Use of equine embryo -derived mesenchymal stromal cells and their extracellular vesicles as a treatment for persistent breeding-induced endometritis in susceptible mares.

Persistent breeding induced endometritis (PBIE) is a significant cause of infertility in mares. The development of a safe, universal, readily available therapeutic to manage PBIE and facilitate an optimal uterine environment for embryo development may improve pregnancy rates in susceptible mares. Mesenchymal stromal cells (MSCs) are being used increasingly as a therapeutic mediator for inflammatory conditions such as endometritis, and early gestational tissue provides a unique source of multipotent stem cells for creating MSCs. Extracellular vesicles (EVs) are mediators of cell communication produced by many different cell types. This study utilized embryo-derived mesenchymal stromal cells (EDMSCs) and their EVs as a potential therapeutic modality for PBIE in two groups: a) PBIE-susceptible mares challenged with pooled dead sperm (n=5); and b) client-owned mares diagnosed as susceptible to PBIE (n=37 mares and 40 estrous cycles). Mares pre-treated with intrauterine EDMSCs or their EVs resulted in a significant reduction in the accumulation of intrauterine fluid post-breeding. Nine of 19 (47 %) mares treated with EDMSCs prior to natural breeding and 13 of 20 (65 %) mares treated with EDMSC derived EVs were pregnant after the first cycle and 12 of 18 (67 %) mares treated with EDMSCs, and 15 of 19 (79 %) mares treated with EVs conceived by the end of the breeding season. These preliminary clinical studies are the first reports of the use of EDMSCs or their EVs as a potential intrauterine therapy for the management of PBIE susceptible mares.

The long-term outcome of revision microdiscectomy for recurrent sciatica.

PURPOSE: To study the long-term outcome of revision microdiscectomy after classic microdiscectomy for lumbosacral radicular syndrome (LSRS). METHODS: Eighty-eight of 216 patients (41%) who underwent a revision microdiscectomy between 2007 and 2010 for MRI disc-related LSRS participated in this study. Questionnaires included visual analogue scores (VAS) for leg pain, RDQ, OLBD, RAND-36, and seven-point Likert scores for recovery, leg pain, and back pain. Any further lumbar re-revision operation(s) were recorded. RESULTS: Mean (SD) age was 59.8 (12.8), and median [IQR] time of follow-up was 10.0 years [9.0-11.0]. A favourable general perceived recovery was reported by 35 patients (40%). A favourable outcome with respect to perceived leg pain was present in 39 patients (45%), and 35 patients (41%) reported a favourable outcome concerning back pain. The median VAS for leg and back pain was worse in the unfavourable group (48.0/100 mm (IQR 16.0-71.0) vs. 3.0/100 mm (IQR 2.0-5.0) and 56.0/100 mm (IQR 27.0-74.0) vs. 4.0/100 mm (IQR 2.0-17.0), respectively; both p < 0.001). Re-revision operation occurred in 31 (35%) patients (24% same level same side); there was no significant difference in the rate of favourable outcome between patients with or without a re-revision operation. CONCLUSION: The long-term results after revision microdiscectomy for LSRS show an unfavourable outcome in the majority of patients and a high risk of re-revision microdiscectomy, with similar results. Based on also the disappointing results of alternative treatments, revision microdiscectomy for recurrent LSRS seems to still be a valid treatment. The results of our study may be useful to counsel patients in making appropriate treatment choices.

The role of embryo contact and focal adhesions during maternal recognition of pregnancy.

