Contributions of flow cytometry to the analysis of the myelodysplastic syndrome.

As the population of North America ages, the incidence of MDS is likely to rise. Epidemiologic survey instruments need to be put in place to document changes in the incidence. The basic mechanism of disease in MDS is largely unknown. No unifying, testable hypothesis is yet available, but apoptosis, with mitochondria playing a key role, are central to any discussion of MDS. Cytogenetic abnormalities have not provided an explanation of MDS but are of diagnostic and prognostic significance. The emergence of immunologic factors is of major importance and emphasizes the need for early detection. Flow cytometry can be used diagnostically to exclude other causes of cytopenias, document the phenotypic manifestations of myeloid dysmaturation, and provide blast enumeration. The distinctions between MDS and acute leukemia are arbitrary, and the process should be conceptualized as a continuum. There is a need for continued work to establish minimal diagnostic criteria for MDS. The current prognostic scoring systems do not incorporate findings from the newer technologies.

Immunologic differentiation of absolute lymphocyte count with an integrated flow cytometric system: a new concept for absolute T cell subset determinations.

We describe a method to obtain results for immune status monitoring that uses a three-test panel, comprised of isotype control and 2 specific Mab tests (CD4/CD8/CD3 and CD16/CD19/CD3), in conjunction with a flow cytometer that directly measures absolute counts. Automated software is used for lineage-specific gating of three-color immunofluorescence to determine lymphocyte and lymphocyte subset counts. The autogating function of this software is shown to yield equivalent results to manual analysis by an expert user, and to be effective when as few as 25 target cells are present. The software is also shown to perform automatic quality control checks of the sample preparation, reagent, and automated analysis. We demonstrate that the sum of T (CD3+), B (CD19+), and natural killer (NK, CD16 + CD3-) cells, as a determination of all lymphocytes, correlates well with lymphocytes measured using a light scatter differential. Moreover, T + B + NK lymphocyte count is shown to be less error-prone than lymphocyte count from light scatter differential, and to minimize errors that arise from between-technician variation in sample preparation. Our data suggest that the new approach that we describe could offer an alternative to the traditional two-stage methods for measuring absolute counts of lymphocyte subsets for immune status monitoring. As such this method could reduce, through objective automated analysis, testing cost and complexity, without sacrificing the quality of results.

Isolation and characterization of an early T-helper/inducer cell line with a unique pattern of surface phenotype, constitutive cytokine secretion and myc oncogene expression.

The cell line AG-F was isolated from the marrow of a neuroblastoma patient undergoing myeloablative treatment and autologous bone marrow rescue. A year later, the patient developed a Hodgkin's type lymphoma. AG-F cell line demonstrated an unusual phenotype, lacking surface CD2 and CD3, but expressing high levels of CD4, CD5, CD7, CD29, and CD45RO. Markers associated with Hodgkin's lymphoma cells, CD15 and CD30, were also positive. AG-F cells grow in suspension in clusters of 50-200 cells, with a doubling time of 9 h. They can also grow in serum-free medium and form tumors in nude mice. AG-F cells have amplified N-myc and c-myc and high levels of the corresponding mRNA transcripts. Cytogenetic analysis revealed a DNA index by flow cytometry of near tetraploid cells and a karyotype of 85-87 chromosomes, with consistent abnormalities in chromosomes 1, 5, and 9. Gene rearrangement studies revealed rearrangement of the beta gene of the T-cell receptor. AG-F cells secrete high levels of IL-6, IL-8, IL-10, and GM-CSF. Cell adherence and formation of long processes could be induced by fibronectin and were enhanced by exposure to PMA. Cells exposed to phorbol myristate acetate (PMA) had increased expression of CD11a, CD11b, CD18, CD45RO, and HLA-DR, whereas expression of CD15 and CD30 was markedly decreased. Similarly, the level of c-myc and N-myc oncoproteins and the levels of the cytoskeletal proteins, actin, tubulin, and vimentin markedly decreased early after PMA-induced differentiation.

Immunophenotyping of acute leukemia by flow cytometric analysis. Use of CD45 and right-angle light scatter to gate on leukemic blasts in three-color analysis.

