Abatacept use in graft-versus-host disease after orthotopic liver transplantation: a case report.

BACKGROUND: Graft-versus-host disease (GVHD) is a rare, serious, fatal disease that occurs after orthotopic liver transplantation (OLT). CASE REPORT: We treated a 60-year-old man who underwent OLT owing to familial amyloidosis. The patient developed fever on postoperative day 16. The fever was persistent and did not respond to antibiotic therapy. Cultures and radiologic studies were done and excluded infection as a potential cause. On postoperative day 26, a skin rash appeared on his chest, accompanied by diarrhea and persistent fever. The rash spread all over the trunk, neck, and arms, but spared the palms of his hands and soles of his feet. In the meantime, his blood cell count revealed pancytopenia. Skin biopsy was done and showed interface lymphocytic infiltrate that are largely centered on the dermal-epidermal junction, is consistent with GVHD (this pattern of rash distribution is unique and different from the rash of GVHD after hematopoietic stem cell transplant, which is confined to palms of the hands and soles of the feet; Fig 1). The diagnosis was confirmed by colonoscopy and multiple forceps biopsies, which revealed extensive crypt loss. After hematology consultation, the patient was treated by withdrawal of all immunosuppressive therapy coupled with abatacept infusion. Abatacept is a chimeric protein that inhibits T-lymphocytes and is approved by the US Food and Drug Administration for the treatment of rheumatoid arthritis. Interestingly, after second dose of abatacept the patient showed marked clinical and laboratory improvement. The patient was discharged after 47 days in a stable condition. CONCLUSION: Because of the lack of a consensus for treatment of these patients, we report our experience with a male patient who had post-OLT GVHD and showed a marked improvement in response to abatacept.

Clinicopathological review of 18 cases of liver allografts lost due to bile duct necrosis.

Clinical, radiographic, and pathological features of 18 patients with biliary necrosis in their explanted liver allografts were reviewed. Twelve patients were men and ages ranged from 27 to 72 years. Indications for initial liver transplant (LT) were viral hepatitis (n = 7), steatohepatitic cirrhosis (n = 3), cryptogenic cirrhosis (n = 3), secondary sclerosing cholangitis (n = 2), primary sclerosing cholangitis (n = 1), biliary atresia (n = 1), and nodular regenerative hyperplasia (n = 1). Donor age ranged from 16 to 75 years. Duct-to-duct biliary anastomoses were fashioned in 13 cases; warm and cold ischemia times were not significantly different from general LT population. Seventeen allograft biopsies after recirculation had no significant findings. Post-LT, clinical and radiographic evaluation indicated biliary strictures (n = 7), bile leak (n = 7), intrahepatic abscess (n = 1), and duodenal perforation (n = 1). Radiographic vascular studies suggested hepatic arterial thrombosis or stenosis in 11 cases. Biopsies prior to retransplantation were performed on 17 patients and showed acute rejection (n = 10), biliary outflow impairment (n = 4), normal histology (n = 2), and centrilobular necrosis (n = 1). Retransplantation was performed 14 to 334 days after initial LT. Pathological examination of explants revealed perihilar duct necrosis in all cases, with bacterial colonies (n = 10) and fungal organisms (n = 2). Arterial thrombi were seen in 10 cases, and two had prominent arteriosclerosis. Infarction and centrilobular necrosis were seen in 9 and 13 cases, respectively. Four explants showed features of biliary outflow impairment. Twelve patients were alive 6 to 18 months following retransplantation. We conclude that post-LT biliary necrosis is associated with ischemia, and such a complication is rarely evident in allograft biopsies. Biliary and vascular imaging studies are essential in evaluating patients for this complication.

Platelet-directed antibody in the serum of patients with primary thrombotic thrombocytopenic purpura.

Utilizing two platelet antibody assay systems, flow cytometric analysis and a microcytotoxicity assay, it was possible to demonstrate for the first time platelet-directed antibody in the sera of three of six patients with primary thrombotic thrombocytopenic purpura. These results lend support for an immune-mediated pathologic process in some patients with this disorder.

Sperm antibodies and human leukocyte antigens in couples with early spontaneous abortions.