Maternal recognition of pregnancy (MRP) in the mare is an unknown process. In a non-pregnant mare on day 14 post-ovulation (PO), prostaglandin F2α (PGF) is secreted by the endometrium causing regression of the corpus luteum. Prior to day 14, MRP must occur in order to attenuate secretion of PGF. The embryo is mobile throughout the uterus due to uterine contractions from day of entry to day 14. It is unknown what signaling is occurring. Literature stated that infusing oil or placing a glass marble into the equine uterus prolongs luteal lifespan and that in non-pregnant mares, serum exosomes contain miRNA that are targeting the focal adhesion (FA) pathway. The hypothesis of this study is embryo contact with endometrium causes a change in abundance of focal adhesion molecules (FA) in the endometrium leading to decrease in PGF secretion. Mares (n = 3/day) were utilized in a cross-over design with each mare serving as a pregnant and non-pregnant (non-mated) control on days 9 and 11 PO. Mares were randomly assigned to collection day and endometrial samples and embryos were collected on the specified day. Biopsy samples were divided into five pieces, four for culture for 24 hours and one immediately snap frozen. Endometrial biopsies for culture were placed in an incubator with one of four treatments: [1] an embryo in contact on the luminal side of the endometrium, [2] beads in contact on the luminal side of the endometrium, [3] peanut oil in contact on the luminal side of the endometrium or [4] the endometrium by itself. Biopsies and culture medium were frozen for further analysis. RNA and protein were isolated from biopsies for PCR and Western blot analysis for FA. PGF assays were performed on culture medium to determine concentration of PGF. Statistics were performed using SAS (P ≤ 0.05 indicated significance). The presence of beads on day 9 impacted samples from pregnant mares more than non-pregnant mares and had very little impact on day 11. Presence of oil decreased FA in samples from pregnant mares on day 9. On day 11, oil decreased FA abundance in samples from non-pregnant mares. Embryo contact caused multiple changes in RNA and protein abundance in endometrium from both pregnant and non-pregnant mares. The PGF secretion after 24 hours with each treatment was also determined. On day 9, there was no change in PGF secretion compared to any treatments. On day 11, presence of peanut oil increased PGF secretion in samples from non-pregnant mares. In samples from non-pregnant mares, presence of an embryo decreased PGF secretion compared to control samples from non-pregnant mares. Results revealed that while beads and peanut oil may impact abundance of FA RNA and protein in endometrial samples, it does not appear to impact PGF secretion. Conversely, embryo contact for 24 hours with endometrium from a non-pregnant mare causes a decrease in PGF secretion. These results suggest that it is not just contact of any substance/object causing attenuation of PGF secretion, but the embryo itself is necessary to decrease PGF secretion.

HMGA2 is regulated by LIN28 and BRCA1 in human placental cells.

The chromatin associated transcription factor HMGA2 is a downstream target of let-7 miRNAs and binds to chromatin to regulate gene expression. Inhibition of let-7 miRNAs by RNA-binding proteins LIN28A and LIN28B is necessary during early embryogenesis to ensure stable expression of HMGA2. In addition to LIN28, HMGA2 is regulated by a BRCA1/ZNF350/CtIP repressor complex. In normal tissues, the BRCA1/ZNF350/CtIP complex binds to the HMGA2 promoter to prevent transcription. However, in many cancers the oncomiR miR-182 targets BRCA1, preventing BRCA1 translation and allowing for increased HMGA2. Little is known about the regulation of HMGA2 during early placental development; therefore, we hypothesized that both LIN28 and BRCA1 can regulate HMGA2 in placental cells. Using siRNA and CRISPR gene editing techniques, we found that knockdowns of both LIN28A and LIN28B increase HMGA2 levels in ACH-3P cells. These cells also demonstrated deficiencies in cell differentiation, seemingly differentiating solely towards the syncytiotrophoblast sublineage, secreting higher amounts of hCG, and displaying upregulated ERVW-1. Additionally, we found that a knockout of both LIN28A and LIN28B caused a significant increase of miR-182 and a decrease in BRCA1 allowing HMGA2 mRNA levels to increase and protein levels to remain the same. Using chromatin immunoprecipitation, we saw binding of the BRCA1 repressor complex to HMGA2. We also saw a decrease in binding to HMGA2's promoter in the LIN28A/B knockout cells. These findings suggest a novel role for BRCA1 during early human placental development.

Chorionic somatomammotropin impacts early fetal growth and placental gene expression.

Several developmental windows, including placentation, must be negotiated to establish and maintain pregnancy. Impaired placental function can lead to preeclampsia and/or intrauterine growth restriction (IUGR), resulting in increased infant mortality and morbidity. It has been hypothesized that chorionic somatomammotropin (CSH) plays a significant role in fetal development, potentially by modifying maternal and fetal metabolism. Recently, using lentiviral-mediated in vivo RNA interference in sheep, we demonstrated significant reductions in near-term (135 days of gestation; dGA) fetal and placental size, and altered fetal liver gene expression, resulting from CSH deficiency. We sought to examine the impact of CSH deficiency on fetal and placental size earlier in gestation (50 dGA), and to examine placental gene expression at 50 and 135 dGA. At 50 dGA, CSH-deficient pregnancies exhibited a 41% reduction (P ≤ 0.05) in uterine vein concentrations of CSH, and significant (P ≤ 0.05) reductions (≈21%) in both fetal body and liver weights. Placentae harvested at 50 and 135 dGA exhibited reductions in IGF1 and IGF2 mRNA concentrations, along with reductions in SLC2A1 and SLC2A3 mRNA. By contrast, mRNA concentrations for various members of the System A, System L and System y+ amino acid transporter families were not significantly impacted. The IUGR observed at the end of the first-third of gestation indicates that the near-term IUGR reported previously, began early in gestation, and may have in part resulted from deficits in the paracrine action of CSH within the placenta. These results provide further compelling evidence for the importance of CSH in the progression and outcome of pregnancy.

