Effect of race on renal transplant outcome

Renal transplant outcome was compared in whites and blacks at a single center. All recipients transplanted between 1984 to 1991 were included in this study. White and black recipients were followed for a mean period of 37.6 (1-96) months. The age, sex, follow-up period, immunosuppressive protocol, number of retransplants, HLA mismatches and etiology of renal disease were comparable in the two races. Overall graft survival was lower in black recipients (p=0.0300). Graft survival in all cadaver (p=0.0520) and primary cadaver (p=0.1430) transplants was lower in blacks, though this was not statistically significant. Percentage of graft losses during the follow-up was higher in black 53/108 (49%), than white recipients 82/257 (32%)(p=0.002), as were cadaver graft losses due to rejection, 39/92 (42%) in blacks, 54/190 (28%) in whites (p=0.02). There was no significant difference in graft losses due to rejection between races in the 1 yr post transplant, but there were significantly more graft losses after 1 yr in blacks 16/83 (19%) compared to whites (16/156(10%)(p=0.05). In cadaver grafts functioning for 6 months, subsequent survival was lower in black recipients (p=0.0418). There was lower patient survival in blacks during the mean follow-up period of 37.6 months (1-96). In conclusion, lower graft survival in blacks can be partially explained by fewer LRD transplants in black recipients. Persistent lower graft survival in all black recipients and significantly more losses due to rejection beyond 1 yr may be related to immunological differences, poor compliance, or a combination of both.

Cyclosporine-ketoconazole interaction. Long-term follow-up and preliminary results of a randomized trial

Forty-three renal transplant recipients receiving cyclosporine were started on 200 mg/day of oral ketoconazole 10 days to 75 months posttransplant. The cyclosporine dose was reduced by 70% when ketoconazole was started. The mean cyclosporine dose was 5.6 mg/kg/day preketoconazole, and 0.9, 0.8, and 0.7 mg/kg/day at one, two, and three years after addition of ketoconazole (cyclosporine dose reduction 84%, 86%, and 88% at one, two, and three years, respectively). Two patients died after two years of combination therapy, six patients returned to dialysis, and ketoconazole was discontinued in four. Renal function in patients on ketoconazole remained stable (serum creatinine 1.8, 1.7, 1.7, and 1.8 mg/dl preketoconazole and at one, two, and three years, respectively). In a second study, 52 patients were randomized to standard doses of cyclosporine (n = 28), or reduced doses of cyclosporine with ketoconazole (n = 24); seven of the patients were not started on ketoconazole. In 28 patients on standard-dose cyclosporine, there were two deaths and one graft loss. In 17 patients receiving ketoconazole there were two deaths and no graft losses. Renal function and the frequency of rejection episodes was similar in the two groups. In the ketoconazole group, the cyclosporine dose was < 20% of that in the patients on standard doses. In both studies addition of ketoconazole to cyclosporine-treated patients resulted in significant inhibition of cyclosporine metabolism and decrease in dosage in patients followed for up to four years. This drug interaction provides a significant reduction in cost of immunosuppressive therapy in organ transplant recipient.

Antibody response to OKT3 and methods for monitoring

Monitoring the antibody response to OKT3 is essential. Retreatment with OKT3 can be accomplished successfully in the great majority of patients. It is important to know the patient's peak antibody status before and during retreatment. Patients with no anti-OKT3 antibodies, or with low-titer (< or = 1:100) antibodies, especially if these do not include anti-idiotypic antibodies, have retreatment success similar to that of patients undergoing primary treatment with OKT3. In contrast, patients with high-titer (> or = 1:1000) antibodies should be treated with immunosuppression other than OKT3. Methods for monitoring the OKT3 antibody response have progressed, allowing one to estimate the titer and specificity (anti-idiotype and/or anti-isotype) in a timely fashion. Improvements still must be made in the area of standardization, so that results between various transplant centers can be more accurately compared.