Twenty-six couples with two or more early spontaneous abortions and 53 couples with recently proven fertility (control group) were typed for human leukocyte antigens (HLA) of A and B loci and screened for the presence of cytotoxic and hemagglutinating antibodies to sperm. Eighteen other couples with two or more abortions were tested for sperm antibodies alone. Both partners in 24 of 44 (54%) aborting couples were positive (titers of greater than or equal to 32), whereas the control group had sperm antibodies in the negative range (titers of 0 to 16; P less than .0001). Thirty-one husbands (70%) and 24 wives (54%) were positive for sperm antibodies in the study group. Sharing of HLA-A and/or -B antigens between partners was similar in the control and study groups. Fourteen of 26 (54%) couples with two or more abortions did not share HLA-A and/or -B antigens, in contrast to 14 of 53 (26%) in the control fertile group (P less than .02). Antigenic frequencies of HLA-B7 singly and in combination with HLA-B35 were increased in females in the aborting but not in the fertile control group (P less than .001). The combined incidence of HLA-B7, -B8, and -B35 in both partners was significantly higher in the aborting couples as contrasted with the control group. It is suggested that the presence of sperm antibodies is associated with early pregnancy wastage. Histocompatibility antigens B7 and B35 may play a role through their association with sperm antibodies and early spontaneous abortions.

Antibodies to microbial, leukocyte and organ antigens.

Hemagglutinating antibodies to Mycoplasma hominis were present in 30 of 83 infertile, 15 of 40 pregnant and 5 of 20 post-partum females and 20 of 82 infertile males in contrast to only 2 of 21 fertile females and 5 of 25 fertile males. Their presence correlated with sperm antibody detection by TAT in Lab. 4, the immunobead-binding assay of Lab. 1 and the SIT of Lab. 11, but not with other sperm antibody assays. Immunofluorescent antibodies to Chlamydia trachomatis, on the other hand, did not correlate with the incidence of sperm antibodies. Among 305 serum samples tested, 12 were positive for testicular antibodies, 8 had antibodies to kidney, 7 to ovary and 15 to endometrium. A majority of serum samples positive for antibodies to testis and ovary, but not endometrium, reacted against sperm in different assays. Eight of 135 samples tested had antibodies to human leukocyte antigenic HLA-Aw19 (Aw19, A28, A29, A30 and A32) and/or B35 (B35, B5 and B15) complexes. Six of these samples were also positive for sperm antibodies by one or more antibody assays. Cross-reactive antigens may be present in sperm, M. hominis, testis, ovary and leukocytes.

Females' isoimmunity to sperm is associated with sperm autoimmunity in their husbands.

One hundred twenty-five fertile couples and 334 infertile couples were tested for the presence of cytotoxic and hemagglutinating antibodies to sperm. Elevated titers of sperm antibodies were absent in both partners of fertile couples. Of 79 infertile males with levels of sperm antibodies in the previously established negative range, 97% had wives who also had low titers of sperm antibodies. Of 255 infertile males positive for serum hemagglutinating antibodies, 56% had wives whose serum contained significant circulating hemagglutinating antibodies, while 93 of 202 (46%) males with significant cytotoxic antibody titers had wives whose serum contained elevated cytotoxic antibody titers. The females developed elevated titers of sperm antibodies in the serum and cervical mucus if their husbands had significant titers of hemagglutinating and cytotoxic sperm antibodies in the serum and seminal plasma samples. Females' isoimmunity to sperm was significantly associated with their husbands' autoimmunity to sperm and infertility.

Antibodies to A19 and Bw35 complexes of human leukocyte antigens are present in infertile subjects with sperm antibodies.

