Acute destruction by humoral antibody of rat skin grafted to mice.

A study has been made of the roles played by complement and polymorphonuclear leukocytes (PMN) in the acute destruction of xenografts of rat skin that follows injection of their hosts with antisera specifically reactive with graft antigens. The rat skin was grafted onto mice whose immune responses were suppressed by removal of the thymus and a brief course of treatment with rabbit antimouse lymphocyte serum. At about 2 wk after grafting the mice were injected intravenously or intraperitoneally with mouse antirat serum (MARS). This time interval was chosen because it avoided the complications that might be associated with either the process of healing in or with incipient rejection. Signs of graft damage were evident as early as 10 min after the injection of MARS, and in most animals so injected the grafts were completely destroyed within 24-48 h. The role of complement (C) in this acute destructive process is indicated by the results of three lines of experimentation. (a) Non-C-fixing antibodies or antibody fragments failed to cause damage to the grafts. Indeed, both chicken antirat serum and F(ab')(2) fragments from rabbit antirat serum completely protected the grafts against the effects of MARS that was administered 24 h later. (b) When mice were depleted of hemolytic C by treatment with cobra venom factor or heat-aggregated gamma globulin, the damage caused by MARS was greatly reduced or completely inhibited. (c) In mice with a genetically determined absence of C5 much greater quantities of MARS were required to cause graft damage; the tempo of the destructive process was consistently slower; and a greater number of grafts recovered from the initial inflammatory process than was the case for animals with an intact complement system. The participation of PMN in serum-mediated destruction of grafts was initially suggested by the results of microscope examination of fixed tissues. The essential role of these cells in the process is indicated by the failure of MARS to cause tissue damage in mice whose circulating PMN have been reduced to very low levels by treatment with nitrogen mustard or more specifically with an anti-PMN serum. The absence of tissue damage when circulating PMN are reduced but C levels are normal suggests that C-mediated cytolysis is unimportant in graft destruction and that the role of C lies in its ability to generate chemotactic factors. The latter may then attract the PMN that provide mediators of tissue damage.

Flow cytometric analysis of urine lymphocytes isolated from patients with renal transplants--purification of urine lymphocytes.

Early diagnosis of rejection is a pivotal problem in renal transplantation. Recent advances in urinary cell analysis using flow cytometry are still burdened with difficulties concerning urine lymphocyte (UL) isolation. The analysis of lymphocytes washed out with the urine from the kidney transplant offers a tool to monitor noninvasively the intragraft immune response. However, the demand for optimal isolation of UL with high viability and good separation of other cell types has not, as yet, been met. The present study was undertaken to evaluate the optimal conditions for harvesting UL in order to perform adequate UL analysis by flow cytometry. We found that UL viability is mainly dependent on the time of urine harvesting. Low UL viability was caused by high urine osmolality due to high concentrations of urea and glucose. In contrast, high protein concentrations protected UL viability. Hence, the following algorithm of adequate UL isolation for flow cytometric analysis was established: (1) Collection of morning urine directly onto foetal calf serum (FCS: 30% v/v): (2) UL isolation within 2 h; (3) Erythrocyte lysis with subsequent two-step density gradient isolation of UL from residual erythrocytes, granulocytes (Ficoll-Isopaque, 1.077 g/cm3) and from uroepithelial cells (30% methylglucamine 3,5-diacetomido-2,4,6-triiodobenzoicum, 1.085 g/cmn3); (4) Flow cytometric analysis of UL using the 'live gate' setting in the area of blood lymphocyte cluster. Adequate UL isolation and special settings of the flow cytometer may provide a useful tool for early diagnosis and the noninvasive monitoring of renal transplant rejection.

Limited T-cell repertoire in renal allograft and allogeneic melanoma transmitted by the graft.

In a patient with metastatic melanoma transmitted by the renal allograft, HLA serves as an alloantigen per se and is associated with tumor antigens at the same time. The influence of this antigeneic pattern on the Vbeta T-cell repertoire in an allogeneic melanoma, allograft, and peripheral blood mononuclear cells (PBMC) was assessed by polymerase chain reaction. Vbeta13.1 and 19 were found in both the melanoma and the graft. Vbeta14 was detected only in the melanoma and Vbeta6 was detected only in the kidney. PBMC revealed an unrestricted Vbeta pattern. Markers for cytotoxic activity of T cells--granzyme B and perforin--were not expressed during immunosuppressive therapy as clinically reflected in a nonrejecting allograft and in a progressing melanoma. In vitro PBMC proliferated to recombinant interleukin-2, whereas recombinant interferon-gamma did not augment this response. Initiation of immune therapy, in addition to discontinuation of immunosuppression, might support the rejection of the allogeneic tumor by dominant Vbeta T cells.

