Dobutamine stress echocardiography predicts reversible dysfunction and quantitates the extent of irreversibly damaged myocardium after reperfusion of anterior myocardial infarction

OBJECTIVES

This study was designed to evaluate dobutamine stress echocardiography in identifying reversible dysfunction and assessing the extent of irreversibly damaged myocardium early in acute myocardial infarction.

BACKGROUND

Several experimental and clinical studies have suggested that dobutamine enhances contractile function of stunned or hibernating, or both, myocardium. It is important for clinical strategy to predict the magnitude of improvement in myocardial function early in acute myocardial infarction.

METHODS

We studied 21 patients with a reperfused first anterior myocardial infarction. Two-dimensional echocardiography was performed before and during dobutamine infusion (10 micrograms/kg body weight per min) at a mean of 3 days after the infarction. Follow-up echocardiography was performed at a mean of 25 days later. To assess segmental wall motion, we divided the left ventricle into 17 segments and assigned a wall motion abnormality score: 3 = dyskinesia or akinesia; 0 = normal. Improvement in wall motion was indicated by a decrease of at least one grade in segmental score. For quantitative assessment, the ratio of endocardial length showing dyskinesia or akinesia to a left ventricular endocardial length (akinetic length ratio) was determined in the apical long-axis view at each stage.

RESULTS

Sensitivity and specificity of dobutamine infusion in detecting improvement in wall motion at follow-up echocardiography were 83% (55 of 66 segments) and 86% (43 of 50 segments), respectively. Excellent correlation was found (r = 0.93, p < 0.001; absolute difference [mean +/- SD] 0.03 +/- 0.05) between the akinetic length ratios measured during dobutamine infusion and in the late convalescent stage.

CONCLUSIONS

In the early stage of acute myocardial infarction, low dose dobutamine stress echocardiography provides a useful method for predicting reversible dysfunction with excellent sensitivity and specificity and can also be used to quantitate the extent of irreversibly damaged myocardium.

[A trial use of prostaglandin E1 for prevention of hepatic veno-occlusive disease after allogeneic bone marrow transplantation]

We performed retrospective analysis of hepatic veno-occlusive disease (VOD) in 57 cases with leukemia after allogeneic bone marrow transplantation (BMT). Prostaglandin E1 (PGE1) was used to prevent VOD in 8 cases at a dose of 0.3 micrograms/kg/hr from day -8 to day 30. No VOD was noted in the PGE1 group, while the incidence of VOD was 8/49 (16.3%) in the non PGE1 group. In twelve patients with pretransplant liver dysfunction, VOD was noted in 0/3 in the PGE1 group and 4/9 (44.4%) in the non PGE1 group, respectively. However, prophylactic effects of PGE1 on VOD is not significant in this study, so further studies are needed to determine the efficacy of PGE1. One of 8 patients with PGE1 prophylaxis had edema and erythema on extremities, however, severe toxicity was not experienced.

[Cyclic thrombocytopenia associated with erythroid hypoplasia--a case]

We report the case of a 75-year-old woman with cyclic thrombocytopenia associated with erythroid hypoplasia. One platelet cycle lasted for about 28-30 days, with the platelet count fluctuating from 1.0 x 10(4)/microliter to 56.0 x 10(4)/microliter. Megakaryocyte count increased in the phase during which platelet count increased, and decreased in the phase during which platelet count decreased. Bone marrow colony formation was observed in serum-free agar, and megakaryocyte colony count was correlated with the platelet cycle. Platelet-associated immunoglobulin was in the normal range when platelet count increased, but increased when platelet count decreased. These findings suggest that the observed platelet count fluctuation was related to the production and destruction of platelet. Our patient also had erythroid hypoplasia, but her erythrocyte count did not fluctuate. This is the first reported case of cyclic thrombocytopenia and erythroid hypoplasia.

Partial splenic embolization for the treatment of chronic idiopathic thrombocytopenic purpura

OBJECTIVE

The purpose of this study was to assess the effectiveness of partial splenic embolization in the treatment of chronic idiopathic thrombocytopenic purpura.

SUBJECTS AND METHODS

Twenty-six patients with chronic idiopathic thrombocytopenic purpura underwent partial splenic embolization and were followed up for 6-61 months. The condition was refractory to steroids in 20 of 26 patients. The other six patients, in whom a response to steroids was shown, could not be withdrawn from steroid therapy because their platelet counts decreased with any decrease in steroid dose. Five of 26 patients underwent splenectomy after partial splenic embolization, and the other patients were followed up without medical treatment until platelet counts decreased below 3 x 10(10)/l. The therapeutic effect of partial splenic embolization was defined on the basis of the platelet count at the last follow-up after partial splenic embolization: complete response, greater than 10 x 10(10)/l; partial response, 5 x 10(10)/l to 10 x 10(10)/l; and no response, less than 5 x 10(10)/l without medication.

