CD3 antibody-induced IL-10 in renal allograft recipients: an in vivo and in vitro analysis.

BACKGROUND: The first administration of CD3 monoclonal antibodies, such as anti-human CD3 (OKT3), induces a massive release of several cytokines, including tumor necrosis factor alpha (TNF-alpha), interferon (IFN)-gamma, interleukin (IL)-2, IL-3, IL-6, and granulocyte-macrophage colony-stimulating factor. METHODS: Cytokine levels in patient's sera were measured by specific ELISA. In vitro cultures were performed using OKT3-stimulated peripheral blood mononuclear cells and/or whole blood from patients and normal controls. RESULTS: Here we describe that OKT3 administration to human renal allograft recipients also leads to a significant release of IL-10. Contrasting with most OKT3-induced cytokines, such as TNF-alpha whose release is transient, IL-10 levels show a more progressive increase, they peak only by 4-8 hr after the first OKT3 injection and persist longer. Thus, significant IL-10 levels are still detectable at the time of the second and the third OKT3 injection. Administration of corticosteroids, 1 hr before the first OKT3 injection, significantly reduced both TNF-alpha and IL-10 release. Experiments were performed to evaluate the source(s) of IL-10 and its (their) influence on the initial T-cell activation. When stimulated in culture with soluble OKT3, the production of IL-10 was dependent on the cooperation between T lymphocytes and monocytes. It is important that, as assessed through the use of a specific neutralizing antibody, the endogenous IL-10 produced in the co-culture system exerted a negative feed-back on the release of the other pro-inflammatory CD3-induced cytokines, which was reproducible. CONCLUSION: These results are supportive of a major role of IL-10 in the down-modulation of the OKT3-triggered T-cell activation cascade.

Distinct HLA class II alleles determine antibody response to vaccination with hepatitis B surface antigen.

Major histocompatibility complex (MHC) determinants control antibody production in response to protein antigens. Vaccination with hepatitis B surface antigen (HBsAg) frequently fails in hemodialyzed patients, but the genetic factors that modulate humoral responsiveness are poorly characterized. We studied the distribution of HLA class II alleles in 415 hemodialyzed Caucasian patients who received a full course of HBsAg vaccination, using class II oligotyping after genomic amplification of the DRB1 and DQB1 loci. Phenotype frequencies were compared in 114 non responders (anti-HBs antibodies < or = 10 SI units/liter), 301 responders (anti-HBs antibodies > 10 units/liter) and 471 healthy controls. DRB1*01 (DR1) and DRB1*15 (DR15) frequencies were lower in nonresponders than in responders and controls (DR1, 12.3% vs. 22.9% and 24.8%, respectively; DR15, 14% vs. 22.9% and 25.1%), while DRB1*03 (DR3) and DRB1*14 (DR14) frequencies were higher (DR3, 32.5% vs. 16.6% and 25.3%, respectively; DR14, 9.6% vs. 3% and 6.6%). Overall, 44.5% of DR3 or DR14 patients were nonresponders, compared to 18.1% of DR1 or DR15 patients (P = 0.0001). In conclusion the humoral response to HBsAg vaccine is influenced by class II allelic variants, which differ in their capacity to bind and present peptides to T lymphocytes.

Adequacy of haemodialysis and nutrition in maintenance haemodialysis patients: clinical evaluation of a new on-line urea monitor.

BACKGROUND: Recent developments in urea sensing monitoring show a good agreement between on-line and direct dialysis quantification which permits evaluation of both effective dialysis efficiency and protein catabolic rate of dialysis patients. METHODS: Fifty chronic haemodialysis patients were enrolled in a prospective study using an automatic urea sensing monitor operating on spent dialysate (U.M. 1000, Baxter). Dietary protein intake (DPI) and energy intake (DEI) were carefully evaluated by a skilled dietitian over 1 week. During this run U.M. 1000 was used to provide urea mass removed, effective Kt/V, and normalized nPCR. Blood samples were drawn pre- and post-dialysis for classical blood-based single pool Kt/V calculations at each session. RESULTS: For all patients results were as follows (mean +/- SD): Effective Kt/V 1.4 +/- 0.3, nPCR 1.2 +/- 0.3 g/Kg/day, DPI 1.2 +/- 0.3 g/Kg/day and DEI 30.1 +/- 7.2 Kcal/kg/day; blood-based single pool Kt/V 1.5 +/- 0.3. A strong correlation was found between nPCR and DPI for the 50 patients over 1 week (r = 0.75, P < 0.0001) and between effective Kt/V and single pool calculated Kt/V (r = 0.76). CONCLUSIONS: Urea Monitor 1000 is easy and convenient to use and there was a good correlation of the predialysis BUN and effective Kt/V with standard blood-side measurements. In stable haemodialysis patients who are not strongly catabolic or anabolic, the urea monitor measurement of nPCR correlated with DPI measured by a 7-day dietary record.