Genetic regulation of the impaired immune response to hepatitis-B vaccine associated with low TCR density in end stage renal disease patients: contribution of complement C4 and factor B alleles.

We have studied the relationship between T-cell receptor (TCR) density, genetic factors and the specific immune response in 153 end stage renal disease (ESRD) patients on haemodialysis immunised with HBsAg vaccine. One-hundred and nineteen patients raised a protective (> 10 U/ml) antibody response to hepatitis-B vaccination (responder, R), while 34 patients were found to be non-responders (NR). The density of the T-cell receptors was determined by flow cytometry. Proliferation of the T-cells induced by autologous monocytes presenting HBsAg was also measured and expressed as a stimulation index (SI). MHC class I, II and III alleles of the patients were also determined. The densities of TCR/CD3 receptors in NR patients were found to be significantly decreased as compared to the R patients (189 +/- 22 vs. 282 +/- 58 arbitrary units, P = 1.3 x 10(-7). TCR/CD3 receptor densities were found to be strongly associated (Spearman correlation coefficient: 0.84, P < 0.000001) with the SI values. Both parameters were found to be under dual genetic control: (a) very low density of the TCR/CD3 receptors and very low SI were found mainly in NR patients carrying HLA-A1, HLA-B8 and HLA-DR3 alleles; and (b) TCR/CD3 densities and function in R group were found to be significantly lower in carriers than in non-carriers of two MHC class III complement protein alleles: C4A*6, and Bf*F. Non-responsiveness to hepatitis-B vaccination was found to be associated with extremely increased neopterin levels. These findings indicate that both genetic and acquired factors contribute to the hepatitis-B vaccination failure in ESRD patients.

Failure of radiotherapy to resolve fatal lung damage due to paraquat poisoning.

The most effective treatment of severe paraquat poisoning in man is uncertain. In order to prevent pulmonary fibrosis, we employed radiotherapy of both lungs in a 23-year-old patient with severe paraquat poisoning; however, it failed to prevent the fatal outcome.

Pharmacokinetics of omega-3-fatty acids during ingestion of fish oil preparations.

An in vivo comparison of three dosages (3 g, 6 g, 12 g) of two different fish oil preparations in terms of plasma concentrations of their major active components eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) was performed. The plasma accumulation was measured during 28 days of ingestion and an equally long wash out period. Data were scrutinized for bioavailability in order to distinguish between the efficiency of the two preparations. Rapid increases in EPA and DHA plasma concentrations can be demonstrated at all dosages during a 28-day ingestion period. EPA accumulated more during ingestion of high than of low dosages of fish oil. DHA revealed almost identical increases and peak values in plasma concentrations in all subgroups. The present data demonstrate dose dependent increases of EPA concentrations whereas DHA plasma concentrations are comparable in all dosages investigated. Measurable EPA and DHA plasma concentration levels are inappropriate means to explain clinical effectiveness. These results were found in both commercially available fish oil preparations. Direct comparison of both preparations revealed no differences in bioavailability.

Early diagnosis and successful treatment of acute cytomegalovirus encephalitis in a renal transplant recipient.

We report the case of a 40-year-old male HIV-negative renal transplant patient with allograft rejection and immunosuppressive therapy who presented with acute cytomegalovirus (CMV) encephalitis. CT and MRI of the brain were normal but EEG showed diffuse slowing and dysrhythmia. In cerebrospinal fluid (CSF) initially 81 cells/microliters were found and immunocytochemistry showed a decreased CD4/CD8 ratio and increased values of activated lymphocytes, natural killer cells and immunoglobulin-containing cells. CMV-specific IgM antibodies in CSF and serum, immunostaining of CMV antigen in CSF cells and virus culture from CSF and urine were negative. During the first 3 weeks of illness no intrathecal production of immunoglobulins could be detected. Early diagnosis of CMV encephalitis was made by in situ hybridization (ISH) on CSF cell preparations and the polymerase chain reaction (PCR) which was positive in CSF and blood. On day 26 diagnosis was confirmed by detection of CMV-specific intrathecal IgG production. The patient was treated with ganciclovir, anti-CMV immunoglobulins and intrathecal beta interferon. He recovered completely after 2 months. Our data demonstrate the usefulness of ISH and PCR in the early diagnosis of CMV encephalitis and perhaps may encourage the use of intrathecal beta interferon in other patients with this disease.