RESULTS

Partial splenic embolization brought a complete response in seven (33%) of 21 patients, a partial response in eight (38%), and no response in six (29%). In four of five patients, who later underwent splenectomy, response to partial splenic embolization was coincident with the response to splenectomy. No serious complications occurred, but minor complications such as abdominal pain, fever, and nausea were observed in most patients.

CONCLUSION

This study suggests that partial splenic embolization might be useful as an alternative to splenectomy in the treatment of chronic idiopathic thrombocytopenic purpura.

[Autologous bone marrow transplantation following high-dose busulfan and etoposide for a patient with non-Hodgkin's lymphoma]

A 26-year-old man was admitted to our hospital with cervical tumor and facial edema on July 8, 1991. Examination of chest X-ray and chest CT showed a bulky tumor in the mediastinum and pleural effusion. A pathological diagnosis of non-Hodgkin's lymphoma (diffuse large cell, immunoblastic type) was made by biopsy of the cervical lymph node. MACOP-B chemotherapy or other combination chemotherapy did not achieve complete remission. The man was given a preparative regimen consisting of busulfan at 16 mg/kg orally and 60 mg/kg of etoposide (Bu-Et); 30 mg/kg of etoposide was administered by continuous intravenous infusion for 12 hours on day-5 and day-4, before he received autologous bone marrow on February 20. He was then given 300 micrograms of G-CSF was given to him to accelerate recovery of hematopoiesis from one day after BMT. The neutrophil count to 500/microliters recovered on day 28, and residual tumors disappeared. Although moderate-grade stomatitis and nasal bleeding developed, these toxicities were controllable and no veno-occlusive disease resulted. Regimen-related toxicities of Bu-Et preparatory regimen have been generally considered to be severe, but continuous and separate administration of etoposide as reported in this case may be useful to reduce side effects of this preparatory regimen.

[A combination chemotherapy of mitoxantrone, etoposide, carboplatin, and prednisolone (MECP) in recurrent or refractory non-Hodgkin's lymphomas]

Twenty-two patients with recurrent or refractory non-Hodgkin's lymphoma were treated with a combination chemotherapy of mitoxantrone, etoposide, carboplatin, and prednisolone (MECP). Of 22 evaluable patients, 11 (50%) responded to MECP and 7 (32%) achieved complete remission. Particularly in relapsed cases, 9 (75%) responded and 6 (50%) achieved complete remission. Myelosuppression was the major toxicity. Thirteen patients (59%) experienced WBC counts under 1,000/microliters, and thrombocytopenia under 50,000/microliters was seen in 12 patients (55%). During myelosuppression, 2 patients developed sepsis and 1 showed intestinal bleeding. Other gastrointestinal toxicities were well tolerated. There was no death due to chemotherapy. These results show that MECP is a well-tolerated treatment regimen, and effective for recurrent or refractory non-Hodgkin's lymphomas.

Preferential expression of the third immunoglobulin-like domain of K-sam product provides keratinocyte growth factor-dependent growth in carcinoma cell lines

Previously, we identified an amplified gene in a stomach cancer cell line, KATO-III, and designated it K-sam. This gene was later found to be identical with a gene for a receptor tyrosine kinase, bek/FGFR2. One of the characteristics of the K-sam gene is structural diversity of its transcripts; K-sam complementary DNA (cDNA) cloned from human brain (K-sam-I) has a completely different sequence at the third extracellular immunoglobulin-like domain as compared to that of the K-sam cDNA derived from KATO-III cells (K-sam-II). Recent study has revealed that this difference signifies a differential ligand affinity; the receptor encoded by the K-sam-I cDNA has a high affinity for basic fibroblast growth factor (bFGF), while the K-sam-II cDNA corresponds to a receptor with the high affinity for keratinocyte growth factor (KGF). Reverse transcription-polymerase chain reaction and RNA blot analysis showed that the K-sam-II-type transcript was present in carcinoma cell lines but not in any of the sarcoma cell lines examined. The K-sam-I-type transcript was expressed in both carcinoma and sarcoma cell lines. Furthermore, KGF enhanced the DNA synthesis of the esophageal cancer cells, TE-1, in a dose-dependent manner, while the effect of bFGF was not substantial. In contrast, the glioblastoma cell line, A-172, that expressed the bFGF receptor showed a mitogenic response to bFGF but not to KGF. These data suggest that KGF is a growth factor used preferentially in cancer cells, and this preference is based on the presence of the K-sam-II-type receptor in carcinoma cells but not in sarcoma cells due to alternative splicing.