Accumulation of 5 alpha-reduced androgen glucosiduronates associated with impaired removal in young male hemodialysis patients.

Hypothalamic-pituitary gonadal function is commonly altered in dialysis patients. Even though an improvement in general status and well-being has been noted after recombinant human erythropoietin supplementation, no significant changes were observed in the sex hormone profile. Pituitary gonadal axis as well as 5 alpha-reduced androgen glucosiduronates (i.e. 5 alpha-androstane,3 alpha,17 beta-diol and androsterone) profiles were studied in 23 young male stable dialyzed patients and compared to an age-matched group of healthy subjects. 5 alpha-Reduced androgen glucosiduronates are products of peripheral testosterone (T) metabolism and seem to be a useful tool in assessment of the male androgen status. Their polarity facilitates their urinary excretion, and their clearance is similar to the glomerular filtration rate in healthy men. We observed 1) a pituitary-Leydig cell dysfunction supported by normal serum estradiol and T levels, low free T, and increased LH levels; 2) an alteration of the dehydroepiandrosterone (DHEA) sulfate-DHEA interconversion, reflected by a dramatic decrease in DHEA while DHEA sulfate levels remained in the normal range; 3) an accumulation of 5 alpha-reduced androgen glucosiduronates, whose removal was impaired as shown by their very low sieving coefficients (< 0.012). Taken together, the above observations are consistent with alteration of spermatogenesis with respect to dialysis duration in which earlier elevated baseline serum LH levels indicate a primary defect in Leydig cell function.

Hepatitis C virus (HCV) infection in haemodialysed patients: HCV-RNA and anti-HCV antibodies (third-generation assays).

Samples from 128 haemodialysed patients were tested by anti-HCV 2nd- and 3rd-generation assays from Ortho: 53 were positive by ELISA 2.0 and 54 (42%) by ELISA 3.0. The 54 anti-HCV-positive patients were tested by RIBA-2 and RIBA-3 and by PCR for the detection of HCV-RNA: 46 of the 47 patients (98%) reactive by RIBA-2 and 48 of the 51 patients (94%) reactive by RIBA-3 were HCV-RNA positive. Three patients with RIBA-3 indeterminate results were HCV-RNA negative. Among the 74 anti-HCV negative patients, 29 were tested by PCR with negative results. Two distinct episodes of hepatitis C have been observed in two patients during the follow-up and 44 of the 50 patients (88%) known positive for anti-HCV since at least 1989 were still viraemic in 1993. A very high correlation was found between anti-HCV antibodies reactive by RIBA and the presence of HCV-RNA. A lack of protection after a resolved infection and a high frequency of chronic disease have been observed as well as a reinfection or a reactivation of the infection in two patients.

[Correlation between hepatitis C virus (HVC) RNA and anti-HVC antibodies in a hemodialysis population]. / Corrélation entre l'ARN du virus de l'hépatite C (VHC) et les anticorps anti-VHC dans une population d'hémodialysés.