Cyclosporin A induces prepro endothelin-1 gene transcription in human endothelial cells.

Cyclosporin A employed in treatment of organ allograft rejection, is associated with hypertension possibly due to endothelin-1. We studied transcriptional regulation of endothelin-1 by cyclosporin A in human endothelial cells using cell transfection experiments and reporter gene assays. Human umbilical vein endothelial cells were established expressing a fusion gene of the coding sequence of the firefly luciferase gene, placed under the control of the rat endothelin-1 promoter. Luciferase assays demonstrate 2.8-fold stimulation of the reporter gene by cyclosporin A (P < 0.01), and Northern blot analysis shows induction of prepro endothelin-1 mRNA. Transcription is tightly repressed in the absence of the immunosuppressant, its regulation occurs Ca(2+)-dependent. Lack of extra- or intracellular Ca2+ prevents cyclosporin A-dependent endothelin-1 gene transcription and mRNA induction. These data demonstrate transcriptional regulation of endothelin-1 over a range of several orders of magnitude in human umbilical vein endothelial cells by cyclosporin A via Ca(2+)-dependent mechanisms. They support the critical role of endothelin- in cyclosporin A-associated hypertension.

Differential transcriptional regulation of endothelin-1 by immunosuppressants FK506 and cyclosporin A.

Calcineurin antagonists FK506 and CsA, administered to treat organ allograft rejection, exert specific effects on renal vasoconstriction and nephrotoxicity, possibly due to endogenous vasoconstrictor release such as ET-1. We investigated contribution of FK506 and CsA on regulation of prepro ET-1 gene transcription in HUVEC. To conclude on transcriptional regulation, ET-1 mRNA levels were quantified by Northern blot analysis upon stimulation with calcineurin antagonists, and newly transcribed luciferase gene, placed under the control of the rat ET-1 promoter, was quantified by reporter gene assays, where luciferase activity reflects ET-1 promoter activation. Calcium fluorometry was employed to examine calcium dependency of ET-1 promoter-dependent gene transcription. Northern blot analysis shows differential induction of prepro ET-1 mRNA in favour of CsA over FK506. Likewise, luciferase assays demonstrate stronger ET-1 promoter-dependent stimulation of the reporter gene by CsA than by FK506. Transcription of prepro ET-1 gene upon stimulation with both calcineurin antagonists is regulated by intracellular calcium levels. Lack of extra- or intracellular calcium prevents ET-1 promoter-dependent gene transcription and ET-1 mRNA induction. These observations demonstrate that calcineurin antagonists FK506 and CsA differ in quality to induce transcription of prepro ET-1 in HUVEC via calcium-dependent nuclear signalling events. To examine the contribution of ET-1 in nephrotoxicity upon CsA and FK506 immunosuppression the availability of endothelin receptor antagonists or endothelin converting enzyme inhibitors is required.

Evidence-based medical quality management in dialysis--Part I: Routine implementation of QiN, a German quality management system.

Increasing medical complexity, centrifugal forces of medical subspecialization and growing economic constraints are the key reasons for the introduction of quality management into routine care processes such as dialysis. Adequate quality assurance and improvement must be implemented in order to supply medical staff, care providers, and patients with the necessary information on critical issues of clinical management of dialysis patients. QiN (Quality in Nephrology), the quality management program of the largest German dialysis provider, is outlined here as a practicable example. The first of 2 parts provides information on the structure, implementation of QiN and achieved clinical improvement in routine care. The second part (quotation) analyzes longitudinal data in order to differentiate whether observed improvements during more than 5 years of QiN can be ascribed to the intervention (application of QiN) or whether they are due to other factors such as generally improved medical knowledge.

Enalapril and losartan augment endogenous nitric oxide release in Takayasu's arteritis--a case report.

