Novel surveillance and cure of a donor-transmitted lymphoma in a renal allograft recipient.

BACKGROUND: In this report we describe a malignant lymphoma of donor origin inadvertently transplanted into two renal allograft recipients, despite standard comprehensive donor screening. The successful clearance of the tumor from both patients and a novel method of surveillance are detailed. METHODS: Initial management consisted of withdrawal of immunosuppression to promote rejection of the allograft and the transplanted tumor in both patients, followed by graft removal. Peripheral blood microchimerism was assessed in both recipients using nested polymerase chain reaction to detect the DYZ3 gene on the Y chromosome (donor male, recipients female). RESULTS: Although microchimerism was detected on day 6 after transplantation and day 1 after explantation, repeat peripheral blood examination at 1, 3, and 6 months after explantation demonstrated no microchimerism. Both patients remain well at 12 months and have been relisted for transplantation. CONCLUSION: Despite inadvertent transplantation of a previously undiagnosed malignancy of donor origin, the recipients' immune response was able to eliminate donor tumor cells after the withdrawal of immunosuppression. Repeated surveillance of peripheral blood from both recipients, using a novel application of the technique of nested polymerase chain reaction to amplify donor DNA, demonstrated no persistence of donor cells, supporting effective eradication of the donor malignancy.

Advanced donor-origin melanoma in a renal transplant recipient: immunotherapy, cure, and retransplantation.

BACKGROUND: A kidney transplant recipient inadvertently contracted donor-origin melanoma, which was found to be very advanced at presentation. Withdrawal of immunosuppression failed to induce rejection, and interferon-alpha was required. When florid allograft rejection was in progress, the allograft was removed, before it was recognized that the transplanted melanoma was not being simultaneously rejected. METHODS: Subsequent immunotherapy was required, which largely recapitulated treatment of recognized value in autologous melanoma and included interferon-alpha, use of cultured melanoma cells as tumor vaccine, pooled allogeneic cell vaccination, and adoptive immunotherapy using lymphokine-activated killer cells. RESULTS: Prolonged immunotherapy eradicated the widespread malignancy, and the patient went on to a successful second renal transplant, with follow-up of over 24 months. CONCLUSIONS: This unique case demonstrates the successful cure of advanced transplanted melanoma through the use of immunotherapy, which did not require sophisticated tumor vaccine technology, and successful retransplantation.

Malignant sacrococcygeal germ cell tumour in an adult.

In adults, malignant sacrococcygeal germ cell tumour is a rare cause for a presacral tumour, with only 17 cases having been reported in the literature since 1907. We report the case of a 34 year old male who presented with a 6 month history of symptoms relating to a malignant presacral tumour which required en bloc excision including the lower sacrum and rectum. He died with lung and mediastinal metastasis 7 months following surgical excision and adjuvant chemotherapy using Cisplatin, Bleomycin and Etoposide. Prior to his death, he had a severe polyarthritis of his peripheral joints and evidence of hypertrophic osteo-arthropathy. The literature indicates that adults with these tumours have a poor prognosis, with only one reported long-term survivor. Surgical excision offers the only chance of cure, with the role of adjuvant therapy not having been defined because of the small numbers.

Renal glomerular lesions in unselected patients with cirrhosis undergoing orthotopic liver transplantation.

Renal biopsies were obtained from 23 patients at the time of orthotopic liver transplantation. Twelve biopsies showed minor glomerular abnormalities, 2 exhibited IgA nephropathy and one showed mesangiocapillary glomerulonephritis type I. The remaining 8 patients had glomerular lesions diagnosed as hepatic glomerulosclerosis (HGS). Immunofluorescence, available in 6 of the 8 biopsies with HGS, revealed granular deposits of immunoglobulins and complement in glomerular capillary walls and/or the mesangium. IgA was seen in 5 biopsies with HGS, but the staining for this protein was no more intense than that for the other immunoglobulins in 4 of these. Electron microscopy in HGS revealed partial mesangial interposition, hypertophy of mesangial and endothelial cells, granular material in a widened subendothelial space, slender projections of endothelial cytoplasm extending into the subendothelial space, and clusters of vesicles in the mesangium and glomerular capillary walls. These ultrastructural abnormalities have not hitherto been reported as a group of associated pathological changes. The renal biopsies were obtained from patients with advanced hepatic disease not selected because of urinary abnormalities or renal dysfunction. The frequency of lesions in this group of patients therefore probably reflects the true incidence of glomerular lesions in cirrhosis and related conditions. Progressive decline in renal function was not observed in any patient during follow up which ranged from 11 days to 55 mths.