A randomized controlled study of granulocyte colony stimulating factor after intensive induction and consolidation therapy in patients with acute lymphoblastic leukemia. Japan Adult Leukemia Study Group

To determine the efficacy and optimal daily dose of recombinant human granulocyte colony-stimulating factor (rG-CSF) after intensive chemotherapy, a prospective randomized study was conducted with daily intravenous administration of 2, 5 or 10 micrograms/kg G-CSF after induction therapy, and 0, 2, 5 or 10 micrograms/kg after consolidation therapy, until neutrophil counts recovered to more than 2000/mm3. The subjects were 41 adult patients with newly diagnosed acute lymphoblastic leukemia (ALL). After the induction therapy, neutrophil recovery to more than 1000/mm3 was significantly faster in the 5 (P = 0.047) and 10 micrograms/kg groups (P = 0.011) than in the 2 micrograms/kg group, but did not differ between the 2 former groups. The median days of neutrophil recovery to more than 1000/mm3 were 8.5, 9 and 12 days, respectively. After the consolidation therapy, neutrophil recovery to more than 1000/mm3 was significantly faster in the 2, 5 and 10 micrograms/kg groups than in the no rG-CSF group (P < 0.001, respectively), but did not differ among the 3 former groups. The median days of neutrophil recovery to more than 1000/mm3 were 12, 11, 10, and 23 days, respectively. Febrile neutropenia and incidence of documented infection tended to be less in the 5 and 10 micrograms/kg groups than in 0 and 2 micrograms/kg groups. A dose of 5 micrograms/kg rG-CSF given by a 30 min infusion daily seems to be an effective and optimal daily dose to accelerate neutrophil recovery after intensive remission induction and consolidation chemotherapy in adults with acute lymphoblastic leukemia (ALL).

[Serum thrombomodulin levels in patients receiving allogeneic bone marrow transplantation]

It has been reported that serum levels of thrombomodulin (TM) reflect endothelial damages in various diseases. We measured serum TM levels between day-10 and day 100 in 6 patients receiving allogeneic bone marrow transplantation. Serum TM levels were increased when patients had transplant related complications including graft versus host disease, hemorrhagic cystitis and interstitial pneumonitis. In patient without complications, serum TM levels were within normal limits. These results suggest that the serum TM level serves as a useful marker of treatment related toxicity and a predictor of complications after BMT.

[Prostaglandin E1 bladder instillations for a patient with severe hemorrhagic cystitis after allogeneic bone marrow transplantation]

A 39-year-old female with AML (M2) underwent allogeneic bone marrow transplantation (BMT) on July 8th, 1991. The post transplantation course had been going well until day 85 post BMT, when severe hemorrhagic cystitis with right hydronephrosis and ureter stenosis developed. Adenovirus type 11 was isolated from the urine. She received instillations of prostaglandin E1 (PGE1) directly into the bladder after the appearance of clots in the urine. Complete resolution of hematuria was obtained by two courses of this treatment. PGE1 bladder instillations seem to be effective for the control of hematuria caused by severe hemorrhagic cystitis after BMT.

The crystal structure of specific granules in human eosinophils studied by thin sectioning and deep-etching with the aid of Fourier transformation

The crystal structures of specific granules in human eosinophils were studied by thin sectioning and deep-etching with the aid of Fourier transformation. The crystal, thought to be a simple cubic by previous studies by thin sectioning, was demonstrated as the body-centered cubic (the cesium chloride type) consisting of two kinds of particles. The crystal parameters obtained by deep-etching were slightly larger (a = b = c = 4.1-4.4 nm) than by thin sectioning (4.0 nm). By deep-etching, the crystal also showed the stacking folds suggesting the piled-up plates. Although it is known that the patients with hypereosinophilic syndrome have more hypodense eosinophils compared with normal persons, no morphological differences could be detected in the crystals between these eosinophils.