Prognosis in Takayasu's arteritis is limited owing to renovascular hypertension. The authors report a patient with Takayasu's arteritis who had been unilaterally nephrectomized and presented with malignant hypertension due to renal artery stenosis. Hypertension was refractory to conventional antihypertensive treatment, and stenosis was not accessible by interventional angioplasty. Initiation of enalapril and losartan therapy was successful in improving blood pressure without deterioration of renal function due to ischemic failure. Antihypertensive treatment resulted in dramatically stimulated endogenous nitric oxide (NO) synthesis, while elevated plasma endothelin-1 levels were unchanged. Renovascular hypertension in Takayasu's arteritis is associated with an imbalance of vasoconstrictor peptide endothelin-1 and vasodilator peptide NO. Successful treatment of hypertension by enalapril or losartan results in improved endogenous NO synthesis, which putatively counterbalances excessive vasoconstrictor actions and may retard the progression of renal failure.

Hemodialysis/hemofiltration: a report of a controlled cross-over study.

In 14 stable ESRD patients an ABA cross-over study comparing conventional hemodialysis with post-dilution hemofiltration was performed in order to test the validity of clinical benefits reported for hemofiltration. No effect on blood-pressure could be observed in hypertensive hemofiltration patients when body weight was kept constant. The claimed positive effect of hemofiltration on hyperphosphatemia in dialysis patients could not be confirmed. A treatment with 3x81 I infusate per week seems to be insufficient treatment in regard to small molecule removal especially in heavy patients without any residual renal function. The decrease in urea nitrogen generation rate during the hemofiltration period might be the result of the lower small molecule removal in hemofiltration when compared to hemodialysis. The main clinical benefit of hemofiltration results from improved tolerance to volume removal due to improved hemodynamic stability during treatment.

Correlation of beta-2-microglobulin concentration changes to changes of distribution volume.

Plasma and ultrafiltrate beta-2-microglobulin (B2M) concentrations were determined during hemofiltration (HF) and hemodialysis (HD) in order to evaluate elimination kinetics of B2M. Calculations were done on the basis of plasma-water-concentrations (PWC). Elimination of B2M during HF follows first order kinetics (r = 0.97) and the volume of B2M distribution was calculated to be 17 +/- 2% of body weight. This reflects extracellular volume (ECV). Changes of ECV in HD were induced by weight loss and further provoked by fluid shifts from intra- to extracellular volume and vice versa induced by varying dialysate sodium concentration. These ECV changes were followed by determining inuline in plasma and total dialysate. Changes of B2M concentration correlate well to changes of ECV (r = 0.98). Thus intratreatment concentration changes of B2M in cuprophane dialysis reflect simultaneous changes of B2M distribution volume. This does not exclude the possibility of B2M generation stimulated by dialysis, but proving such effects in vivo will be difficult because of multiple variants, that must be controlled.

Hemodynamics in hemofiltration.

To study the established but not well understood phenomenon of improved intratreatment vascular stability during hemofiltration the same 10 stable hemodialysis patients were investigated during one hemodialysis and one hemofiltration treatment. Both treatments were matched in regard to linear fluid withdrawal (3 kg/240 minutes), small molecule removal rate (Curea 120 ml/min). Sodium (140 meq/l) and acetate (35 meq/l) concentration in dialysate and replacement fluid were identical. Outcome measures included mean arterial blood pressure, total peripheral vascular resistance by thermodilution, plasma noradrenaline concentration as index of sympathetic activity and sodium loss per treatment. Blood pressure was maintained during hemofiltration, while total peripheral vascular resistance and plasma noradrenaline concentrations increased. During hemodialysis mean arterial blood pressure fell significantly, total peripheral resistance and plasma noradrenaline concentrations remained unchanged. During both treatment modalities sodium loss was comparable. It is concluded, that the improved hemodynamic stability during hemofiltration is due to a maintained physiologic response to ultrafiltration, which is impaired during hemodialysis. Vascular stability during hemofiltration is not due to sodium retention relative to hemodialysis.

[Immunologic, alloantigen-dependent factors in chronic graft rejection]. / Immunologische, alloantigenabhängige Faktoren in der chronischen Transplantatabstossung.

