Controlled trial of two different methylprednisolone doses in cadaveric renal transplantation

In a controlled trial the effects of two different methylprednisolone (MP) schedules were studied in 100 cadaver kidney adult recipients followed for 18-46 months. Group A patients were given 160 mg/day i.v. for 3 days, then oral MP (0.8 mg/kg/day), which was tapered by 4 mg/week to a maintenance dose of 16 mg/day up to the 6th month. Group B patients were given 80 mg/day i.v. for 3 days followed by 0.4 mg/kg/day oral MP; the dose was reduced by 2 mg/week to 16 mg/day. In both groups, the dose was further reduced bimonthly to a final dose of 8 mg/day. No significant differences were evidenced between the two groups in patients and kidney survival or in the incidence of complications. The number of patients with at least one rejection episode was significantly higher in the lower dose group.

Intravenous methylprednisolone pulse therapy in essential mixed cryoglobulinemia nephropathy

In 15 patients with essential mixed cryoglobulinemia, 24 exacerbations of renal disease, characterized by an increase in plasma creatinine (13 episodes) and/or proteinuria (18 episodes), were treated by 3 intravenous pulses of methylprednisolone (1 g each), followed by oral prednisone (0.5 mg/kg/day). Plasma creatinine levels fell within a week (P less than 0.025), while a significant decrease in urinary protein excretion was observed only after one month (P less than 0.05). After therapy, plasma creatinine levels remained stable in 8/10 patients for 3 to 60 months. These beneficial results suggest that MP pulses may be useful in the treatment of cryoglobulinemic nephropathy.

Cutaneous manifestations in renal transplant recipients

Out of 105 renal transplant recipients 100 had skin lesions: 55% iatrogenic, 74% infectious, 12% precancerous or cancerous and 4% miscellaneous. Many of these lesions were at least in part transient, and steroid-related skin lesions became less frequent as years progressed. The more frequent infections were the fungal ones, followed by viral and bacterial infections with different patterns of onset. All the precancerous lesions appeared late and were almost exclusively represented by actinic keratoses; 2 evolved into squamous cell epitheliomata. 2 patients died due to Kaposi's sarcoma and melanoma. The high incidence of skin cancers in transplanted patients and the rapid evolution of dyskeratoses into spinaliomas warrants close dermatological surveillance.

Quaternary derivatives of narcotic antagonists: stereochemical requirements at the chiral nitrogen for in vitro and in vivo activity

We have studied three pairs of diastereoisomers of quaternary narcotic antagonists and their parent tertiary amines, levallorphan, nalorphine and naloxone, to see how configuration about the chiral nitrogen affects in vitro and in vivo activity. In each series only the diastereoisomer obtained by methylation of the N-allyl substituted tertiary amine (N-methyl diast.) was potent in displacing 3H-naltrexone from rat brain membranes (Ki 10(-8) - 10(-7)M) and as pure morphine antagonist in the guinea-pig ileum (Ki 10(-8)-10(-7)M). Conversely, diastereoisomers obtained by reacting N-methyl substituted tertiary amines with allyl halide (N-allyl diast.) did not displace 3H-naltrexone, up to 10(-6)M, and had negligible antagonist activity and slight agonist action in the guinea-pig ileum. In vivo findings (charcoal meal transit test in mice) were generally consistent with those in vitro. Thus only the N-methyl but not the N-allyl diast. inhibited morphine constipation and behaved as pure antagonists.