Treatment of myelodysplastic syndromes with all-trans retinoic acid. Leukemia Study Group of the Ministry of Health and Welfare

We treated 23 patients with myelodysplastic syndromes (MDS); 2 refractory anemia (RA) with prior therapy, 11 RA with excess of blasts (RAEB), and 10 RAEB in transformation (RAEB-T), with daily oral 45 mg/m2 all-trans retinoic acid (ATRA) in a multiinstitutional prospective study. In two patients with RAEB and one with RAEB-T, a more than 1,000/microL increase of peripheral neutrophil counts was observed with some reduction of blast percentage in the bone marrow 2 to 9 weeks after the start of ATRA. However, the effect was transient and did not last for more than 5 weeks despite the continuation of ATRA therapy. In one other patient with RA, one patient with RAEB, and one patient with RAEB-T, slight increase of hemoglobin levels or reduction of blast percentage in bone marrow was noted. Toxicities attributable to ATRA were minimal and included cheilitis, xerosis, dermatitis, gastrointestinal disorders, abnormal liver function tests, and high serum triglyceridemia. Although ATRA works remarkably as a differentiation therapy in acute promyelocytic leukemia, its effect in MDS included in this study was modest. Further study of this agent alone or in combination may be warranted in less advanced stages of this disease.

Chemiluminescence of neutrophils in patients with myeloproliferative or myelodysplastic hematologic diseases--relation to neutrophil alkaline phosphatase activity

In hematological diseases such as myeloproliferative disorders (MPD) or myelodysplastic syndromes (MDS), some abnormalities in the chemiluminescence of neutrophils are observed. There are two groups; one includes chronic myelogenous leukemia (CML), essential thrombocythemia (ET) and MDS, which all have decreased chemiluminescence of neutrophils. The other group includes polycythemia vera (PV) which has increased neutrophil chemiluminescence. We studied the neutrophil function by analyzing the chemiluminescence in 35 patients with hematological diseases. In most of these cases the defects in chemiluminescence in 35 patients with hematological diseases. In most of these cases the defects in chemiluminescence in response to N-formyl-L-methionyl-L-leucyl-L-phenylalanine (FMLP) were correlated with those in response to phorbol 12-myristate 13-acetate (PMA). But there were exceptional cases in which the maximal light emission of chemiluminescence (Max CL) in response to FMLP was obviously lower than controls despite the fact that the Max CL in response to PMA was the same as the controls. These facts suggest a heterogenicity of the defect site in these diseases. There was a correlation between the level of chemiluminescence and the neutrophil alkaline phosphatase (NAP) activity in these patients. In vitro culture of CML neutrophils with granulocyte colony-stimulating factor (G-CSF) showed a correlation between the increase in the level of chemiluminescence and NAP activity. These results suggest that NAP may take part in the control of neutrophil function.

[Chromosomal abnormalities in Castleman's disease with high levels of serum interleukin-6]

Chromosomal abnormalities in Castleman's disease with high levels of serum IL-6 were reported. A 69-year-old male was found to have superficial lymph node swelling and polyclonal hypergammaglobulinemia, when he was admitted to the department of otolaryngology for carcinoma of the tongue in July 1991. In December, he was referred to our department after completing radiation therapy. Laboratory examination revealed 7.7 g/dl hemoglobin, 10.8 g/dl total protein, and 56.0% gamma-globulin. Serum electrophoresis revealed polyclonal hypergammaglobulinemia and no Bence-Jones protein. Bone marrow aspirates showed an increase of plasma cells to 21.8%. Serum IL-6 was 252 pg/ml. Chromosomal analysis of cells in the lymph node showed a karyotype of 46,XY,t(7;14)(p22;q22). The lymph node histology showed marked hyperplasia of plasma cells at interfollicular areas. These plasma cells were stained with both anti-kappa and anti-lambda antibody. He was diagnosed as multicentric form Castleman's disease. Treatment with prednisolone and melphalan resulted in improvement of clinical findings such as anemia, lymph node swelling and hypergammaglobulinemia in concurrence with decrease in serum levels of IL-6. Since the IL-6 gene is located on 7p21-22, the translocation 7; 14 may be related to the high level of serum IL-6.