BACKGROUND: The pathogenesis of chronic renal allograft rejection is still speculative. Amongst other factors immune-mediated graft injury is proposed. Since the allo-antigen is specifically recognized by the variable (V) alpha and beta chains of the T-cell receptor, a restricted T-cell repertoire might support the notion of allo-antigen involvement in chronic rejection. METHODS: By the means of semiquantitative polymerase chain reaction the V beta families 1-20 were assessed in allograft biopsies with histologically confirmed chronic and acute rejection. At the same time the V beta repertoire was analyzed in PBMC. RESULT: The intragraft V beta repertoire was limited to 1 to 3 dominant V beta families in chronic and acute rejection. The response was highly individual and did not correlate to the type or degree of HLA mismatches. The T-cell repertoire in PBMC was polyclonal and did not reflect the immune response in the graft. CONCLUSION: The finding of a restricted V beta repertoire in both forms of rejection might indicate an immunological basis not only for acute, but also for ongoing chronic rejection. Tailor-made antibodies against the dominant V beta clones might provide a tool for selective immunosuppression in both entities of rejection targeting only those T cells which were activated by allo-antigens.

[Resistance to therapy in primary nephrotic syndrome: effect of MDR1 gene activity]. / Odpornosc na leczenie w przebiegu pierwotnego zespolu nerczycowego: wplyw aktywnosci genu MDR1.

MDR1 gene encodes for a transmembranous glycoprotein, gp-170, which acts as a drug export pump and is also a cyclosporine(CsA)-binding protein. This study aimed at evaluating MDR1 expression in NS sensitive(S) and resistant(R) to therapy (steroids/S/, cyclophosphamide/C/, CsA) patients. Twenty six boys, 13 girls aged 3-8 years were included to the study. MDR1 was analysed using: 1) evaluation of gp-170 activity according to DiC2/3/ [3,3-Diethyloxa-carbocyanine Iodide] by means of flow cytometry and as 2) mRNA expression of MDR1 determined by RT-PCR. The analysis was performed in the lymphocyte subset CD4/CD45RA presenting suppressor-inducer activity. Negative control, Jurkat-T-cell line, not expressing the MDR1 phenotype, was transfected with viral expression vector containing a full-length cDNA for the human MDR1 gene. We found that: in SR-NS the high expression of MDR1 was associated mainly with the suppressor-inducer T-cells (CD45RA+CD4+) and was subsequently enhanced during an ineffective treatment with C and/or CsA. C-R-NS and CsA-R-NS were partially reversible by S- and R-Verapamil; this was in vitro confirmed by inhibition of export pump activity, gp-170. SS-NS, C-S-NS and CsA-S-NS presented the low expression and activity of MDR1 comparing to R-children (p < 0.001) and healthy controls (p < 0.00001). Resistance to therapy in NS patients seems to be resulted from the enhanced expression of MDR1 gene and subsequent high activity of export pump P-gp-170. Calcium channel blockers may reverse the MRD1-related resistance in the therapy of NS. Analysis of MDR1 may help to detect of suspected therapy resistance in NS.

[Reactivity to hepatitis B vaccination (HBV) in patients with uremia: association with defined HLA antigen configuration and complement protein allotypes C4A, C4B and B factor (Bf)]. / Reaktywnosc na szczepienie przeciwko wirusowemu zapaleniu watroby typu B (HBV) u chorych z mocznica: zaleznosc od okreslonej konfiguracji haplotypów ukladu HLA oraz od allotypów bialek dopelniacza C4A, C4B I czynnika B (Bf).

Genes, which are responsible for the effectivity of immune response are located on the chromosome 6 similarly as the genes of the class I and II of the major histocompatibility complex (MHC) together with the genes of some complement proteins (C4A, C4B, B factor/Bf/). The study investigates the interdependence between HLA configuration as well as complement protein allotypes (C4A, C4B, Bf) with the reactivity to HBV vaccination of ESRD [end stage renal disease]-patients. 153 ESRD-patients (68 females, 85 males; mean duration of hemodialysis therapy 8.2 +/- 5.1 years) were studied. Subjects were vaccinated (Gen-H-B-Vax-D; Merck, Sharp and Dohme, 40 micrograms/dosis i.m.) in the schedule at 0, 1, 2, and 6 month. Non-responders (NR) were defined when the anti-HBs antibody titer was below 10 U/liter. HLA typing was performed by means of microlymphocytotoxicity assay, whereas complement allotypes were estimated by using high voltage gel electrophoresis with subsequent specific immunofixation with antibodies against C4A, C4B and Bf. In the non-responders group [NR = 34] a) the significantly higher occurrence of single HLA-A1 and/or HLA-B8 and/or Cw4 or DR3 or DR7 or DQ2 have been found. In about 40% of NR HLA-A1, -B8, -DR3, or -DQ2 antigens occurred as homozygotes.