before transplantation showed that the absence of HBIG and transplantation after March 1990 were independent significant risk factors for chronic hepatitis C after transplantation. CONCLUSIONS: Polyclonal immunoglobulins that are treated for viral decontamination and contain anti-HCV could prevent HCV infection.

Passive immunoprophylaxis after liver transplantation in HBsAg-positive patients.

110 HBsAg-positive patients underwent orthotopic liver transplantation and received long-term anti-hepatitis B virus (HBV) passive immunoprophylaxis with anti-HBs immunoglobulin. During a mean follow-up period of 20 months, all patients became HBsAg negative after transplantation but circulating HBsAg reappeared in 25 (22.7%). Overall 1-year survival was 83.6% and overall 2 year actuarial recurrence of HBsAg was 29% (59% after posthepatitis B cirrhosis, 13% after posthepatitis B-delta cirrhosis, and 0% after fulminant hepatitis B). Patients with HBV cirrhosis who were HBV-DNA positive had a much greater risk of HBsAg recurrence than patients who were HBV-DNA negative (96% vs 29% at 2 years). Reappearance of HBsAg was associated with evidence of HBV replication and abnormal histological findings in the graft. Long-term passive anti-HBV immunoprophylaxis significantly reduced HBV reinfection and improved survival in patients without evidence of active HBV replication before orthotopic liver transplantation.