[Cyclosporine-induced graft-versus-host disease in a syngeneic bone marrow transplantation]

A 33-year-old woman with AML (M4) resistant to chemotherapy received syngeneic marrow graft from her identical twin following high dose busulfan and etoposide. However, the relapse was confirmed on the 60th day after the procedure. Since she failed to achieve remission despite intensive chemotherapy, a second BMT from the same donor was performed following total body irradiation and high dose etoposide on the 126th day after the initial BMT. At this time, cyclosporine (1 mg/kg/day) was administered to induce graft-versus-host disease (GVHD). Skin rash appeared on the 18th day after the 2nd BMT, and biopsy from the rash on the 23rd day showed a typical picture of cutaneous GVHD (grade 2) and there was no evidence of viral infection. On the 36th day after the 2nd BMT, the patient died of veno-occlusive disease. Although graft-versus-leukemia effect in this patient could not be evaluated because of early death, the induction of GVHD with cyclosporine might be effective to reduce the relapse rate after syngeneic or autologous BMT. Further studies are required to confirm this effect.

Effect of interferon (IFN) on refractory idiopathic thrombocytopenic purpura: administration of 6 million units of recombinant IFN alpha-2b

Five patients (six courses) with refractory idiopathic thrombocytopenic purpura (ITP) were given 6 million units of recombinant interferon (IFN) alpha-2b in 12 doses to achieve an improved response rate compared to previous studies using 3 million units. From the initial IFN administration, the platelet count increased from a pre-treatment level of 20.7 +/- 17.7 x 10(3)/microliters (mean +/- SD) and reached its first peak in weeks 2 or 3 of therapy (p < 0.05). In week 5, the platelet count made its second and maximum peak (66.5 +/- 57.9 x 10(3)/microliters; p < 0.05). A relatively good response of the platelet count (an increase to > 50 x 10(3)/microliters) was observed in three patients (four courses) out of five. These responses were not much faster or more improved than in previous reports, and a dose of 6 million units may be too large to treat some ITP patients. The platelet-associated IgG level showed a tendency to be reduced with IFN therapy. The mechanism for the increase of the platelet count may be the modification of platelet autoantibody production.

[Multiple myeloma in a patient in remission from malignant lymphoma]

A 71-year-old man was admitted because of right cervical lymph node swelling in February 1986. Lymph node biopsy revealed that he suffered from diffuse, large cell malignant lymphoma. Immunological staining showed lymphoma characterized by B cell markers, IgG, kappa type. Bone marrow aspiration, revealed no evidence of lymphoma and 0.2% plasma cells. The clinical stage was IIA. The patient was treated with the CHOP regimen (doxorubicin, cyclophosphamide, vincristine and prednisolone), which achieved complete remission. In October 1988, he was re-admitted because of a subcutaneous abscess, and biopsy of the inguinal lymph node showed reactive lymphadenitis. Although he improved with antibiotic therapy, laboratory date on admission showed monoclonal gammopathy. Serum immunoelectrophoresis demonstrated a monoclonal bow of IgA kappa type, and bone marrow aspiration revealed hypercellularity with an increased number of plasma cells (76.8%). The patient was diagnosed as having multiple myeloma, and combination chemotherapy was begun. He now attends the out-patient department at our hospital. The development of multiple myeloma has not been reported previously during a course of malignant lymphoma. Although the association of these two B cell neoplasias was unknown, in this case both showed the characteristic of kappa type light chains. This case may provide information concerning tumor cell origin.

Lymphocyte subset reconstitution following human allogeneic bone marrow transplantation: differences between engrafted patients and graft failure patients

To define the relationship between hematopoietic reconstitution and lymphocyte subset analysis in human allogeneic bone marrow transplantation (BMT), we compared lymphocyte subset reconstitution during the first 4 weeks after BMT in nine engrafted patients with that in three graft failure patients using flow cytometry. Marked differences were observed between the two groups. In graft failure patients, the percentage of CD3+ lymphocytes had increased 2 weeks after BMT by over 90% (p less than 0.05). The percentage of CD16+ lymphocytes and CD16+ CD57- lymphocytes did not increase (CD16+ at 3 and 4 weeks: p less than 0.05, CD16+ CD57- at 3 weeks; p less than 0.05, at 4 weeks: p less than 0.01), nor did the percentage of CD8+ 11b+ lymphocytes. The percentage of CD8+ 11b- lymphocytes had increased markedly 2 weeks after BMT (at 2 weeks: p less than 0.05, at 3 and 4 weeks: p less than 0.01). Of particular interest is the difference in the percentage of CD3+, CD16+, and CD8+ CD11b- T cells between the two groups. These cells may play a role in allogeneic bone marrow cell engraftment.