Equine endometrial gene expression changes during and after maternal recognition of pregnancy.

The mechanism for maternal recognition of pregnancy (MRP) in horses is unknown. To maintain a pregnancy, a mobile conceptus must be recognized by the uterus before d 14 postovulation (PO). This recognition prevents endometrial secretion of PGF2α on d14 through 16, which would otherwise initiate luteolysis. The objective of this study was to evaluate gene expression in the endometrium of pregnant and nonpregnant mares during and after MRP to identify possible genes involved during this time. Twelve normally cycling mares were used in a crossover design and randomly assigned to a specific collection day. Endometrial samples were collected from a pregnant and nonpregnant (nonmated) mare on cycle d 12, 14, 16, and 18 (n = 3/d) PO. Microarray analysis comparing the endometrial gene expression in pregnant and nonpregnant mares revealed no differences at d 12. Ten genes were identified to have consistently higher or lower expression levels in the endometrium from pregnant versus nonpregnant mares on d 14, 16, and 18 (P < 0.001). The expression of these 10 genes was further analyzed with real-time PCR. d 14, 16, and 18 gene expression patterns were consistent with the microarray analysis, but on d 12, 4 of the 10 were identified as differentially expressed. Endometrial samples were then collected on d 13 PO (n = 3) and processed for western blot and immunohistochemical analysis of 2 proteins due to their reproductive significance. SPLA2 and DKK1 antibody specificity were confirmed via western blot analysis but were not different in samples from pregnant and nonpregnant mares (P = 0.114 and P = 0.514, respectively) and cellular localization was examined by immunohistochemical analysis. This is the first study to describe gene expression and cellular localization in the endometrium at the time of MRP for these genes and suggests that the uterus does not prepare to support a pregnancy until d 14. The function of these genes may be critical in the process of MRP.

Identification of heat shock protein 10 within the equine embryo, endometrium, and maternal peripheral blood mononuclear cells.

Early pregnancy factor has been identified as a 10-kDa extracellular homolog of heat shock protein 10 (Hsp10). Hsp10 has been detected during early pregnancy in serum of mice, sheep, pigs, horses, cows, and humans by the rosette inhibition test. Hsp10 has also been associated with several neoplastic and autoimmune diseases. The goal of the present study was to determine if Hsp10 could be detected in the early equine embryo through the use of immunohistochemistry and quantitative real-time PCR. Additionally, analysis of systemically harvested peripheral blood mononuclear cells (PBMCs) from both pregnant and nonpregnant mares was evaluated to determine expression levels of HSP10. Embryos were collected from Quarter Horse mares by uterine lavage at either 8 or 25 days after ovulation. Collection and separation of PBMCs occurred on Day 8 for both pregnant and nonpregnant mares. Immunohistochemistry revealed cytoplasmic localization of HSP10 throughout the single layer of ectodermal cells forming the trophoblast in Day-8 embryos. Day-25 embryos demonstrated intense localization focally along the apical border of ectodermal cells forming the trophoblast layer of the developing chorion. There was no nuclear staining in either embryonic population. Quantitative real-time PCR detected the presence of mRNA for HSP10 in both 8- and 25-day equine embryos. Day-25 embryos exhibited an elevated degree of expression (P = 0.006) compared with the 8-day embryos for HSP10. Endometrial samples did not display any significant difference in degree of expression for HSP10 (P = 0.10). Finally, PBMCs from pregnant mares demonstrated elevated (P = 0.03) expression of HSP10 compared to the nonpregnant mares on Day 8 of the estrous cycle. This study confirmed the presence of HSP10 protein and mRNA expression of HSP10 in equine embryos at two maturation stages. Additionally, the presence of increased gene expression within PBMCs of pregnant mares suggests communication, possibly leading to necessary immunomodulatory effects between the embryo and mare.

[Headache and impaired consciousness due to the spontaneous intracranial hypotension syndrome]. / Hoofdpijn en verminderd bewustzijn veroorzaakt door het spontane liquorhypotensiesyndroom.