Glomerular localization of circulating antiglobulin activity in essential mixed cryoglobulinemia with glomerulonephritis

Kidney biopsy samples from 27 patients with essential mixed cryoglobulinemia of the IgG-IgM(k) type and glomerulonephritis were studied to assess whether glomerular immunodeposits display antiglobulin (AG) activity similar to that of serum cryo-IgM. A preparation of heat-aggregated human IgG (FAIgG) was used to search for tissue AG activity, and blocking tests and reactivity tests were carried out to define the nature of this activity. Glomerular localization of FAIgG was observed in 17 out of 27 kidney specimens, the positive findings being always associated with IgM deposits. Prior exposure of tissue sections to anti-IgM serum blocked the FAIgG reaction, but no such effect was produced by the pretreatment with other antisera. The positive FAIgG tissue specimens yielded a similar fluorescence pattern with aggregated alkylated-reduced IgG, but did not react at all with the aggregated F(ab')2 or aggregated albumin. The IgM recovered in the eluate of a kidney biopsy specimen displayed AG activity. Patients with AG deposits showed more severe histologic changes and a greater renal functional impairment than did those without. The data support the notion that circulating cryo-IgM anti-IgG participates in the formation of glomerular immunodeposits and in the genesis of renal damage.

Factor VIII/von Willebrand factor in glomerular nephropathies

Levels of factor VIII/von Willebrand factor were measured in 105 patients affected by glomerulonephritis either of primary origin or associated with systemic diseases. The median plasma concentration of factor VIII-related antigen was significantly higher in the patients than in healthy controls. Amongst patients with primary glomerulonephritis, higher levels were observed in minimal change nephropathy than in other types. In patients with secondary glomerulonephritis, plasma factor VIII-related antigen was particularly elevated in lupus nephritis and in renal amyloidosis. Altogether, patients with the nephrotic syndrome showed higher levels than patients with lesser degrees of proteinuria. A negative correlation was found between the plasma concentration of factor VIII-related antigen and that of serum albumin but no correlation was observed with the extent of proteinuria. In 48 patients, plasma factor-VIII procoagulant activity was also measured and found to be elevated to the same extent as factor VIII-related antigen in the majority of cases. The urinary excretion of factor VIII-related antigen, evaluated in 72 patients, was found in variable amounts in 31 cases without any correlation with proteinuria. Glomerular deposits of factor VIII-related antigen were an uncommon finding. After 24 months, there was no clear evidence of an unfavourable association between increased plasma levels of factor VIII-related antigen and the course of the disease. Our findings suggest that the measurement of levels of factor VIII/von Willebrand factor in plasma or urine must be interpreted with caution in predicting the clinical course of patients affected by glomerular disease.

[Results of renal transplantation from cadavers in 200 patients]

We report our experience of 202 cadaveric renal transplant performed over a 9 year period. Actuarial patient survival rate was 87.5% at 1 year and 81% at 9 years; graft survival rate was 58.5% at 1 year and 43% at 9 years. In order to improve patient and graft survival, from September 1977 renal transplantation was performed only in patients with a previous careful clinical selection and who had received at least three blood transfusions. Out of 18 patient, actuarial patient and graft survival rate at 1 year were 100% and 76% respectively.

[Prognostic significance of anuric acute rejection]

32 graft rejection episodes requiring dialysis within four days appeared in the first month after transplantation in 224 renal transplants. Our report shows that oliguric renal failure is not related to the severity of rejection but probably to the appearance of an acute tubular necrosis. Therefore graft renal failure requiring dialysis is not necessarily related to a bad prognosis.

Comparison between immunofixation and crossed immunoelectrophoresis for the detection of C3 activation products

C3 breakdown products were measured in 51 fresh and stored sera and/or EDTA plasma samples from 18 healthy subjects, 8 patients affected by essential mixed cryoglobulinaemia, and 15 patients with miscellaneous glomerulonephritis, by simultaneous crossed immunoelectrophoresis and immunofixation. C3 splitting products, as determined by both methods compared well, and showed a highly significant correlation. The advantages and reliability of these two methods are discussed. Immunofixation seems to be the most suitable for routine use in clinical practice, being less expensive and more rapid to perform.