Sera and secretions from 100 couples with unexplained infertility were tested for sperm antibodies by cytotoxicity and passive hemagglutination and also for antibodies to human leukocyte antigen (HLA) by cytotoxicity assays. Lymphocytes of the study subjects were typed for 61 HLA-A and B alleles. Thirteen of 30 (43%) men with sperm autoimmunity also had HLA antibodies in their serum and/or seminal plasma samples, in contrast to 2 of 35 (6%) nonautoimmune males (P = 0.0003). Twenty-five of 35 (71%) sperm antibody-positive infertile women had HLA antibodies in their sera and/or secretions, while only 7 of 31 (23%) women without sperm antibodies were positive (P = 0.00007). Antibodies to HLA-A19 (A26, A29, AW30, AW31, AW32, AW33, and AW34) and Bw35 (B5, B15, B17, and B18) complexes were present in 19 of 22 (86%) infertile men and 44 of 48 (92%) infertile women positive for HLA antibodies (P less than 0.01). The presence of antibodies to HLA-A19 and/or Bw35 in the infertile subjects did not correlate with the presence of HLA-A19 and/or Bw35 in the husbands. The presence of antibodies to HLA-A19 and/or Bw35 in the cervical mucus of the infertile women correlated with their presence in the seminal plasma of their husbands. It is suggested that antibodies to sperm antigens cross-reactive with HLA-A19 and/or Bw35 may be relevant to infertility.

Detection of platelet antibodies by flow cytometric analysis.

A rapid, sensitive indirect immunofluorescence assay utilizing flow cytometry to detect immune-mediated thrombocytopenia is described. Fluorescein-conjugated F(ab')2 antihuman IgG or IgGAM is reacted with donor platelets after their incubation with test sera and the resulting immune complex is measured using flow cytometric analysis. With this technique excess of Ig on the platelet, expressed as a ratio of fluorescence of test sera/autologous control sera, was noted in 24 of 30 patients (80%) with immune thrombocytopenias caused by auto- or allo-antiplatelet antibodies. Twenty-four sera from nonimmune thrombocytopenic patients were consistently negative. This technique has the advantage of being highly reproducible and avoids the subjective interpretation inherent with manual immunofluorescence assays.

Association of human leukocyte antigens B7 and BW35 with sperm antibodies.

One hundred three infertile couples and 50 fertile couples were tested for the presence of sperm antibodies by passive hemagglutination and cytotoxicity assays and typed for human leukocyte antigens (HLAs) of the A and B loci. Fifty-four percent of the males and 43% of the females with sperm antibodies were found to have the HLA-B7 antigen, in contrast to 19% of a general population (P less than 0.0001). HLA-BW35 (a Workshop antigen of the B locus) was also present at a significantly increased antigenic frequency (P less than 0.00001) in those females with sperm antibodies. Of the 73 infertile couples with sperm antibodies, 79% shared the B7, B8, and/or BW35 alleles. Two of 12 infertile couples and 10 of 50 fertile couples without sperm antibodies shared these alleles. The significant association of HLA-B7 and BW35 alleles with sperm antibodies in infertile subjects suggests a selective disadvantage of these antigens in human reproduction.

Cytotoxic antibodies to lymphocytes: relationship to sperm immunity.

Sperm and T lymphocytes share antigens, and sera from infertile subjects with sperm immunity have agglutinating antibodies to T lymphocytes. In the present study, cytotoxic antibody titers to sperm (C-Sp) and lymphocytes (C-Ly) were measured in sera, seminal plasma, cervical mucus and vaginal secretions of 52 infertile couples. The samples were divided into C-Sp negative and C-Sp positive groups. C-Ly titers against control T lymphocytes were significantly elevated in C-Sp positive sera of 35 males (P less than 0.005) and 27 females (P less than 0.05) as compared with C-Sp negative sera. C-Ly titers against autologous or partner T lymphocytes were similarly elevated in the sera of both groups. Titers of C-Ly in C-Sp positive secretions (seminal plasma, cervical mucus and vaginal secretions) against autologous and partner, as well as control, T lymphocytes were significantly elevated. In addition, elevated titers of C-Ly to autologous, partner and control B lymphocytes were observed in sera, cervical mucus and vaginal secretions from females with sperm immunity. The infertile males, however, did not have significant B lymphocyte immunity. Immunofluorescence assays revealed a significantly higher incidence of sperm and T lymphocyte antibodies (primarily IgG) in the C-Sp positive than in the C-Sp negative group. Titration of 100 sera from infertile subjects (50 couples) against a panel of lymphocytes of known HLA specificities failed to reveal a pattern of activity against HLA antigens of the A, B and C loci. Absorption of immune sera with sperm or lymphocytes reduced C-Sp and C-Ly titers significantly (P less than 0.001). These results suggest that infertile subjects with sperm immunity produce antibodies to cross-reactive antigens present on sperm and T lymphocytes.