This article describes a procedure for performing routine three-color flow cytometric analysis for acute leukemia on lysed whole bone marrow preparations. This technique uses the combination of CD45 intensity and right-angle light scatter (RALS) to distinguish leukemic cells from normal lymphocytes, monocytes, neutrophils, eosinophils, and nucleated red blood cells. On this display, leukemic cells occupy a unique blast region characterized by intermediate CD45 density and low RALS, which, in normal marrows, contains less than 5% of the total cells. This approach was applied to 39 cases of acute leukemia and 8 cases of myelodysplasia or myeloproliferative disorders. The estimate of blasts by flow cytometric analysis was correlated highly with morphologic leukemic cell counts over a wide range. Moreover, the pattern seen on the CD45-RALS display was different for different French-American-British subtypes of leukemia, suggesting that this pattern might be useful for categorization. When CD45-peridin chlorophyll alpha protein was combined with other pairs of fluorescein isothiocyanate- and phycoerythrin-conjugated reagents, it was possible to set an analysis window on the leukemic blasts and display dual-parameter (ie, green vs. red fluorescence) data regarding expression of two additional markers on the leukemic population. This gating strategy was superior to traditional forward-angle versus RALS displays in that it did a better job of isolating the leukemic cells analytically.

Reimbursement for clinical flow cytometry testing.

Throughout the United States, reimbursement for new laboratory technology is not well understood by the clinicians and laboratory personnel who provide it. It is important to understand how new technology will be paid for in today's changing, more tightly controlled, health-care funding environment. For flow cytometry testing, specifically, this confusion is not just restricted to providers of the tests. The carriers from many states still list flow cytometry as "investigational", contrary to the 1988 HCFA ruling. Although the HCFA ruling is not subject to interpretation by state Medicare carriers, it is often up to the provider whose claims are being denied to educate the carrier concerning its mistake. When confronted with the appropriate evidence (sometimes including a phone call from the regional HCFA office), most carriers relent. It is critical to note that claims must be billed correctly. This means that approved ICD-9-CM codes must be used with the appropriate CPT-4 codes. If there is no prevailing rate established in the state or if it has been established prohibitively low, it will be necessary to lobby and educate the carrier in regard to the medical necessity of the testing, as well as justifying the cost. This can be done by providing the medical director of the carrier with all necessary patient information, laboratory reports, and scientific literature validating the use of the technology for each individual claim. It may also require submitting cost justification data supporting the request. The importance of the development of a good working relationship with one's local Medicare carrier cannot be overemphasized. This relationship is a critical component of establishing a fair and appropriate rate for the reimbursement of any test.

Role of intracellular calcium in priming of human peripheral blood monocytes by bacterial lipopolysaccharide.

To determine the role of intracellular calcium ([Ca2+]i) in the priming of monocytes (M phi) by bacterial lipopolysaccharide (LPS), the membrane expression of two functional proteins and phagocytosis and respiratory burst were examined by microfluorimetry. LPS induced a significant increase in HLA-DR and C3bi receptor (CR3) expression within 2 h of its addition to whole blood. The enhanced expression of both antigens by LPS was dose-dependent, with concentrations as low as 0.1 ng/ml producing a response. The involvement of [Ca2+]i was demonstrated by loading isolated M phi with the intracellular calcium chelator quin-2 or the inhibitor of intracellular calcium redistribution TMB-8 prior to addition of LPS. Both compounds inhibited the LPS-induced increase in HLA-DR and CR3 expression. No role for extracellular calcium, for calcium slow channel flux, or for the calcium-calmodulin complex in LPS priming was demonstrated when LPS was added in the presence of EGTA, trifluperazine (TFP), or verapamil. The addition of the calcium ionophores A23187 or ionomycin failed to increase expression of either antigen. Prior exposure to LPS primed M phi for enhanced phagocytosis and respiratory burst activity. These functions were inhibited by TMB-8, but not by TFP or verapamil. Addition of LPS to isolated M phi increased [Ca2+]i by 23% at 30 sec and 42% at 5 min, as measured by the calcium-sensitive, intracellular probe indo-1. These results suggest that intracellular Ca2+ mobilization is necessary, but not sufficient, for LPS-induced priming of human peripheral blood monocytes.

Flow cytometric evaluation of leukocyte function.

The marriage of monoclonal antibody technology and flow cytometry has provided clinical researchers with a powerful tool for the characterization of leukocytes from various sources. In this regard, flow cytometry has been primarily used for the immunophenotyping of peripheral blood lymphocytes in leukemias and various immunodeficiency disorders. Flow cytometry is also useful for the evaluation of leukocyte function in vitro and in vivo. This review discusses the various applications of flow cytometry for the assessment of leukocyte function. Since several cell surface antigens are important constituents involved in cell function, immunofluorescence identification of these markers can provide significant information regarding cell function. Analysis of activation antigen expression by monoclonal antibodies and flow cytometry can provide significant insights about the presence of functional leukocyte populations in patients. Flow cytometry can also be used to directly analyze leukocyte function. Procedures for the quantitative flow cytometric analysis of proliferation of activated lymphocyte subsets are reviewed. Early cell activation is also amenable to flow cytometric measurement. Early activation events such as alterations in membrane potential, intracellular free calcium redistribution, intracellular pH, and changes in membrane fluidity, as well as the direct measurement of enzyme activity, are also described.