Polymerase chain reaction (PCR) was applied to detect HCV-RNA in 75 hemodialyzed patients. Anti-HCV status was determined by ELISA-2 and by RIBA-2 for reactive samples by ELISA. ALT levels were monthly determined during the year preceding the end of the study. For 60 patients, anti-HCV serology was known since 1989 and 39 of them were tested for the presence of HCV-RNA at least four times during the 2 preceding years. The 9 patients who were negative for anti-HCV antibodies were negative by PCR. Of the 7 patients with an indeterminate profile by RIBA-2, 3 were positive by PCR: 1/1 with C-33c band only and 2/6 with C22-3 band only. Of the 59 patients reactive by RlBA-2, 57 were HCV-RNA positive. Of the 2 HCV-RNA negative patients, one had been PCR positive before interferon therapy. Of the 38 patients without acute hepatitis tested by PCR on 5 successive samples, all the specimens of 11 and 23 patients were HCV-RNA negative and HCV-RNA positive respectively. In 4 patients, a transient viremia was observed. The group of HCV-RNA positive patients had mean ALT levels greater than those who were negative. A correlation was established between HCV infection and both the time on dialysis and the number of blood transfusions. A high concordance (97%) was observed between antibodies to HCV and HCV-RNA.

Antibodies to hepatitis C virus by second generation test in hemodialyzed patients.

To assess the prevalence and the incidence of hepatitis C virus (HCV) in a dialysis unit, we prospectively tested for anti-HCV in chronic hemodialysis patients and staff members since January 1989, using a first generation assay. Incidence was nil in staff and low in patients (3.7% in 89, 1% in 90), and prevalence was 30% in patients. In January 1991 blood samples from 115 patients were tested by first (EL1) and second generation (EL2) ELISA (Ortho Diagnostic System). Positive subjects were tested by a RIBA-2 confirmation test. Fifty-three patients were negative by all tests. Positive tests were observed in 62 patients (54%) including 36 positive in EL1 and EL2, and 26 only by EL2. All positive patients were reactive by RIBA-2 but nine were classified undetermined (only one positive band). In five patients reactivity of antibodies to 5-1-1 and C-100-3 gradually declined during the study. Second generation tests gave a better correlation with time on dialysis and blood transfusion. We conclude that second generation tests for HCV are more accurate for estimating true prevalence of HCV infection in hemodialysis units.

HLA genetic heterogeneity of hepatitis B vaccine response in hemodialyzed patients.

Major histocompatibility complex (MHC) determinants are critical to the induction or suppression of immune response and have been shown to control the ability to produce antibodies in response to protein antigen. Hepatitis B vaccine commonly fails among patients with renal failure, but genetic factors that modulate response to this vaccination are not yet characterized. The availability of HLA Class II genotyping by hybridization with specific oligonucleotidic probes, following DNA amplification by the polymerase reaction (PCR), has made the analysis of HLA class II loci a reliable and practical approach. Antibody response to HBs and HLA class II oligotyping were assessed among 203 hemodialyzed patients having received a full course of vaccination. Twenty-two percent (N = 45) produced less than 10 IU (radioimmunoassay) of anti-HBs antibodies following the fourth injection. These nonresponder patients had a significantly decreased frequency of the DR2 haplotype compared to responder patients or to a group of 405 normal controls (8.9% vs. 21.5% and 26.2%, P < 0.01). The frequency of the DR3 haplotype was not increased among subjects with lower response. No significant difference appeared in the responder group. These results argue in favor of the presence of HLA-linked immune response gene(s) controlling humoral response to HBs antigen, rather than in favor of the presence of an immune suppressive gene.

[The clinical value of correction of acidosis by acetate-free biofiltration in patients on regular dialysis treatment].

Effects of metabolic acidosis were compared between bicarbonate dialysis (BCD) and acetate-free biofiltration (AFB). Three stable dialysis patients (1M, 2F, mean age 30 yrs) were selected for the study because their bicarbonate (BC) pre-dialysis plasma concentration were always under 16 mmol/l while they were on 33 mmol/l-BCD thrice weekly for 12 months. They were switched to a 6 months period of AFB. Pre- and post-dialysis BC plasma concentration, other blood chemical parameters and mass removal (total collection of used dialysate) of urea (U), creatinine (Cr), uric acid (UA), and phosphate (P) were measured during the last week of each period, including 3 dialysis sessions. Mean calorie and protein intake were 29.4 KCal/kg.d and 1.5 g/Kg.d (BCD period) and 38.2 Kcal/Kg.d and 1.5 g/Kg.d (AFB period) respectively. BC plasma concentration (Mean +/- SE, mmol/l) at the pre and post-dialysis in AFB were significantly higher than those in BCD (16.6 +/- 0.7 vs 20.8 +/- 0.6; p less than 0.001, 22.7 +/- 0.8 vs 25.8 +/- 0.8; P less than 0.02). Pre- and post-dialysis U plasma concentration (Mean +/- SE, mmol/l) in AFB were significantly lower than those in BCD (34.3 +/- 2.51 vs 20.8 +/- 0.59, 10.5 +/- 1.32 vs 7.5 +/- 0.92; P less than 0.001). Pre-dialysis P plasma concentration (Mean +/- SE, mmol/l) in AFB was significantly lower than that in BCD (1.85 +/- 0.09 vs 1.50 +/- 0.15; P less than 0.01). Cr, UA and P mass removal in BCD and AFB were not significantly different. However, U mass removal in AFB was significantly lower than that in BCD.(ABSTRACT TRUNCATED AT 250 WORDS)

