Persistent nausea and anorexia after marrow transplantation: a prospective study of 78 patients.

BACKGROUND: Persistent nausea, vomiting, anorexia, and poor oral intake are common after hematopoietic cell transplantation. In the past, herpesvirus infections and acute intestinal graft-versus-host disease (GVHD) were the most common causes. METHODS: We studied 76 patients with 78 episodes of these symptoms to discern the causes. Diagnoses were based on histology of skin and intestinal biopsy specimens, viral cultures, and responses to therapy. RESULTS: The mean day of study entry was day 57+/-31.3 posttransplant. Acute GVHD was the most common cause of symptoms, affecting 63 patients (81%) as the sole cause of symptoms and an additional 4 patients (5%) who had other concurrent causes. Patients with GVHD had marrow donors who were unrelated or HLA-mismatched in 27/63 cases. Gastric edema, erythema, and apoptotic epithelial cells were the most useful findings for the diagnosis of GVHD. Prednisone therapy (1-2 mg/kg/day) was effective in 58 of 63 patients (92%). Infection by herpes simplex virus, cytomegalovirus, or Candida was found in six patients, three of whom had concurrent GVHD. Other causes of symptoms were medications (one patients), parenteral nutrition (one patient), and sagittal sinus thrombosis (one patient). CONCLUSIONS: Acute GVHD is now the dominant cause of persistent nausea and anorexia in marrow transplant patients who are beyond day 20 posttransplant. The diagnosis can be made clinically in most cases and confirmed by endoscopic biopsy of gastric mucosa. Infections, medications, and rare cases of central nervous system disease are much less common.

Cyclin kinase inhibitors are increased during experimental membranous nephropathy: potential role in limiting glomerular epithelial cell proliferation in vivo.

The inadequate proliferative response of the visceral glomerular epithelial cell (GEC) following injury in vivo may contribute to the development of progressive glomerulosclerosis in many forms of glomerular disease. Cell proliferation is ultimately controlled by cell-cycle regulatory proteins, including cyclins that bind to cyclin dependent kinases (CDK), and the active complex formed is necessary for progression through the cell-cycle. By inhibiting cyclin-CDK complexes, cyclin kinase inhibitors arrest the cell-cycle and prevent proliferation. To determine the mechanisms that may be responsible for the lack of GEC proliferation in vivo, we examined GEC expression of specific cell-cycle proteins in normal rats and in the passive Heymann nephritis (PHN) model of membranous nephropathy, where the GEC are the target of complement-mediated injury. Following antibody deposition and complement activation there was a marked up-regulation in the cyclin kinase inhibitors p21 and p27 in rats with PHN. By associating with cyclin A-CDK2 complexes, p21 and p27 limited the kinase activity of CDK2. Giving bFGF to rats with PHN was associated with an increase in GEC mitosis and ploidy and a decrease in expression of p21, but not CDK2 or p27. Furthermore, apoptosis was not present in PHN, but was increased in rats given bFGF. In conclusion, this study shows that the low proliferative capacity of the GEC in vivo in response to immune injury may be due to an increase in the expression of specific cyclin kinase inhibitors. The increase in mitosis in PHN rats given bFGF may be due to a decrease in p21. Thus, changes in cell cycle regulatory proteins may regulate the response of GEC to injury and underlie the development of progressive glomerulosclerosis in diseases of the GEC.

Deregulated Bcl-2-immunoglobulin transgene expands a resting but responsive immunoglobulin M and D-expressing B-cell population.

We characterized the basis for the follicular lymphoproliferation in transgenic mice bearing a Bcl-2-immunoglobulin (Bcl-2-Ig) minigene representing the t(14;18) of human follicular lymphoma. Discriminatory S1 nuclease protection assays revealed that the Bcl-2-Ig transgene was overexpressed relative to endogenous mouse Bcl-2 in spleen and thymus. Western (immunoblot) analysis demonstrated the overproduction of the human 25-kilodalton Bcl-2 protein, which arose from the transgene, in spleen, thymus, and the expanded B-cell subset. Despite the generalized lymphoid pattern of deregulation, two-color flow cytometry and density gradient centrifugation indicated that the expanded lymphocytes were predominantly small, resting B cells coexpressing B220, immunoglobulin M (IgM), IgD, Ia, and kappa. Cell cycle analysis confirmed that about 97% of these expanded B cells reside in G0/G1. An extensive characterization of transgenic lines revealed a fourfold excess of IgM-IgD-expressing B cells in spleen and dramatically increased numbers in bone marrow. While resting, these cells proliferated in response to lipopolysaccharide and anti-IgM and demonstrated normal B-cell colony formation in soft agar. Moreover, these B cells, which demonstrated an extended survival in vitro even in the absence of stroma, were also resting in G0, yet were capable of proliferative responses. These findings provide consistent evidence that the accumulation of B cells after Bcl-2 overproduction is secondary to prolonged cell survival and not increased cell cycling. This suggests a unique role for Bcl-2 as a proto-oncogene that enhances cell survival independent of promoting cell division.

Apolipoprotein B subspecies in chylomicrons isolated from a patient with chyluria.

The diagnosis and the clinical course of a 17-year-old white male with chyluria are reported. Cloudy, milky urine appeared spontaneously, in the absence of edema or any signs or symptoms of parasitic infection. Pedal lymphangiography demonstrated the presence of a lymphatic renal fistula, and digital subtraction angiography showed aneurysmal dilatation of the aorta at the level of the renal arteries. This case provided an opportunity to ascertain which of the forms of apolipoprotein B were present in lymph chylomicrons. Apolipoprotein B is needed for chylomicron secretion. It exists in several forms--B-100, B-74, B-48, and B-26. After a meal consisting of fat, chylomicrons in which apolipoprotein B-48 was virtually the only apolipoprotein B present appeared in the urine, while apolipoprotein B-100 was the only apolipoprotein B present in the plasma very low-density lipoproteins. Chyluria disappeared two weeks after institution of a low-fat diet. This case illustrates an interesting, rare cause of chyluria. Because of the presence of chyluria, it was also demonstrated that chylomicrons in which apolipoprotein B-48 is virtually the only apolipoprotein B present are a physiologically normal product of the intestine.