Rapid detection of anti-OKT3 antibodies with the Transtat assay

The ability to successfully reuse OKT3, a mouse monoclonal antibody, is dependent upon the host's response to the antibody during and following the first treatment course. Antiidiotypic and/or antiisotypic antibodies may develop after exposure to OKT3. Antiidiotypic antibodies will bind OKT3, rendering it ineffective, while antiisotypic antibodies do not influence the efficacy of OKT3. A new membrane-based immunoassay, Transtat OKT3 (Sangstat Medical Corp, Menlo Park, CA) detects anti-OKT3 antibodies in less than 15 min. It allows simultaneous detection of antiidiotype and antiisotype antibodies. A total of 180 serum samples were initially analyzed by ELISA; results were negative, low-titer (1:100), or high-titer (> or = 1:1000). Retrospectively, these same samples were analyzed by Transtat for both anti-OKT3 (idiotype) and IgG2a (isotype). A total of 109 samples of 180 (60.6%) tested negative by ELISA and Transtat, while 71 (39.4%) tested positive. Of the negative samples by ELISA, 98 of 109 (89.9%) also tested anti-OKT3-negative by Transtat. Of the 109 specimens that were anti-OKT3 negative by Transtat, 98 (89.9%) tested negative by ELISA. There were 22 discrepant samples between the two methods; all were low-titer-positive (ELISA and Transtat). The 71 positive ELISA samples consisted of 53 low-titer (1:100) and 18 high-titer (> or = 1:1000), while the 71 anti-OKT3 positive Transtat samples consisted of 44 low-titer (1:10) and 27 high-titer (1:50). Sixty of 71 (84.5%) ELISA-positive samples were also positive by Transtat. Similarly, 60 of 71 (84.5%) Transtat-positive samples were also positive by ELISA. Of 71 patient samples positive for anti-OKT3 antibodies, 63 had an antiisotypic component present by Transtat. In conclusion, the Transtat OKT3 assay for measuring OKT3 and IgG2a antibodies offers a rapid and accurate assay for OKT3 monitoring.

Stable transformation of Trypanosoma cruzi: inactivation of the PUB12.5 polyubiquitin gene by targeted gene disruption

Analysis of gene expression in Trypanosoma cruzi has been impeded by the lack of efficient, stable, DNA-mediated transfection systems. We describe here the establishment of such a system for T. cruzi. Stable transformants were isolated following integration of the circular transforming plasmid into the chromosome by homologous recombination. Mutants with a disrupted PUB12.5 polyubiquitin gene, resulting from targeted integration of the plasmid vector, have been isolated. A mutant harboring the disrupted PUB12.5 gene lacks the intact PUB12.5 mRNA as well as transcripts corresponding to the truncated gene. Genomic Southern-blot analysis indicates that the inserted plasmid is tandemly repeated in each of the clones analyzed. A secondary recombination event in one clone resulted in a deletion within the 2.65 calmodulin-ubiquitin locus, encompassing the sequence from the CalA2 calmodulin gene to the PUB12.5 polyubiquitin gene.

The effect of indomethacin on the febrile response following OKT3 therapy

Fifty renal transplant recipients with histologically documented acute allograft rejection were treated with OKT3 monoclonal antibody therapy. Group 1 (n = 25) received standard premedication with steroids, acetaminophen, and diphenhydramine. Group 2 (n = 25) received these agents plus indomethacin in an attempt to minimize the early adverse effects associated with OKT3. At 1 hr prior to the first dose of OKT3, 50 mg of indomethacin was administered orally followed by 25 mg every 6 hr for the next 48 hr. Demographics were similar in the two groups. Reversal of rejection occurred in 23 of 25 (92%) in group 1, and in 22 of 25 (88%) in group 2. Graft survival rates at six months after the rejection were 88% in group 1 and 80% in group 2. There was a single patient death in group 2, due to a suicide in a patient with a functioning kidney and pancreas graft. The maximum temperature was significantly diminished in the group receiving indomethacin during the first three days of OKT3 therapy. The percentage of patients with a maximum temperature less than 100 degrees F was significantly higher in group 2: day 1--16% vs. 36%, day 2--12% vs. 48%, day 3--52% vs. 68% for group 1 and group 2, respectively. No serious side effects occurred in either group--however, subjective side effects were less common in group 2. Serum creatinine levels were similar in the two groups prior to rejection, at the start of OKT3 therapy, at the peak during OKT3 therapy, at the end of OKT3 therapy, and 30 days and 180 days post OKT3. The data indicate that the concurrent use of indomethacin with OKT3 appears to significantly decrease the initial febrile response without compromising renal function or the efficacy of OKT3 therapy.