A 51-year-old man presented with a 6-week history of progressive headache, confusion and ataxic gate. The symptoms were not preceded by trauma or lumbar puncture. A CT-scan of the brain revealed bilateral subdural fluid accumulation and hyperdensities in the subarachnoid space. In view of the signs of a subarachnoid haemorrhage, angiography was performed but showed no indications of an aneurysm. An MRI-scan of the head revealed abnormalities in line with intracranial hypotension. CT-myelography of the whole spine revealed a cerebrospinal fluid leak at the level of the fifth and sixth thoracic vertebrae. The patient recovered completely after placement of an epidural blood patch at this level. Spontaneous intracranial hypotension shows clinical similarities with the symptoms following a lumbar puncture. In most cases it can be treated by conservative measures. However, invasive measures are sometimes necessary to close the defect in the meninges.

Expression of CD80 on Kupffer cells is enhanced in cadaveric liver transplants.

In experimental animals inhibition of T cell co-stimulation immediately after organ transplantation effectively prevents rejection. We investigated whether the expression of co-stimulatory molecules is enhanced in cadaveric liver transplants, whether their expression is influenced by the transplantation procedure, and whether variation in expression between liver transplants is related to the occurrence of acute rejection. Expression of CD80, CD86 and the macrophage marker CD68 were determined by immunohistochemistry in biopsies from 40 clinical liver transplants obtained at different time-points during the transplantation procedure, and in normal liver tissue obtained from 10 human livers. Expression of CD80 and CD86 on Kupffer cells was graded by comparison with CD68-staining. In a subgroup CD80 and CD86 mRNA was quantified by real-time detection polymerase chain reaction. CD86 was expressed in all liver transplants and normal livers on the majority of Kupffer cells. CD80 was absent or sporadically expressed in normal liver tissue, but in 18 of 40 liver transplants at least one-quarter of Kupffer cells expressed CD80. CD80- and CD86-mRNA and protein expression in liver transplants did not change during the warm ischaemic and reperfusion phases of the transplantation procedure. CD80-expression on Kupffer cells varied strongly between individual donor livers; this variation was, however, not significantly related to the occurrence of acute rejection after transplantation. In conclusion, in nearly half of cold-preserved cadaveric liver transplants an increased proportion of Kupffer cells express CD80 at the time of transplantation in comparison with normal liver tissue. The expression was not further induced by warm ischaemia and reperfusion. However, the observed variation in CD80-expression between liver transplants is not a accurate predictive measure for acute rejection.

Intraoperative monitoring of brain tissue oxygen and carbon dioxide pressure in peritumoural oedema by stereotactic placement of multiparameter microsensors.

Ischaemia may play an important role in peritumoural brain oedema and swelling, but little data exist so far on brain tissue oxygenation adjacent to a tumour mass. We have monitored brain tissue oxygen tension (ptiO2) and brain tissue CO2 tension (ptiCO2) in 19 patients undergoing craniotomy for resection of a brain tumour using a multiparameter sensor placed in the brain parenchyma. Accurate placement of this probe in the peritumoural area was accomplished with the aid of a 3-D neuronavigation system. Due to various problems we obtained useful data in only 13/19 patients. The presence of brain swelling was associated with a significant rise in ptiO2 upon opening of the dura from 7.1 +/- 7.8 to 23.6 +/- 14.7 mm Hg. The average ptiO2 before tumour resection was 18.1 +/- 10.8 mm Hg. A significant improvement in ptiO2 occurred after tumour resection to an average ptiO2 of 29.7 +/- 15.2 mm Hg. From these preliminary data, we conclude that ptiO2 is depressed in the peritumoural area, and improves following tumour resection. Stereotactic placement of sensors for intraoperative ptiO2 monitoring is feasible and may enhance data quality. Nevertheless, the high incidence of failures with this type of sensor remains a matter of concern.

Abnormal microcirculation in brain tumours during surgery.

Orthogonal Polarisation Spectral imaging is a new clinical technique that uses polarised light to visualise the microcirculation of organ surfaces. We have used this technique to compare the functional microcirculatory properties of three types of brain tumour with those of the normal cortex. Meningiomas were characterised by chaotic and dilated vessels with almost no erythrocyte movement and a dark background, glioblastoma by few vessels with low flow and a background close to that of the healthy cortex, and metastases by a very dark background, almost no flow, and a chaotic vascular pattern. This technique could provide useful information about microcirculatory morphology and kinetics for diagnostic use during neurosurgery.