Sperm immunity in infertile couples: antibody titers are higher against the husbands' sperm than to sperm from controls.

Titers of hemagglutination and cytotoxic antibodies to sperm were determined in the sera, seminal plasma, cervical mucus, and vaginal secretions from 69 infertile couples, using sperm from the husbands and from normal control subjects. Titers of hemagglutination and cytotoxic antibodies were significantly higher (p = 0.002 and p less than 0.001, respectively) against autologous sperm as contrasted with sperm from control subjects in sera from 55 autoimmune males. Hemagglutination and cytotoxic antibody titers were also significantly higher (p = 0.044 and p less than 0.001, respectively) against their husbands' sperm as contrasted with control sperm in sera from 46 females with isoimmunity to sperm. Ninety percent of males and females with sperm immunity were positive for histocompatibility antigens HLA-B7, HLA-B8, and/or HLA-BW35. In males, the presence of increased serum cytotoxic antibody titers against autologous versus control sperm was significantly associated with the presence of HLA-B7 allele (p = 0.0017) and with HLA-B7, HLA-B8, and/or HLA-BW35 in general (p less than 0.05). In the females, increased serum antibody titers to their own husbands' versus control sperm were not preferentially associated with HLA-B7, HLA-B8, or HLA-BW35 antigens.

Role of neutrophil antigen NA1 in an infant with autoimmune neutropenia.

A nontransfused 14-month-old female infant was investigated for persistent neutropenia of eight months' duration, with absolute neutrophil counts ranging from 410 to 935 cu mm. The patient's sera reacted with neutrophils from her own peripheral blood, from normal donors, and from her mother, all these having the neutrophil antigen NA 1, but not with neutrophils from NA 1-negative donors, including the father. The autoantibody was detectable by capillary agglutination and by indirect immunofluorescence techniques but not by complement-dependent cytotoxicity. No antibody was found in the mother's serum. Studies on three occasions showed good correlation between the appearance of circulating autoantibody and the peripheral neutrophil counts. Our observations, together with previously published reports, suggest a possible relationship of NA 1 antigen and the disease susceptibility of NA 1-positive infants to autoimmune neutropenia.

Platelet collection and transfusion using the fenwal CS-3000 cell separator.

A prototype model of the Fenwal CS-3000 Blood Cell Separator (Deerfield, IL) was studied for plateletpheresis in 63 donors and 5 transfusions in patients. Donor effects were consistent with platelet removal and mild hemodilution. The incidence of reactions (9 of 63) was low and all were mild "citrate" type. A two-hour collection yielded 4.0 +/- 0.72 x 10(11) platelets at an efficiency of 45 +/- 6.9 per cent. The product had little contamination with leukocytes (0.26 +/- 1.2 x 10(9) and red blood cells (hematocrit less than 1%). Morphology and pH were well preserved during 24 hours of storage. Four patients with uncomplicated aregenerative thrombocytopenia were transfused on five occasions, with a mean of 4.5 +/- 0.87 x 10(11) platelets resulting in a mean platelet count increment of 55,000/microliter and dramatic reduction in template bleeding times.

The response of human platelets to hypotonic stress: direct measurement of volume change.

Human platelets stored at 22 degrees C were subjected to standard hypotonic stress at intervals up to five days after collection. Changes in light absorbance were recorded during the reaction, and size distribution was measured directly using a Coulter Model ZBI Counter and Channelyzer. Recovery following osmotic stress was measured by change in absorbance, as well as by change in platelet size distribution. Significant correlation was demonstrated between the two methods. By both measures, fresh platelets demonstrated substantial recovery following hypotonic stress, but platelets stored for five days had lost this ability. The requirements for intact sulphydryl groups and the lack of effect of colchicine were confirmed.