The effects of OKT3 therapy on infiltrating lymphocytes in rejecting renal allografts

OKT3 antibody therapy is effective in the treatment of renal allograft rejection. However its exact mode of action is unknown. Following OKT3 administration, peripheral blood lymphocytes fail to express the CD3 antigen, although other membrane antigens are relatively preserved. In this way the lymphocytes are unable to respond to foreign antigens. It is not known whether this modulation of CD3 on lymphocytes occurs within the rejecting allograft. Ten patients who received OKT3 therapy for steroid-resistant renal allograft rejection were studied. The aim of the study was to examine whether OKT3 antibody therapy altered the degree or the relative composition of the inflammatory infiltrate and to assess whether OKT3 treatment resulted in modulation of CD3 on intragraft lymphocytes. The study involved immunoperoxidase examination of biopsy material and flow cytometric analysis of peripheral blood lymphocytes obtained before and during treatment with OKT3 antibody. The results show that the total number of infiltrating leukocytes decreased after 5 days of treatment (3215 +/- 700 cells/l. 0 mm2 of tissue before vs. 1730 +/- 635 at day 5; P less than 0.001). The relative proportions of macrophages, total lymphocytes, CD4 +ve and CD8 +ve cells did not alter during therapy. Despite marked modulation of peripheral blood lymphocytes (CD3/CD2 ratio 0.89 +/- 0.13 before vs. 0.10 +/- 0.11 during treatment, P less than 0.001), there was no evidence of modulation of intragraft lymphocytes (CD3/CD2 ratio 0.98 +/- 0.14 before vs. 0.90 +/- 0.21 during treatment, P = NS). Although OKT3 antibody therapy is effective clinically at improving renal allograft rejection, this study demonstrates that it does not appear to cause modulation of the CD3 antigen on intragraft lymphocytes.

Assessment of the symptomatic benefit of cool dialysate

Symptoms were evaluated in 13 haemodialysis patients at dialysate temperatures between 37 and 35 degrees C. After a control period at 37 degrees C (stage 1) dialysate flow rate was increased from 300 ml/min in half the patients but no change in temperature was made (stage 2). In stage 3 dialysate temperature was reduced to 36.5 degrees C and in stage 4 to 35 degrees C. Blood pressure and temperature were measured pre- and post dialysis and patient completed a questionnaire indicating if they experienced any of nine specified symptoms: itch, restless legs, nausea, vomiting, headache, cramp, lethargy, hypotension and change in temperature. Trial stages were compared with chi 2 analysis using Yates correction. Symptoms per dialysis fell from 1.11 to 0.71 between stage 1 and 2 (p less than 0.0005). This was considered to be a trial effect. There was no further significant improvement in symptoms overall as the temperature was reduced to 35 degrees C. However, if complaints of coldness are excluded, there was a progressive reduction in symptoms from stage 1 to stage 4. Dialysate flow rate did not affect symptom reporting. There was no effect on body core temperature or blood pressure due to cool dialysate. Our results suggest there may be some benefit in lowering the dialysate temperature but this is small in relation to the placebo effect. Caution must be used in assessing similar studies using small numbers of dialyses.

Bilateral pelviureteric junction obstruction causing renal failure in two elderly patients

Two elderly patients presented with renal failure due to pelviureteric junction (PUJ) obstruction. After dialysis, obstruction was relieved by percutaneous nephrostomy and the diagnosis was established radiologically. Differential renal function was assessed by direct measurement or isotope scanning. Surgical correction resulted in both patients remaining free of dialysis at follow-up 2 years later. PUJ obstruction is an uncommon cause of renal failure, particularly in the elderly, but is potentially correctable.

Zygomycosis requiring amputation of the hand: an isolated case in a patient receiving haemodialysis

A case of zygomycosis due to Rhizopus microsporus variety microsporus in a patient who was receiving haemodialysis is described. This infection resulted in amputation of the right hand. Criteria to identify the fungus are presented. The pathogenesis and treatment of zygomycosis are discussed.

Hemodynamic and plasma renin responses to treatment of a renal arteriovenous malformation

We report a case of a right renal arteriovenous malformation with high output cardiac failure and hypertension which was cured by nephrectomy. Hemodynamic findings pre- and post-operatively are presented. Plasma renin activity (PRA), both from peripheral venous and renal vein samples, was assessed. The fall in PRA associated with nephrectomy lends support to the suggestion that the renin-angiotensin system plays a role in the hypertension in these patients.