In vitro cytokine production of TNFalpha and IL-13 correlates with acute liver transplant rejection.

Individuals may differ in their capacity to produce cytokines. Since cytokines play a key role in allograft rejection, we investigated whether inter-individual differences in cytokine production by in vitro stimulated PBMC are related to the occurrence of acute liver transplant rejection. Our study group comprised 49 liver transplant recipients and 30 healthy individuals. Rejection, which occurred within one month after liver transplantation, was defined in 22 patients ("rejectors") as biopsy-proven rejection, treated with high dose prednisolone. Patients who never experienced rejection episodes were termed as "nonrejectors" (n=27). PBMC of healthy individuals and of liver transplant recipients, collected late after transplantation (mean 3.5 years), were cultured in the presence and absence of Concanavalin A. The production of TNF-alpha, IFN-gamma, IL-10, and IL-13 was measured in supernatant after 1, 2, 3, 4, and 7 days of cell culture. In cell culture, stimulated PBMC of rejectors were found to produce significantly higher levels of TNF-alpha, while there was a trend towards higher production of IFN-gamma and IL-10 as compared to nonrejectors. After grouping patients into high or low cytokine producers based upon reference levels of the healthy individuals using multivariate analysis it was found that occurrence of acute liver transplant rejection correlated to high production of TNF-alpha and low production of IL-13. After stimulated cell culture PBMC of liver transplant recipients show a differential production of TNF-alpha and IL-13 which is correlated with the occurrence of acute liver transplant rejection.

Comparison of two types of surgery for thoraco-lumbar burst fractures: combined anterior and posterior stabilisation vs. posterior instrumentation only.

This retrospective study compares clinical outcome following two different types of surgery for thoracolumbar burst fractures. Forty-six patients with thoracolumbar burst fractures causing encroachment of the spinal canal greater than 50% were operated on within 30 days performing either: combined anterior decompression and stabilisation and posterior stabilisation (Group 1) or posterior distraction and stabilisation using pedicle instrumentation (AO internal fixator) (Group 2). We evaluated: neurological status (Frankel Grade), spinal deformities, residual pain, and complications. The average follow-up was 6 years. There were no significant differences between the patients in both groups concerning age, sex, cause of injury and the presence of other severe injuries. Neurological dysfunction was present in 39% of all cases. Bony union occurred in all patients. Loss of reduction greater than 5 degrees and instrumentation failure occurred significantly more often in Group 2 compared to Group 1, but the kyphosis angle at late follow-up did not differ between groups, due to some degree of overcorrection initially after surgery in Group 2. The clinical outcome was similar in both groups, and all but one patient with neurological deficits improved by at least one Frankel grade. Indirect decompression of the spinal canal by posterior distraction and short-segment stabilisation with AO internal fixator is considered appropriate treatment for the majority of unstable thoracolumbar burst fractures. This is a less extensive surgical procedure than a combined anterior and posterior approach.

Human bone allografts can induce T cells with high affinity for donor antigens.

We analysed the cellular immune response in ten transplantations of different massive bone allografts, of which five had a poor clinical outcome. Cytotoxic T lymphocytes (CTL) and T helper lymphocytes (TH) against mismatched donor antigens were found in all patients. More importantly, CTL with a high affinity for donor antigens were found in five cases. High-affinity CTL need no CD8 molecule to stabilise the antigen binding and are strongly associated with rejection of heart and corneal transplants. Even after removal of most of the bone-marrow cells, we found high-affinity CTL and high TH frequencies. This T-cell response could be detected over a period of years. We conclude that frozen bone allografts can induce high-affinity donor-specific CTL. The present assay allows qualification and quantification of the levels of CTL and TH in the blood. This approach may be helpful in studying the effect of the immune response on the outcome of the graft.

Pathogenesis of traumatic brain swelling: role of cerebral blood volume.

The pathogenesis of traumatic brain swelling is unclear. Brain edema (increased water content) is considered an important cause of swelling, but there is also evidence that vasodilatation with increased cerebral blood volume (CBV) plays a role. We have evaluated early posttraumatic changes in CBV in 37 head-injured patients, using dynamic contrast-enhanced computerized tomography (CT) in combination with stable Xenon-enhanced CT for measurement of cerebral blood flow (CBF). This technique enables rapid determination of CBV without interfering with patient care. CBV values ranged from 2.0 to 10.1 ml/100 g. There was no relationship the time after injury at which the measurements were taken. CBV did not correlate with CBF in the early posttraumatic period. Patients with raised ICP (> 20 mm Hg) had significantly higher CBV that patients with normal ICP (5.4 +/- 2.1 vs 3.7 +/- 0.9 ml/100 g). Yet, the presence of signs of brain swelling on CT had no relation to the level of CBV. These data suggest that increased CBV may contribute to raised ICP, but that brain swelling is not caused by increased CBV alone, and is more likely accounted for by brain edema. We speculate that cerebral energy failure is the unifying cause of both intracellular edema and cerebral vasodilation leading to swelling of brain tissue.