Mechanism of prostaglandin E2 inhibition of acute changes in vascular permeability.

In order to determine the mechanism of antiinflammatory activity, prostaglandin E2 (PGE2) or diluent was administered to rats 2 h prior to intradermal injections of various mediators of inflammatory vascular permeability changes. Vascular permeability was measured as the accumulation of [125I]rat serum albumin at the site of mediator injunction. PGE2 at 500 micrograms significantly inhibited protein leakage produced by histamine, platelet activating factor, zymosan, and zymosan-activated plasma. Pretreatment with PGE2 had no effect on protein leakage induced by injection of lysosomal enzymes, glucose oxidase, or xanthine oxidase. The accumulation of polymorphonuclear leukocytes (PMNs) at the site of injection of zymosan or zymosan-activated plasma was not altered by PGE2 administration. In separate experiments, the ability of PGE2 to alter phagocytosis and oxygen radical production by PMN was examined. PGE2 significantly inhibited phagocytosis at 2 h, but this returned to normal by 6 h. Production of hydrogen peroxide by PMN was not affected by PGE2. These results suggest that PGE2 prevents acute changes in vascular protein leakage by preventing endothelial cell contraction and by inhibiting specific PMN functions.

Alterations in select immunologic parameters following total artificial heart implantation.

We examined select immunologic parameters in three recipients of a total artificial heart and correlated changes with the clinical course. Two patients remain alive and were studied for 320 and 240 days, respectively; the third died 10 days after implantation. All patients demonstrated transient complement activation immediately postoperatively, as indicated by an increase in plasma levels of C3a des Arg. In the two long-term survivors, C3a des Arg levels again increased, concomitant with intravascular hemolysis associated with high blood shear rates imposed by the drive system of the heart. All three patients had a marked lymphopenia immediately postoperatively, and the two long-term survivors demonstrated marked fluctuations in total lymphocyte count. There was a progressive decline in the number of peripheral blood helper/inducer T cells in the two long-term survivors. A large number of activated (HLA-DR positive) suppressor/cytotoxic T cells were also noted in these two patients. A progressive decrease in B cells was also observed; however, total IgG and IgM levels were not decreased. No changes in neutrophil phagocytic or respiratory burst capacities were identified. The cause of these changes in lymphocyte populations is not clear; however, they may have impact on the use of this device as a bridge to transplantation and may lead to decreased immunocompetence during long-term use.

Regulation of oxygen radical release from murine peritoneal macrophages by pharmacologic doses of PGE2.

The ability of pharmacologic doses of PGE2 to alter the release of superoxide (O2-) and hydrogen peroxide (H2O2) from elicited peritoneal macrophages (M theta) was studied. Twice-daily administration of 200 or 100 micrograms of PGE2 to mice during accumulation of peritoneal M theta resulted in a significant reduction in M theta recovery and in the triggered release of H2O2, but not O2-. Cultivation of elicited M theta from normal mice with concentrations of PGE2 in excess of 10(-7) M for 24-48 h resulted in a significant reduction in the triggered release of H2O2, but not O2-. Cultivation for shorter periods of time or with lower concentrations of PGE2 failed to alter H2O2 release. This effect of PGE2 was reproduced by the phosphodiesterase inhibitor theophylline. The ability of PGE2 to inhibit H2O2 release in the presence of normal production of O2- was not prevented by the addition of superoxide dismutase. Cultivation of peritoneal M theta with 10(-5) M PGE2 for 48 h failed to increase intracellular catalase, although increased H2O2 scavenger activity was demonstrated. The inhibition of extracellular release of H2O2, but not O2-, by pharmacologic doses of PGE2 may be one mechanism for the anti-inflammatory action of this compound.

Variable susceptibility to immune complex glomerulonephritis among mice sharing the same major histocompatibility complex.

Three inbred strains of mice were identified which demonstrated different susceptibilities to induction of immune complex glomerulonephritis (ICGN) despite sharing the same major histocompatibility complex haplotype (H-2k). Groups of mice from each of these three strains, B10.BR, CBA and C3H/HeJ, were injected with one of two different dose schedules of horse apoferritin (HAF) for 4 weeks, after which glomerular morphology, immunoglobulin deposition, and serum anti-HAF antibody levels were examined. With either dose schedule, only those mice which demonstrated a high level antibody response developed ICGN and glomerular immunoglobulin deposition. These results suggest that susceptibility to ICGN in this model is related to the level of antigen exposure and to the magnitude of the antibody response, which is not under strict control of the major histocompatibility complex.

