Hyperimmune globulin therapy of clinical cytomegalovirus infection in renal allograft recipients

Intravenous cytomegalovirus (CMV) hyperimmune globulin therapy was used in 24 episodes of proven CMV disease in 22 renal allograft recipients. All patients had fever up to 39-40 degrees C for at least 3 days. Many patients had thrombocytopenia, leukopenia, and/or elevation of serum transaminase levels. Five had pneumonitis. The diagnosis of CMV infection was confirmed by isolation of virus from urine or bronchoalveolar lavage fluid using a rapid culture method based on the demonstration of CMV early nuclear protein in cell culture monolayers and/or by the demonstration of CMV specific IgM antibodies. The hyperimmune globulin was given until fever disappeared. The infusions were well tolerated and no side effects were recorded. A clinical response defined as normalization of body temperature, occurred in 23/24 cases. One patient with septic fever and a fatal outcome had a superinfection with tuberculosis. Two other fatal complications were caused by invasive pulmonary aspergillosis and by multiple penetrating duodenal ulcers. Two reversible acute rejections and one recurrence of the original renal disease were recorded. 19/22 patients are alive, 18 with normal renal function. We conclude that hyperimmune globulin therapy is well tolerated and may help to control sever CMV infections in renal transplant recipients.

Diet and urinary estrogen profile in premenopausal omnivorous and vegetarian women and in premenopausal women with breast cancer

The urinary estrogen profile was studied in the midfollicular phase twice, and diet four times during 1 yr in 10 premenopausal breast cancer (BC) patients consuming an omnivorous normal Finnish diet and in two control groups, one consuming an omnivorous (n = 12) and the other a lactovegetarian (n = 11) diet. Total fat intake in relation to caloric intake was almost identical in all three groups. Only with regard to grain fiber intake did the BC patients differ significantly from both other groups. No differences were found between the groups with regard to urinary excretion of 13 individual estrogens and total estrogens, with the exception of 4-hydroxyestrone (4-OH-E1), which was significantly lower (P less than 0.05) in the BC group than in the vegetarians. A high carbohydrate to protein ratio in the diet had a negative correlation with the excretion of 2-hydroxyestrogens and 2-hydroxyesterone (2-OH-E1) to 4-OH-E1 ratio. The BC group had significantly higher urinary 2-OH-E1 to E1 ratio (P less than 0.05) compared to the vegetarians. The 2-OH-E1 to 4-OH-E1 ratio was highest in the BC group (= 7.1) and differed significantly from that of the omnivores (= 4.3; P less than 0.02) and vegetarians (= 3.6; P less than 0.005). This ratio showed a negative correlation with intake of carbohydrates, starch, total and grain fiber. Urinary excretion of 4-OH-E1 correlated positively with total and grain fiber intake and plasma SHBG. Protein intake correlated positively with urinary 2-methoxy-E1 excretion, and retinol intake positively with catechol estrogen, E1 and E2 excretion. It is concluded that estrogen production and urinary estrogen profile in premenopausal breast cancer patients is normal with the exception of a low 4-OH-E1 excretion and high urinary 2-OH-E1 to 4-OH-E1 ratio. This ratio, which seems to depend on diet, is the only urinary estrogen parameter separating premenopausal BC patients from the control omnivorous and lactovegetarian women.

Fine-needle aspiration biopsy in the monitoring of liver allografts. I. Correlation between aspiration biopsy and core biopsy in experimental pig liver allografts

We have used allogeneic pig liver transplants to investigate the structure of inflammation in acute liver allograft rejection. An inflammatory episode of acute cellular rejection was observed in 9/10 allografts in nonimmunosuppressed recipients, when monitored with simultaneous fine-needle aspiration biopsies (FNAB) and core needle biopsies (NB). The intensity of inflammation in FNAB was quantitated using the corrected increment method and correlated with NB findings. In FNAB, all inflammatory episodes were detected on the 4th day after transplantation with lymphoid blast and lymphocyte infiltration, later accompanied by monocytes and macrophages. Maximal intensity of inflammation was recorded in FNAB on day 14. In NB, histology demonstrated distinct inflammation in the portal area on day 4. The predominantly lymphocytic infiltration, also containing varying numbers of plasma cells, eosinophils, neutrophils and macrophages, reached its maximum 7-14 days after transplantation. With the indirect immunoperoxidase technique, lymphoid cell subpopulation analysis of FNAB demonstrated an increase of both T4 and T8 cells during rejection. The T4/T8 ratio was first low, and increased at the beginning of the episode, on day 4, but decreased again on days 7 and 14. The number of B cells in the graft was also elevated during rejection. The cellular changes in the corresponding blood specimens followed approximately the same lines, although the changes were less prominent. NB immunohistology, using immunoperoxidase and frozen sections, correlated well with FNAB results, and demonstrated a T4 predominance in the portal area on day 4 but a T8 predominance on days 7 and 14. In addition to lymphoid cells, macrophages/granulocytes were also frequent in the portal area and scattered in the parenchyma on days 7 and 14. An additional inflammatory cell component in liver allograft rejection, detectable only in the NB, was eosinophils in the portal area, recorded in maximum on day 14. Taken together, the inflammatory changes in the FNAB and NB were similar, and time-related changes of cellular infiltrate in FNAB and NB correlated closely.