Donor-related secondary haemorrhage complicating renal transplantation.

We report two cases of secondary haemorrhage in renal transplant recipients that would appear to relate to their common donor. Our experience confirms the inadequacy of arterial repair in this setting. One patient, a middle aged diabetic male, required excision of his external iliac artery, but recovered without reconstructive surgery. In the second case nephrectomy was performed on day 8 because of accelerated rejection. This was followed by recurrent sepsis due to E. coli, which was implicated in the previous case. Haemorrhage from the donor aortic wall patch occurred 3 weeks later. We now recommend that if secondary haemorrhage occurs, recipients of other organs from the donor should be carefully monitored for evidence of infection. If this is found and a similar organism cultured, consideration to transplant nephrectomy should be made with removal of all donor tissue to avoid the risk of subsequent secondary haemorrhage.

Invasive squamous cell carcinoma of the conjunctiva.

A 73-year-old man had been treated for a sore, red, left eye for 4 months before a clinical diagnosis of squamous cell carcinoma of the limbus was made. This diagnosis was confirmed on examination of a biopsy specimen, but after an initial surgical attempt to fully excise the tumor, there was clinical evidence of intraocular spread. An extensive corneoscleral resection and iridocyclectomy appeared to completely excise the tumor, as indicated by frozen section review. However, 1 year later, the patient re-presented with obvious residual squamous cell carcinoma of the iris and trabecular meshwork, well away from the original tumor site. Subsequent exenteration has resulted in a tumor-free patient for 1 year. Apparent surgical clearance of an extensive squamous cell carcinoma does not ensure total intraocular clearance of residual tumor, which may be remote from the original tumor site.

Arterial endothelialitis in chronic renal allograft rejection: a histopathological and immunocytochemical study.

Transplantation is the preferred method of renal replacement therapy in end-stage renal failure. Short- and medium-term graft survival is good but, in the longer term, grafts are lost due to vascular obliteration, i.e. chronic vascular rejection. The pathogenesis of these changes is unclear. We carried out a histopathological and immunocytochemical study of 31 vessels from 20 graft nephrectomies. Four patterns of arterial pathology were identified: (1) subendothelial inflammation ('endothelialitis') with little intimal thickening; (2) 'Endothelialitis' with thickening; (3) Intimal thickening without 'endothelialitis'; and (4) Intimal thickening with calcification and cholesterol clefts ('natural atherosclerosis'). We suggest that the lesions of chronic vascular rejection evolve, at varying rates, from an early 'endothelialitis' to a later stage with pronounced intimal thickening but no subendothelial inflammation. These changes probably reflect a delayed type hypersensitivity response involving activated macrophages and T lymphocytes and smooth muscle cell proliferation.

International standardization of criteria for the histologic diagnosis of renal allograft rejection: the Banff working classification of kidney transplant pathology.

A group of renal pathologists, nephrologists, and transplant surgeons met in Banff, Canada on August 2-4, 1991 to develop a schema for international standardization of nomenclature and criteria for the histologic diagnosis of renal allograft rejection. Development continued after the meeting and the schema was validated by the circulation of sets of slides for scoring by participant pathologists. In this schema intimal arteritis and tubulitis are the principal lesions indicative of acute rejection. Glomerular, interstitial, tubular, and vascular lesions of acute rejection and "chronic rejection" are defined and scored 0 to 3+, to produce an acute and/or chronic numerical coding for each biopsy. Arteriolar hyalinosis (an indication of cyclosporine toxicity) is also scored. Principal diagnostic categories, which can be used with or without the quantitative coding, are: (1) normal, (2) hyperacute rejection, (3) borderline changes, (4) acute rejection (grade I to III), (5) chronic allograft nephropathy ("chronic rejection") (grade I to III), and (6) other. The goal is to devise a schema in which a given biopsy grading would imply a prognosis for a therapeutic response or long-term function. While the clinical implications must be proven through further studies, the development of a standardized schema is a critical first step. This standardized classification should promote international uniformity in reporting of renal allograft pathology, facilitate the performance of multicenter trials of new therapies in renal transplantation, and ultimately lead to improvement in the management and care of renal transplant recipients.