[Growth hormone deficiency (hGH) in 1 case of terminal renal insufficiency treated with chronic hemodialysis]. / Déficit en hormone somatotrope (hGH) dans un cas d'insuffisance rénale terminale traitée par hémodialyse chronique.

The authors report the clinical history of a seventeen years old boy with renal failure treated with chronic haemodialysis since eleven and a half years of age. Growth velocity was 1.5 cm/year. The stature was below 5 SD as compared to the mean for the age. Hormonal measurements showed a complete growth hormone (hGH) deficiency and hyperparathyroidism. Thyroid, adrenal and gonadic secretions were normal, but the responses of TSH and prolactin to TRH were abnormal, showing an hypothalamic disturbance. hGH treatment, with thyroxin substitution, enhanced growth velocity up to 4 cm/year. Respective influences of hGH treatment, puberty and hyperparathyroidism on the incomplete correction of growth velocity are discussed.

[One-year treatment of 43 chronic hemodialysis patients with recombinant human erythropoietin]. / Traitement pendant un an de 43 malades hémodialysés chroniques par l'érythropoïétine recombinante humaine.

Twenty men and 23 women aged from 18 to 65 years, who had been under maintenance haemodialysis for 2 to 16 years and whose haematocrit had been below 30 percent for at least 3 months received recombinant human erythropoietin intravenously at the end of each session for one year. Anaemia was corrected in all patients, the delay in response to each dosage variation being about 4 weeks. The necessary maintenance dosage ranged from 96 to 240 u/kg/week. The number of leucocytes increased significantly until the 4th month, from 5880 +/- 1760 to 6600 +/- 1920 per cubic mm (P less than 0.01). During treatment, pre-dialysis blood creatinine concentrations and potassium and phosphate levels rose, while blood calcium levels fell significantly from 2.45 +/- 0.16 to 2.36 +/- 0.19 mmol/l (P less than 0.01). A nonsignificant increase in systolic and diastolic pressures was also observed, from 129 +/- 16 to 134 +/- 18 mmHg (P = 0.06) and from 75 +/- 9 to 78 +/- 10 mmHg (P = 0.07) respectively. Eight patients (18 percent) required antihypertensive drugs or a higher dose of those previously prescribed. There were 7 cases of vascular thrombosis on pre-existing stenosis, and the dosage of heparin during dialysis had to be increased in most patients. This study confirms that erythropoietin plays a major role in the genesis of the anaemia associated with renal failure. The absence of severe complications in this series was probably due to the criteria of inclusion in the study.

Vascular changes in hemodialysis patients in response to recombinant human erythropoietin.