Gonococcal endocarditis complicating pregnancy: a case report and literature review

The incidence of gonorrhea has decreased substantially in the past decade. Disseminated gonorrhea is more common in women than in men, although gonococcal endocarditis is more common in men. Disseminated gonorrhea is most commonly described in women during menses or pregnancy. Only two cases of gonococcal endocarditis during pregnancy have been reported in the literature since 1942. We report a patient who experienced sudden hemodynamic decompensation at 30 weeks' gestation, resulting in fetal death. Aortic valve replacement was performed, but extensive involvement of the aortic root made complete eradication of infection impossible and eventually resulted in maternal death.

Oral tocolysis with magnesium chloride: a randomized controlled prospective clinical trial

A prospective randomized clinical trial was conducted to assess the efficacy and safety of enteric-coated magnesium chloride (SLOW MAG) as an oral tocolytic agent. Seventy-five patients between 24 and 34 weeks' gestation who were treated with intravenous magnesium sulfate for a first episode of preterm labor were enrolled. After a 12-hour contraction-free period on intravenous therapy, patients were randomized by sealed envelope to one of three groups: group 1, SLOW MAG (535 mg every 4 hours); group 2, oral ritodrine (20 mg every 4 hours); or group 3, no therapy (control). Patients receiving oral therapy were treated until delivery or completion of 36 weeks' gestation. No difference was found between groups with respect to time gained with the use of oral therapy or number completing 36 weeks' gestation. Therapy with enteric-coated magnesium chloride was associated with significantly fewer side effects (20%) as compared with ritodrine (48%) (p less than 0.01). Our results suggest that compared with ritodrine, enteric-coated magnesium chloride is as effective in prolonging pregnancy and preventing recurrent preterm labor. However, neither enteric-coated magnesium chloride nor ritodrine appeared to be any more effective in the prevention of preterm delivery than observation alone.

Effect of 1,25-dihydroxyvitamin D3 on mesangial cell proliferation

We have studied the effect of 1,25-dihydroxyvitamin D3 (1,25, (OH)2D3) on mesangial cell growth. Previous studies have shown that the monocyte-macrophage is the principal effector cell in immune-mediated nephritis; this cell infiltrates the glomerular mesangium, and its products may have important effects on the physiology of the mesangial cell. One of the substances produced by the activated macrophage is 1,25,(OH)2D3. We have investigated the effect of 1,25,(OH)2D3 on mesangial cell growth and found that this vitamin D metabolite suppresses the proliferation of mouse mesangial cells as assessed by mesangial cell tritiated thymidine uptake and by cell counts; this substance also antagonizes the mitogenic effect of epidermal growth factor on mesangial cell growth. By comparison, the vitamin D metabolite 25 hydroxyvitamin D3 has no significant suppressive effect on the proliferation of mesangial cells. It has also been possible to demonstrate that 1,25,(OH)2D3 could suppress the growth of mesangial cells that had been committed to proliferate by the prior addition of epidermal growth factor. The results of these studies are relevant to our understanding of the pathogenesis of the cellular abnormalities that occur in immune-mediated nephritis, and especially in subjects who have concurrent hypertension, because a segment of subjects with hypertension have demonstrable abnormalities in the levels of circulating 1,25,(OH)2D3.

Renal replacement therapy in autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) accounted for 4.6% of our end-stage renal disease (ESRD) population. Initial ESRD therapy consisted of hemodialysis in 78% and continuous ambulatory peritoneal dialysis in 22% with significant intertherapy transfers. Half of these patients underwent one or more renal transplantations. Infections, primarily related to ADPKD or ESRD therapy, were the leading cause of morbidity in these patients. 3% of total time on ESRD therapy was spent in hospital, half of it due to problems related to ADPKD and ESRD therapy. Overall mortality and morbidity (as measured by hospitalization rates) in ADPKD patients were similar to those in a non diabetic ESRD population.

Diffuse proliferative lupus nephritis: long-term observations in patients treated with ancrod

Twenty-two patients with histologically demonstrated diffuse proliferative lupus nephritis (DPLN) and glomerular thrombosis received a 14-day course of ancrod, followed in most by nitrogen mustard (mechlorethamine hydrochloride) 0.4 mg/kg. Many were referred when renal function was deteriorating despite large doses of prednisone. The patients had severe disease; there was a high degree of glomerular sclerosis; the median serum creatinine was 137 mumol/l, the diastolic blood pressure 101 mm Hg. Reported previously was a short-term improvement in renal function, blood pressure, and renal histology. Reported here is the long-term follow-up on all 22 patients for an average of 58 months. Three died of causes other than renal failure. Eleven developed end-stage renal disease an average of 27 months after ancrod treatment. The other 8 are alive with no deterioration of renal function after an average of 70 months. This outcome seems satisfactory when disease severity is taken into consideration. Factors present at treatment start that might be associated with subsequent renal function deterioration were: prior prolonged prednisone treatment, extensive glomerular sclerosis, high plasma alpha 2-antiplasmin and possibly triglycerides. During the follow-up period after completion of treatment, later relapses of SLE and DPLN appeared to be an important predictor of deterioration of renal function.