Glomerular abnormalities in children undergoing orthotopic liver transplantation.

A prospective study of renal function was undertaken on an unselected group of 8 children with chronic progressive liver disease on whom a renal biopsy was performed subsequently at the time of orthotopic liver transplantation. Two patients had abnormal urinalyses and 2 elevated urinary albumin/creatinine ratios. The remainder had no clinical evidence of renal dysfunction. All had normal serum creatinine concentrations. Glomerular abnormalities were present in all renal biopsies and were of two types: hepatic glomerulosclerosis (n = 5) and minor glomerular abnormalities (n = 3). IgM immunofluorescence was present in all biopsies and IgA in 6. Elevated serum immunoglobulin levels were observed in all patients, with IgM elevation in 6, IgA in 4 and IgG in 6. C3 and/or C4 were reduced in 5 patients and increased circulating immune complexes containing IgM were noted in 4. The clinical significance of these cirrhosis-associated glomerular abnormalities can only be established by long-term follow-up studies after orthotopic liver transplantation.

Universal occurrence of glomerular abnormalities in patients receiving liver transplants.

We conducted a prospective study of renal histology and function in 18 consecutive nonalcoholic patients who underwent orthotopic liver transplantation (OLT). Despite well-preserved renal function, all patients had abnormal renal biopsies. Four patterns of glomerular injury were identified: minor glomerular abnormalities (eight patients), hepatic glomerulosclerosis (seven), membranoproliferative glomerulonephritis (one), and IgA nephropathy (one). In one patient there was insufficient tissue to allow classification. There was a trend toward lower plasma bilirubin and higher plasma albumin in patients with minor glomerular abnormalities than in the group of patients with more severe forms of glomerular injury (29 v 82 mumol/L, 35.5 v 30 g/L; P = 0.1, 0.1 greater than P greater than 0.05, respectively). Glomerular changes persisted in the three patients who died within 7 weeks post-OLT. IgM immunofluorescence was present in all biopsies and IgA in 11. IgM-containing circulating immune complexes occurred in five patients, suggesting a pathogenic role for IgM immune complex deposition. The significance of cirrhosis-associated glomerular abnormalities is not yet known. They may contribute to the hepatorenal syndrome and the renal dysfunction that occurs in up to 94% of patients post-OLT.

Effects of hypoxia on morphological and biochemical characteristics of renal epithelial cell and tubule cultures.

Apoptotic cell death plays an important role in the pathogenesis of renal atrophy in diseases of the kidney involving chronic mild ischemia. The present study constitutes an in vitro model of these diseases and assesses the modes of cell death involved after hypoxic treatment of renal epithelium. Cultures of MDCK cells or primary cultures of rat renal parenchymal tubules were treated in either a physiological or a hypoxic atmosphere. Cultures were collected before treatment and at 24 h and 48 h, for morphological and biochemical studies. Both apoptosis and necrosis were observed at significantly increased levels by 48 h of hypoxia in the MDCK cell cultures. DNA gel electrophoresis patterns supported these findings. Experiments using tubule cultures demonstrated that, during the 48 h of study, tubular epithelial cells in the center of the control tubule structures died by apoptosis, possibly as a result of mild oxygen and/or nutrient depletion. With added hypoxic treatment, however, the entire tubule structure became necrotic. Results are similar to those found during in vivo studies, thus providing in vitro models that may be developed further to define factors in the pathogenesis of some renal diseases.

Intravascular large cell lymphoma: diagnosis on renal biopsy.

The case is reported of a woman aged 60 yrs who presented with systemic symptoms and who was found to have proteinuria of 3.5 g per day. A renal biopsy revealed numerous neoplastic cells filling many of the glomerular capillary lumina. Immunoperoxidase stains revealed that the phenotype of the malignant cells was LCA+, L26+, MB2+, UCHL1-, CD43-, CAM5.2- and S100-, indicating that they were of lymphoid origin and B-cell lineage. The diagnosis of intravascular large cell lymphoma was therefore made. Remission was induced by chemotherapy with CAVP (cyclophosphamide, adriamycin, vincristine and prednisone). A subsequent relapse was treated with cyclophosphamide, VP16 and prednisone, and again remission occurred. This is the first case known to the authors in which the diagnosis of intravascular large cell lymphoma was made on renal biopsy. We confirm the experience of others that chemotherapy with regimens utilized in other varieties of large cell lymphoma may also be appropriate for this unusual neoplasm.