Fine-needle aspiration biopsy in the monitoring of liver allografts. II. Applications to human liver allografts

Serial fine-needle aspiration biopsies (FNAB) were used for clinical monitoring of human liver allografts. Nine liver allograft recipients were monitored with FNAB at 1-3 day intervals. No complications were recorded. All patients underwent at least 1 inflammatory episode of acute rejection; altogether 11 episodes, all reversible, were recorded. The inflammatory infiltrate consisted mainly of lymphoid cells, including lymphoid blasts, with minor involvement of monocytes, monoblasts, and macrophages. Further analysis of lymphoid cell subpopulations by immunoperoxidase techniques demonstrated an increase of T cells during rejection, both the CD4 (T4) and CD8 (T8) subsets were increased. A slight increase of B cells in the graft was also seen. The CD4/CD8 (T4/T8) ratio was first low, peaked at the onset, and decreased toward the end of the episode. No clear correlations to the intragraft cellular events were recorded in corresponding blood specimens. However, an episode of eosinophilia was seen in the blood at the beginning of rejection, correlating with fever in the recipient. Degenerative changes in the parenchymal cells and bile droplets in the hepatocytes, indicating cholestasis and hepatocyte damage, were seen during all episodes of rejection, and these changes persisted even 10 days after the inflammation had subsided. The FNAB-findings correlated well with biochemical laboratory parameters, but the diagnosis of rejection could be established by the FNAB already 1-5 days earlier than elevated serum values indicated liver dysfunction.

Diagnosis of acute rejection in liver transplantation

Eleven acute rejections were found in 9 patients with liver transplantation due to end-stage liver cirrhosis. The rejections were diagnosed with fine-needle aspiration biopsy (FNAB) giving the cellular picture of immunoactivation in the liver graft when compared to a simultaneous sample of peripheral blood. s-Alkaline phosphatase and s-bilirubin increased within 1 week after onset of rejection in 7 and 10 cases, respectively. s-Alanine amino-transferase and b-ammonium were of no value in the diagnosis of acute rejection. A core biopsy was obtained only in a case of severe liver damage, mainly to estimate the need for retransplantation. One year after grafting, 6 out of 7 cirrhotic patients are well, all with normal liver function. Two have died of sepsis. One patient died from pulmonary metastases of occult liver carcinoma 6 months after the transplantation. FNAB seems helpful in detecting early acute rejection and also excluding such an event in the liver graft.

Acute phase proteins and liver allograft rejection

We studied the sequential changes in the positive acute phase reactants orosomucoid, alpha 1-antichymotrypsin, alpha 1-antitrypsin, haptoglobin and C-reactive protein, and in the negative acute phase reactant, prealbumin, as well as in alpha 2-macroglobulin and beta 2-microglobulin in serum following orthotopic liver transplantation in nine adult patients. Synchronous increases in all five positive acute phase reactants were observed in association with acute liver rejection episodes; the elevations were statistically significant for orosomucoid and alpha 1-antichymotrypsin. In four out of nine well-documented rejection episodes C-reactive protein did not increase at all. Marked variations occurred in post-transplant prealbumin and alpha 2-macroglobulin levels; both proteins tended to decrease 2-3 days after the rejection was diagnosed. The circulating levels of beta 2-microglobulin were raised during the post-transplant period and markedly increased in association with acute graft rejection episodes. The results demonstrate marked changes in plasma protein concentrations in association with acute liver allograft rejection episodes; the kinetics of serum acute phase reactants is very similar to that found in inflammation and tissue injury in general.

Effects of cyclosporine, azathioprine, and steroids on the renal transplant, on the cytologic patterns of intragraft inflammation, and on concomitant rejection-associated changes in recipient blood