Mechanism by which methylprednisolone inhibits acute immune complex-induced changes in vascular permeability.

Intravital microscopy was used to quantitate protein leakage which resulted from the deposition of immune complexes in the vasculature of the rat cremaster muscle. Immune complex deposition was initiated by the addition of 80 micrograms/ml of ovalbumin to the bath surrounding the muscle, followed by the intravenous administration of antiovalbumin. Administration of 25 mg/kg of antiovalbumin produced significant leakage of protein from the third-order venules, while 7.5 and 2.5 mg/kg had no effect. Administration of methylprednisolone (MP), 30 mg/kg, 1 h prior to the deposition of immune complexes significantly inhibited protein leakage. In separate experiments, MP inhibited intradermal edema formation and protein exudation induced in rats by histamine, platelet activating factor, or C5a. However, MP had no effect on protein exudation or edema produced by xanthine oxidase or glucose oxidase. Intravenous administration of MP inhibited the ability of polymorphonuclear leukocytes (PMNs) to phagocytize bacteria, but failed to alter hydrogen peroxide production. These results suggest that MP prevents acute changes in vascular permeability following immune complex deposition by inhibiting the effects of soluble mediators of edema on vascular endothelium and by inhibiting PMN phagocytosis.

Serial changes in humoral and cellular immunity induced by prostaglandin E2 treatment of murine immune complex glomerulonephritis.

To examine the mechanism by which prostaglandin E2 (PGE2) inhibits the development of apoferritin (HAF)-induced immune complex glomerulonephritis (ICGN), weekly determinations of glomerular histologic conditions, blood urea nitrogen (BUN), total immunoglobulin levels, anti-HAF antibody, peripheral blood and splenic T cell subsets, and splenic suppressor cell activity were compared between mice receiving HAF and mice additionally treated with PGE2. PGE2 therapy prevented the development of glomerular hypercellularity and the increase in BUN concentration. Administration of PGE2 reduced anti-HAF IgG levels, but total IgM and IgG1, IgG2a, and IgG2b levels were unchanged. Mice receiving HAF alone demonstrated serial reductions in phenotypically identified peripheral blood pan-T cells and suppressor-cytotoxic T cells. PGE2-treated mice maintained normal levels of peripheral blood T cell subsets. Significant reductions in splenic total T cells and suppressor-cytotoxic cells occurred in mice receiving HAF as compared with normal mice. This reduction was offset by an increase in splenic B cells. PGE2 therapy prevented the decrease in splenic T cells at week 1, but not at week 4. Nonspecific suppressor cell activity, as measured by the ability of spleen cells from experimental mice to suppress a mixed lymphocyte reaction (MLR) or to suppress MLR-induced polyclonal IgG synthesis, was not different between the two groups. We conclude that prevention of HAF-ICGN by PGE2 is associated with a reduction in nephritogenic antibody production without an alteration in total immunoglobulin synthesis or the generation of nonspecific suppressor T cells. Changes in the percent of peripheral blood and splenic T cells and B cells may represent an effect of PGE2 on antigen-stimulated B cell proliferation.

Alterations in serum antibody and peripheral T-lymphocyte subsets resulting from treatment of murine immune complex glomerulonephritis with PGE2.

The effects of treatment with 16,16-dimethyl prostaglandin E2 (DMPGE2) on histologic damage, glomerular immune complex deposition, serum total IgG subclass levels, anti-apoferritin IgG levels, and peripheral blood T-lymphocyte subsets were determined in apoferritin-induced immune complex glomerulonephritis of mice. The results demonstrate that doses of DMPGE2 ranging from 2.5 to 10 micrograms twice daily significantly reduced the degree of glomerular damage in a dose-dependent manner. Similarly, these doses of DMPGE2 reduced the amount of immunoglobulin deposition along peripheral capillary loops. Total IgM, IgG1, IgG2a, and IgG2b were unaffected by DMPGE2 administration. Serum anti-apoferritin IgG levels were significantly reduced in mice receiving DMPGE2 at doses of 5 and 10 micrograms twice daily. Nephrotic mice had significantly reduced peripheral blood total T lymphocytes (Lyt-1+) and a reduction of T-suppressor (Lyt-2+) cells. Administration of DMPGE2 at doses of 5 and 10 micrograms twice daily prevented these T-lymphocyte alterations. These studies indicate that treatment of mice receiving apoferritin with DMPGE2 may prevent glomerulonephritis by altering both cellular and humoral immune responses.