The role of apoptosis in the development of renal cortical tubular atrophy associated with healed experimental renal papillary necrosis.

An animal model of chronic analgesic nephropathy, in which renal papillary necrosis was induced by the administration of a single injection of bromoethylamine 2-hydrobromide in male Sprague-Dawley rats, was used to investigate the pathogenesis of the atrophy of tubules that leads to cortical atrophy or 'scarring' in analgesic nephropathy. One of the major objectives was documentation of the participation of apoptosis, a distinctive mode of cell death, in the process of cortical tubular atrophy. Control and treated groups of animals were studied at 2 wks, and at subsequent monthly intervals up to 4 mths. At each time, light microscopy and ultrastructure were used to relate changes in cellular pathology to alterations in renal mass. Apoptosis was quantitated in paraffin sections, and autoradiographic identification of cells showing tritiated thymidine uptake was used as an indication of cell proliferation. In animals with total renal papillary necrosis (RPN), focal or diffuse cortical atrophy developed, the extent of which appeared to be proportional to the extent of the RPN. Renal mass was reduced only in those kidneys that developed extensive, diffuse lesions. Compensatory renal growth occurred in the areas of healthy tissue adjacent to the foci of atrophy, with both cellular hyperplasia and hypertrophy playing roles in its development. One of the prominent cellular events was the appearance of apoptotic cells and bodies, with invading intraepithelial macrophages involved in their phagocytosis and degradation. We propose that this form of cell death plays an important role in the pathogenesis of cortical atrophy. Current descriptions of the cortical lesions that occur in analgesic nephropathy refer to the changes as 'scars'. Although the focal lesions have a macroscopic appearance that resembles scars, the results of the present study indicate that usage of this terminology may be misleading, since scarring is often described after severe tissue injury or necrosis, which was not identified in the present study.

Ultrastructural studies of the reaction of urate crystals with a cultured renal tubular cell line.

Hypotheses concerning the development of uric acid and gouty nephropathy suggest that the initiating disease mechanism involves an interaction between uric acid or monosodium urate monohydrate (MSUM) crystals and renal tubular epithelial cells. We have studied the interaction of these crystals with Madin-Darby canine kidney (MDCK) cells, which exhibit many of the characteristics of cells of the collecting duct epithelium. Addition of MSUM crystals to monolayer cultures of MDCK cells leads to the formation of reaction sites, localised areas which are raised above the monolayer forming a 3-dimensional structure. These reaction sites are evident within 4-8 h and appear to be initiated by the interaction of a single crystal or small number of crystals with a single cell. With time, both cells and crystals accumulate at the site. By 24 h most reaction sites involve 6-12 cells and numerous crystals. Interaction of MSUM crystals and MDCK cells not only involves the attachment of crystals to cells but, by 8 h, some crystals appear to be completely or partially covered by the cell membrane, and MDCK cells appear to react by growing around the crystals. Transmission electron microscopy shows that crystals are found not only within cells, but also within the intercellular spaces. Within the cells, crystals have been shown in vacuoles containing lysosomal enzymes, indicating the formation of a phagolysosome. Ultimately, enzyme release occurs. These studies support the hypothesis that some interstitial deposits of urate and uric acid in the kidney may be derived from intratubular deposits that react with the tubular epithelium and pass into the interstitium; loss of tubular integrity may not be a prerequisite for crystal migration.

Cellular events in experimental unilateral ischemic renal atrophy and in regeneration after contralateral nephrectomy.