In vitro sensitivity to prednisolone may predict kidney rejection after steroid withdrawal.

A maintenance immunosuppressive regimen of cyclosporine and steroids after renal transplantation has proven to be a successful policy to obtain long-term graft survival. However, serious side-effects are associated with this therapy; these include an increased risk for infections, cancer, and cardiovascular morbidity and mortality. Therefore, this pilot study was conducted to investigate the possibility of reducing the immunosuppressive load after transplantation. To this end, we tried to develop an in vitro assay to predict graft rejection after withdrawing steroids from the immunosuppressive therapy. Patients who had stable renal function at least one year after transplantation were randomly divided into a group that continued to receive standard immunosuppression of cyclosporine and steroids and a group to be withdrawn from steroid therapy, the latter group being the subject of the present study. Patients withdrawn from steroids were monitored closely and when a biopsy-proven rejection occurred, steroid treatment was reestablished. Blood was collected from patients preceding steroid withdrawal and at fixed time points thereafter. In case of suspected rejection, blood was also taken before biopsy, before steroid treatment was reestablished. In the in vitro limiting dilution analysis-assays cytotoxic T lymphocyte precursor frequencies directed against kidney donor HLA-antigens were determined, in the absence or presence of cyclosporine and several concentrations of prednisolone and the combination of these agents. Confirming earlier results, we found that the number of cyclosporine-resistant cytotoxic T lymphocytes increased prior to a rejection crisis, while they did not change or even decreased in patients who retained normal graft function after steroid withdrawal. More importantly, the results show that 10(-7) M prednisolone in vitro differentially affected donor-specific cytotoxic T lymphocyte precursor frequencies in patients who experienced a rejection crisis after steroid withdrawal, compared with those who remained to do well. This heterogeneity could be detected before the start of steroid withdrawal. Therefore, we conclude that the present data justify a prospective clinical trial to investigate the possible application of this in vitro assay to predict for which patients steroid withdrawal might be considered.

Pregnancy can induce priming of cytotoxic T lymphocytes specific for paternal HLA antigens that is associated with antibody formation.

Some transplant centers consider paternal HLA antigens as unacceptable mismatches for mothers awaiting kidney transplantation. It is feared that a pregnancy may cause priming of the maternal immune response directed toward paternal HLA antigens. Should a woman receive an organ from a donor who shares those paternal HLA antigens, the risk of graft rejection might be increased. It is known that some women, as a consequence of pregnancy, develop antibodies specific for paternal HLA antigens. The purpose of the present study was to investigate whether a pregnancy can also prime the cellular immune response and whether this occurs in all cases. Frequencies of maternal cytotoxic T lymphocytes directed to paternal HLA antigens were evaluated in limiting dilution analysis assays and compared with those directed to third-party HLA antigens. Differentiation between naive and in vivo primed cytotoxic T lymphocytes was made by performing these assays in the absence and presence of anti-CD8, respectively. No difference in the frequency nor sensitivity to blocking by anti-CD8 was found when maternal cytotoxic T lymphocytes directed toward paternal HLA antigens were compared with those against third-party HLA antigens. However, more heterogeneous responses were detected against paternal HLA antigens. Therefore, paternal antigens that had been inherited by children were analyzed separately from the paternal antigens that had not been inherited. Furthermore, the presence of pregnancy-induced HLA antibodies was taken into consideration. Naive cytotoxic T lymphocyte responses were detected against paternal antigens that had never been inherited and those that had been inherited but had not induced antibody formation. In contrast, inherited paternal antigens that had induced HLA-specific antibodies in the mother gave rise to elevated cytotoxic T lymphocyte precursor frequencies, as compared with the response to third-party antigens. Also, the cytotoxic T lymphocytes were found to be more resistant to inhibition by anti-CD8, suggesting that these cells had been primed in vivo. These results suggest that not all paternal HLA antigens have to be considered as unacceptable mismatches. Only those individuals who share a paternal HLA antigen against which a mother has formed HLA-specific alloantibodies should be excluded from organ donation.