The partial correction of anemia with recombinant human erythropoietin (rHuEpo) is frequently associated with an increase in arterial pressure and could oppose the beneficial effect of anemia correction on myocardial function. In order to analyze the influence of rHuEpo therapy on the vessels and the heart, we performed systemic and regional hemodynamics studies in 11 hemodialysis patients before and 10 to 35 weeks after initiation of rHuEpo therapy, when hemoglobin concentration was 6.8 +/- 0.9 and 10.6 +/- 0.66 g/dl (mean +/- SD), respectively. The mean arterial pressure remained unchanged during this period (88 +/- 21 vs. 88 +/- 15 mm Hg). Echocardiographic study showed that rHuEpo treatment led to a decrease in left ventricular end-diastolic diameter (4.9 +/- 0.5 vs. 5.1 +/- 0.6 cm; P less than 0.03), left atrial diameter (3.22 +/- 0.30 vs. 3.43 +/- 0.33; P less than 0.03), and left ventricular mass index (109.8 +/- 30.6 vs. 133 +/- 30.8 g/m2; P less than 0.05). Left ventricular ejection volume decreased from 86 +/- 24 to 75 +/- 19 ml (P less than 0.03) and heart rate from 76 +/- 9 to 70 +/- 10 beats/min (P less than 0.05). Cardiac index decreased from 4715 +/- 700 to 3635 +/- 444 ml/min/m2 (P less than 0.01) and peripheral resistances rose from 1480 +/- 162 to 1943 +/- 250 dynes.sec.cm-5.m2 (P less than 0.01). Fractional ejection and mean circumferential fiber shortening remained unchanged. The treatment with rHuEpo did not change the aortic diameters.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo T cell preactivation in chronic uremic hemodialyzed and non-hemodialyzed patients.

The production and targeting of a major T cell derived lymphokine, Interleukin 2 (IL-2), were studied in 23 uremic patients undergoing regular hemodialysis treatment and 20 uremic patients prior to the onset of renal replacement therapy. In hemodialyzed patients, abnormally increased proportions of circulating T cells spontaneously expressing high affinity IL-2 receptors (IL-2 Rec) were detected: they bound a monoclonal antibody specifically directed to the IL-2 Rec 55 kDa chain (Tac antigen) (mean +/- SEM: 7.12 +/- 0.81% in patients vs. 2.15 +/- 0.39% in normal controls, P less than 0.0001) and significantly proliferated in presence of human recombinant IL-2 alone (mean +/- SEM: 5438 +/- 729 cpm in patients vs. 1647 +/- 244 cpm in normal controls). Hemodialyzed patients also exhibited significantly increased serum levels of soluble IL-2 receptor (mean +/- SEM: 4036 +/- 947 U/ml in patients vs. 253 +/- 29 U/ml in normal controls. P less than 0.001). Moreover, a significantly decreased IL-2 activity was detected in the supernatants of stimulated T cells from hemodialyzed patients (mean +/- SEM: 0.93 +/- 0.12 U/ml in patients vs. 2.49 +/- 0.22 U/ml in normal controls, P less than 0.0001). In nine hemodialyzed patients who were analyzed before and immediately after the hemodialysis session no acute modifications of the various parameters analyzed were detected. Although less profound, a similar pattern of T cell abnormalities was observed in the uremic non-hemodialyzed patients studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Utilization of erythropoietin in the treatment of the anemia due to chronic renal failure.

Administration of recombinant erythropoietin constitutes a revolution in treatment of the anemia of chronic dialysis patients. Such treatment has been anxiously awaited. Its realization has been possible thanks to the spectacular progress allowed by the newly developed techniques of recombinant genetics. Correction of this type of anemia can be obtained rapidly and permanently if treatment is continued without interruption. It is followed by a remarkable transformation of the patient's physical and psychic status. The occurrence of certain side effects (e.g., elevation of blood pressure and an increased tendency toward vascular thrombosis), however, requires increased awareness in the follow-up of patients at risk and adaptation of erythropoietin administration to individual needs.

Kinetics of erythropoiesis in dialysis patients receiving recombinant erythropoietin treatment.

In eleven patients with uraemia on intermittent haemodialysis treatment, recombinant human erythropoietin (rHuEpo) was used at a dosage schedule of 100 IU/kg bodyweight thrice weekly. Erythrokinetic studies (blood volume, RBC survival and iron kinetics) were performed in nine cases before and after 6 months of treatment. The remaining two patients had only RBC and plasma volume determinations before and after treatment. Although total blood volume remained unchanged, RBC volume was increased in all cases. Red cell loss was not modified, and quantitative improvement of RBC production was noted in all cases. No qualitative defect of erythroid maturation or release was observed in the treated patients. In conclusion, rHuEpo treatment improves the anaemia of haemodialysis patients by normalising circulating RBC volume only through an increase in red cell production.