We have investigated the impact of various immunosuppressive drugs and their combinations on the graft, on the intragraft inflammatory patterns of rejection, and on rejection-associated effects in the recipient circulation by fine-needle aspiration biopsy and an extensive computer program. The patients were randomized into three treatment groups, 32 patients each, with the following postoperative immunosuppression: (1) Aza (2.1 mg/kg/d) plus MP (3.6 mg/kg/d tapered to 0.5 mg/kg/d by day 15), (2) CsA (10 mg/kg/d tapered to 8 mg/kd/d by day 28) and, (3) CsA (as above) plus MP (3.6 mg/kg/d tapered to 0 mg/kg/d by day 9). The groups were homogeneous in regard to all tested pretransplantation parameters. Graft parenchymal cell morphology was significantly (P less than .05) deteriorated and urine output reduced in CsA-treated patients, compared to those receiving Aza + MP; concomitant administration of steroids partially (P = NS) protected against the CsA-associated effects. The first episode of inflammation occurred significantly earlier (P less than .001) in patients receiving initially only CsA, compared to those receiving Aza + MP or CsA + MP, the total duration of intragraft inflammation was longer and the clinical signs of rejection were significantly prolonged (.001 less than P less than .05). Although the influx of lymphocytes and monocytes into the graft and the peak intensity of intragraft inflammation was similar in the three groups of patients, the inflammatory patterns of rejection were distinctly different. The number of (T) lymphoblasts in CsA-treated grafts was significantly (P less than .05) lower and their appearance delayed, compared to those treated with Aza + MP and even lower and more delayed in grafts treated initially with CsA + MP. The number of (B) plasmablasts was also reduced and their appearance delayed, but the differences to conventional treatment with Aza + MP were smaller and no longer significant. On the other hand, a significant (P less than .01) early maturation of blood-borne monocytes into tissue macrophages was observed in the CsA-treated grafts in context of first rejection, which was lacking from those treated with CsA + MP or Aza + MP. In the blood, the first episodes of inflammation under CsA were associated with significant (P less than .001) thrombocytosis, which was lacking from the Aza + MP- and CsA + MP-treated patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Hepatic dearterialization in the treatment of carcinoid syndrome

Fourteen patients with carcinoid syndrome due to metastatic ileal (10), ileo-coecal (3) or appendiceal (1) carcinoid tumours were treated with hepatic dearterialization procedures: 15 surgical interruptions of arterial connections to the liver and 1 angiographic embolization of hepatic arteries. 11 patients had complained of recurrent attacks of flush, diarrhea and/or dyspnea and 3 patients had already progressed to general debility and cardiac failure caused by tumour products. Hepatic dearterialization abolished the carcinoid syndrome symptoms for 3-60 months (mean 19 months). Urinary 5-HIAA decreased for a mean period of 27 months. After relapsing symptoms 2 patients had redearterialization of the liver with a renewed symptomless period and lowered 5-HIAA excretion. Operative mortality was 19%: the deaths occurred when liver dearterialization was performed for end-stage patients or simultaneously with bowel resection, which should be considered as contraindications. Hepatic dearterialization seems to be temporarily effective in relieving carcinoid syndrome symptoms and in reducing hormonally active tumour mass and serotonin formation.

Effect of dietary components, including lignans and phytoestrogens, on enterohepatic circulation and liver metabolism of estrogens and on sex hormone binding globulin (SHBG)

A brief account of our present knowledge on the enterohepatic metabolism of estrogens and on the origin, metabolism and biological effects of mammalian lignans and phytoestrogens is undertaken. Furthermore, recently published results on the effects of dietary fiber, fat and carbohydrates on estrogen metabolism are reviewed. New preliminary results are presented on quantitative assays of lignans and phytoestrogens in urine of women belonging to various dietary and population groups and in a group of chimpanzees. The highest values of lignans and phytoestrogens were found in the non-human primates, and in macrobiotic, lactovegetarian and Japanese women, all groups considered having a low risk for the development of breast and other hormone-dependent cancer. New results on correlations between intake of various fibers, lignan and phytoestrogen excretion and plasma levels of estrogens, free testosterone and SHBG in women are presented. There is a significant positive correlation between the intake of fiber and urinary excretion of lignans and phytoestrogens, and the concentration of plasma SHBG. Fiber intake and urinary excretion of lignans and equol correlated negatively with plasma percentage free estradiol. Enterolactone excretion correlated negatively with plasma free testosterone. It is concluded that dietary macro- and micronutrients seem to play an important role in estrogen metabolism.

Liver transplantation in Europe--present status

Liver transplantation is an exciting new therapeutic procedure that over the past few years has shown signs of increasing interest among physicians and health care providers (26;36). The history of liver transplantation dates back to the immediate post-World War II years when early experiments showed the technical feasibility of transplanting a functioning liver into a recipient, either heterotopically as an accessory organ or orthotopically, i.e., by complete replacement of the original organ (29).

Intramuscular myxoma--a clinicopathological study of twenty-three cases

Twenty-three cases of intramuscular myxoma were analyzed clinically and histologically. The mean age of the patients was 54 years, and two-thirds were women. Clinical follow-up of 2 to 17 years' duration revealed no recurrences or metastases. Intramuscular myxoma thus appears to be a completely benign tumor. One patient simultaneously had a myxoma in the muscle of the thigh and a lesion of fibrous dysplasia in the femur. In addition, 14 of 16 patients studied with x-ray had a significantly higher incidence of minor abnormalities in bones as compared with the normal population. The myxomas were characterized histologically by sparse cellularity, abundant intercellular material digestible with hyaluronidase, and lack of mitotic figures. At the ultrastructural level, the tumor cells showed characteristics of fibroblasts and myofibroblasts. Immunohistochemical analysis of intermediate filament proteins revealed vimentin- but no desmin-positivity in the tumor cells, and endothelial cell markers as well as S-100 protein were absent. This is compatible with fibroblastic-myofibroblastic nature of the myxoma cells.