Two related morphological studies were undertaken in rats. In the first, cellular events involved in the development of ischemic renal atrophy induced by renal artery stenosis were recorded. One primary objective was to document the pathogenetic role that a distinct form of cell death, termed apoptosis, played in the development of renal tubular atrophy. A small, partially closed ligating clip was used to produce stenosis of the left renal artery, or a sham operation was performed. Animals were killed 2-28 days after operation. The ensuing ischemic renal atrophy was studied histologically and ultrastructurally, and apoptosis was counted in paraffin sections, using established criteria for its identification. Nuclear [3H]thymidine uptake was used as an indicator of cell proliferation. Morphometric studies recorded changes in area of transected tubular profiles. Correlation was sought between the morphological changes, data gained by the above quantitations, and the progressive reduction in renal mass that occurred during the experiment. Our results showed that during the acute phase (2-8 days), cell death was effected by both apoptosis and necrosis and increased tubular epithelial cell labeling and mitoses provided evidence of epithelial repair. During the chronic phase (10-28 days), when the mass of the ischemic kidney underwent significant reduction, cell death was effected by apoptosis alone, and the level of tubular epithelial cell labeling and mitosis returned to near normal. Intraepithelial macrophages were significant in removing the apoptotic bodies. Area of tubular epithelium was reduced in atrophic tubules, and it is proposed that this reduction may be explained by apoptotic cell deletion, as well as cell shrinkage. In the second study, evidence of regeneration was sought in atrophic kidneys after surgical reversal of renal artery stenosis and, in other animals, after unilateral nephrectomy of the contralateral kidney. Our results showed that regeneration, involving both hypertrophy and hyperplasia, was stimulated only by removal of the hypertrophied contralateral kidney and occurred whether or not stenosis of the renal artery was reversed.

Reaction of MDCK cells to crystals of monosodium urate monohydrate and uric acid.

Madin-Darby canine kidney (MDCK) cells exhibit many of the characteristics of cells of the cortical collecting tubule. Since hypotheses concerning the development of gouty and uric acid nephropathy involve a reaction between such cells and crystals, either of monosodium urate monohydrate (MSUM) or uric acid, the reaction between MDCK cells in culture and the above crystals was studied, both morphologically and functionally. In monolayer cultures, reaction sites developed within four hours of exposure to urate crystals. These increased in number for up to 72 hours and subsided gradually after removal of the crystals. At these reaction sites, crystals were observed to have passed beneath the cell surface and could be demonstrated both within intra-cellular lysosomes as well as within the inter-cellular spaces. When the MDCK cells were maintained as single cells in suspension, phagocytosis of crystals by the majority of the cells could be observed, but the response was much more rapid than in monolayers. During the cell/crystal reaction, significant amounts of lysosomal enzymes and prostaglandin E2 were released and, to a less significant degree, cytosolic enzymes, presumably due to cell lysis. This enzyme release did not occur in MDCK cells grown in protein-free medium, and protein coating of the crystals was necessary for reactivity with cells. In this regard, coating with IgG or lysozyme was more effective than albumin. The reaction with uric acid crystals revealed a reactivity which was lesser in degree but qualitatively similar to that of urate crystals.(ABSTRACT TRUNCATED AT 250 WORDS)

Cell death by apoptosis following X-irradiation of the foetal and neonatal rat kidney.

A light and electron microscopic study was undertaken to determine the type of cell death induced by X-irradiation in the developing kidney. Five-day-old Sprague-Dawley rats were exposed to a whole-body dose of either 2 or 5 Gy, and foetuses in the eighteenth day of development were exposed to a dose of 4 Gy. The kidneys were examined at 4, 8 and 24 h, and at 1 and 2 weeks post-irradiation. The dying cells from both control and treated kidneys showed the morphological features of apoptosis, a distinct form of cell death that has been identified in mammalian tissues under physiological as well as pathological conditions. Necrosis was not detected. Apoptosis was infrequent in control kidneys and insignificant in extent when compared with the proliferative activity of the cells of the superficial nephrons. There was a pronounced increase in apoptosis during the first day after irradiation. The findings are in agreement with recent ultrastructural studies which report the presence of apoptosis following irradiation of rapidly proliferating adult cell populations, and irradiation of other immature mammalian tissues. There is evidence that apoptosis involves active cellular self-destruction, and it has been suggested that activation of apoptosis might bring about selective elimination of cells with critical DNA damage in irradiated tissues, thus minimizing propagation of genetic abnormalities.

Functioning lipoadenoma of the parathyroid gland.

A lipoadenoma of the parathyroid gland was discovered at autopsy as the result of a search for the cause of terminally detected hyperparathyroidism in an elderly man who had suffered cerebral infarction. It is the only case known to the authors in which this uncommon cause of hyperparathyroidism was found at post-mortem examination after hypercalcemia and raised levels of serum immunoreactive parathormone were documented during life.