Antimurine antibody formation following OKT3 therapy

OKT3 is an IgG2a murine monoclonal antibody directed against the CD3 antigen receptor of human T lymphocytes. A major concern with OKT3 treatment in solid organ transplant recipients is the development of antimouse antibody, which may preclude retreatment with this agent. We have administered OKT3 on 215 occasions (150 renal, 34 hepatic, 26 cardiac, 5 pancreatic) in 179 patients between April 1982 and December 1988. The mean duration of treatment was 10.5 days (range, 2-22 days). Antimouse antibody data were analyzed on the most recent 133 treatment courses where the antibody status was available pretreatment. Determination of antimouse antibody production was elicited by ELISA technology at days 0, 7, 14, and 28 of OKT3 treatment. Patients were categorized according to the antibody response as follows: (a) absence of antibody; (b) low titer (1:100); or (c) high titer (greater than or equal to 1:1000). Our earlier experience has demonstrated that retreatment with OKT3 is successful in groups a and b. The development of antimurine antibodies was analyzed with regard to the following parameters: (1) The duration of OKT3 treatment; (2) treatment type (prophylactic, primary, or secondary); (3) primary treatment or retreatment; (4) concomitant immunosuppressive regimen (double or triple therapy); (5) dosage of concomitant immunosuppressive drugs; and (6) transplant organ type. The following results were obtained. (1) Duration of treatment had no effect on antibody production (11.0 days in antibody negative and 10.0 days in antibody positive). (2) There was no difference in antibody formation rates for the first treatment of OKT3 when it was used as prophylaxis (26%), primary (19%), or secondary (27%) therapy. (3) Antibody formation rate with first treatment was 29%; with retreatment, patients who were antibody negative following first treatment became positive in 28% of cases, and retreated patients who were low titer positive following first treatment converted to high titer in 57% of cases. (4) Antibody formation was higher in patients receiving double immunosuppressive therapy (36%) than in those receiving triple immunosuppressive therapy (21%) during OKT3 treatment. (5) Concomitant immunosuppression was lower in the antibody-positive group during OKT3 therapy: steroids, 61 mg/day vs. 52 mg/day; azathioprine, 89 mg/day vs. 66 mg/day; CsA, 317 mg/day vs. 186 mg/day. (6) Antibody formation rates were lower in non-renal transplants following first treatment with OKT3 (liver 17%, heart 17%, kidney 28%); this reflects the higher doses of concomitant immunosuppressive therapy used in nonrenal transplants.(ABSTRACT TRUNCATED AT 400 WORDS)

Conversion of arteriovenous shunts to fistulae for maintenance haemodialysis: its applicability in a developing country

Arteriovenous shunts in the forearm of 30 patients with end-stage renal disease were converted to arteriovenous fistulae using the same, previously cannulated blood vessels. The shunts were done because these patients needed immediate dialysis. After 2-4 weeks when the cephalic veins had dilated sufficiently shunts were converted to fistulae. In 28 patients fistulae were usable within 24-48 hours without interruption of the dialysis schedule and without loss of access site. In one patient the use was delayed for 20 days while a local skin infection was treated. In another patient the fistulae did not function.

Absence of alpha-2 adrenergic effects on cAMP production in a genital tract smooth muscle cell line

This study sought to evaluate alpha-2 and beta adrenergic modulation of cAMP production in the DDT1 MF-2 transformed smooth muscle myocyte. After stimulation with forskolin or adrenergic agonists with or without subtype specific antagonists, cAMP production was determined. These experiments confirmed an increase of cAMP in response to forskolin, isoproterenol, epinephrine, and norepinephrine; the adrenergic stimulation was inhibited by propranolol. On the other hand, the alpha-2 agonist clonidine did not inhibit cAMP production. Likewise, alpha-2 receptor blockade did not increase cAMP production in response to epinephrine. These studies, therefore, suggest that the DDT1 MF-2 myocyte does not contain a significant population of functional alpha-2 adrenergic receptors.