[Transient B lymphocytosis associated to hepatitis B after allogeneic bone marrow transplantation]

A 42-year-old male suffered from AML (M2) and achieved remission with chemotherapy. After that, he was successfully treated with allogeneic bone marrow transplantation. About eight months later, jaundice and general malaise developed and diagnosis of acute hepatitis B type was made based on laboratory findings. After 3 months of a conservative therapy, he recovered from the disease. During the clinical course of the hepatitis, B lymphocytes were increased to about 70% of peripheral blood lymphocytes (PBLs) transiently, and furthermore CD5 positive B lymphocytes occupied 12% of the PBLs at that time. This B lymphocytosis disappeared gradually along with the improvement of the hepatitis. The remarkable increase of B lymphocytes in PBLs was considered to be an abnormal reaction induced by HB virus infection, when his immune system was in the recovering phase after bone marrow transplantation.

Hepatic veno-occlusive disease in a patient with lupus anticoagulant after allogeneic bone marrow transplantation

A 37-year-old man with acute myeloblastic leukemia (FAB M2) in first remission underwent a bone marrow transplant (BMT) following conditioning with high-dose cytarabine and total body irradiation. The donor was an HLA-identical brother. Graft rejection occurred and a second BMT was performed from the same donor following conditioning with cyclophosphamide. Engraftment was achieved, but the patient developed severe jaundice and died of respiratory failure on day +46 after the second BMT. Liver biopsy revealed luminal narrowing of the central veins and a diagnosis of hepatic veno-occlusive disease (VOD) was made. The coagulation studies showed a prolonged kaolin clotting time which was not corrected by 1:1 mixture with normal plasma, and the platelet neutralization test was positive. Dilute tissue thromboplastin time and dilute Russell viper venom time were also prolonged. These results fulfilled the criteria for lupus anticoagulant, which may have contributed to VOD in this patient.

[Lymphocyte subset reconstitution following human allogeneic bone marrow transplantation]

We analysed the reconstitution of lymphocyte subset during the first 4 weeks after human allogeneic bone marrow transplantation (BMT) in relation to the recovery of hematopoiesis. Lymphocyte subset analysis was performed with flow cytometry. We performed allogeneic BMT from HLA matched sibling donor in 9 patients. We analysed the positive percentage of each surface antigen and analysed data prior to conditioning therapy and weekly during the first 4 weeks after BMT. Results were as follows: Two or 3 weeks after BMT, percentages of CD8+ (CD8+ CD11b+) lymphocyte and CD16+ (CD16+ CD57-) lymphocyte (NK cell) were increased, and those of CD3+ lymphocyte and CD4+ (CD4+ Leu8+) lymphocyte decreased. And the ratio of CD4+ lymphocytes to CD8+ lymphocytes decreased below 1.0 at 2 or 3 weeks after BMT and remained low. In relation to the recovery of hematopoiesis, CD16+ lymphocyte (especially CD16+ CD57- lymphocyte) percentages at the third weeks correlated significantly to the recovery of granulocyte, reticulocyte, and platelet. It seems that CD16+ lymphocytes may play a role in bone marrow cell engraftment and the recovery of hematopoiesis.

Histologic and immunophenotypic evaluation of pretreatment renal biopsies in OKT3-treated allograft rejections

The histologic features immunophenotype of intragraft mononuclear populations, and HLA-Dr expression in pretreatment formalin-fixed renal allograft biopsies were correlated with outcome of OKT3 therapy in 35 steroid resistant renal transplant rejections. Therapeutic response (63% overall) was better in pure acute cellular rejections (ACR) (13/15, 87%) than ACR with interstitial fibrosis (4/12, 33%) or with vascular injury (5/8, 62%). Intragraft T lymphocytes were more numerous in vascular rejection (mean 566/mm2) compared with pure ACR (mean 265/mm2, P = .049), and macrophages were greater in pure ACR (203/mm2) compared with ACR with interstitial fibrosis (83/mm2, P = .051). Distribution of T cells, B cells, plasma cells, and macrophages among various histologic categories was otherwise statistically similar. There was no correlation between therapeutic response to OKT3 and intragraft concentrations of individual mononuclear cell subsets. Vascular and/or epithelial HLA-Dr expression was present in 17/25 (68%) cases and was not associated with histologic features or treatment response. Follow-up graft function (median 7 months) correlated significantly with therapeutic response to OKT3 (P = .0004) and histologic presence of interstitial fibrosis (P = .031), but was not related to concentration of individual mononuclear subsets or HLA-Dr expression. We conclude that intragraft concentrations of major mononuclear cell types may relate to histology, but that these do not predict treatment response or graft outcome, and thus poorly reflect intensity or possible heterogeneity of host immunologic rejection mechanisms.