Urinary excretion of factor VIII after renal transplantation

The urinary excretion of factor-VIII-related antigen (VIIIRAg) was measured in 72 patients with kidney transplants and compared with that of two end-products of fibrin-fibrinogen lysis (fragments D and E) to assess their usefulness in monitoring the onset of rejection episodes. Specific and sensitive radioimmunoassays were used to measure the three proteins. Unconcentrated urine samples of 24-hour collections were obtained from 20 healthy subjects, 48 patients with stable transplants, and 24 patients with recent transplants serially followed up from the day of transplantation. Factor VIIIRAg and fragments E and D were not detectable in the urine from healthy subjects but were present in 39%, 60%, and 100% respectively of samples from patients with stable transplants. During 33 acute rejection episodes in 19 patients with recent transplants factor VIIIRAg and fragments E and D were significantly increased above the values observed in patients with stable transplants in 82%, 73%, and 64% of samples respectively; in patients with recent transplants showing no clinical sign of rejection increased excretion of these proteins was observed in 11%, 26%, and 22% of samples respectively. The presence of factor VIIIRAg in urine from patients with kidney allografts suggests that endothelial cell-factor VIII-platelet interactions might pay a key part in the pathogenesis of acute rejection. The results suggest that the assay of factor VIIIRAg in urine is more useful than assays of fragments D and E as a corroborative index of transplant rejection.

Correlations between anti-dsDNA antibodies, complement levels and clinical course in SLE patients treated with steroid pulse therapy

In patients with SLE dsDNA binding activity, C3 and C4 levels are correlated with the clinical course of the nephritis. In fact the study of these serological parameters has a prognostic value in patients treated with methylprednisolone pulse therapy. This treatment can rapidly normalize an acute phase.

Serum complement pattern in essential mixed cryoglobulinaemia

In twenty-six patients affected by essential cryoglobulinaemia, 188 determinations of serum complement components (SCC) were made. A peculiar pattern was observed which was characterized by: (a) low levels of early components (Clq, Cls and C4), (b) normal levels of C3 and high concentrations of late components (C5, C9) and (c) CH50 values significantly lower than normal. No relationship could be observed between early SCC and C3 levels. Thirty-three crossed immunoelectrophoreses were performed in thirteen patient's blood samples. The C3c peaks were not different from normal. Follow-up data (156 serum samples from twenty-four patients) during a 6-40 month period showed a non-homogeneous SCC behaviour. However, no relationship was found between the complement concentrations and clinical score. These findings suggest that SCC abnormalities are related to a complement hyposynthesis, which could be caused by a reduced C2 production or by a negative feedback effect of active components or their fragments.

The prognostic value of some clinical and histological parameters in membranoproliferative glomerulonephritis (MPGN): report of 112 cases

112 cases of MPGN, whose diagnosis was made on light microscopy, were reviewed. Histological examination showed 66 cases of 'classical' MPGN, 33 of MPGN with a lobular pattern and 13 of MPGN with epithelial crescents. In 11 patients dense intramembranous deposits were observed. On immunofluorescence (95 cases) 62 patients showed deposits of C3 together with immunoglobulins, 20 had a predominant deposition of C3 and in 13 C3 alone was present. At the moment of biopsy 57 patients had nephrotic syndrome, 43 hypertension, 43 impaired renal function and 65 hypocomplementaemia. In 23 cases, one or more episodes of macroscopic haematuria occurred. The actuarial survival was 70% after 10 years and 50% after 20 years from onset. At last observation 25 patients were dead or on haemodialysis, 22 had impaired renal function, 62 had normal renal function and 2 were in complete remission. The histological variety with epithelial crescents had a significantly worse outcome. The presence of dense deposits or of any specific immunofluorescence pattern had no prognostic significance. Nephrotic syndrome, renal function impairment and hypertension indicated a poor prognosis: however, macroscopic hamaturia or hypocomplementaemia did not influence the outcome.

Immunofluorescence patterns in chronic membranoproliferative glomerulonephritis (MPGN)

90 patients, whose renal biopsies showed on light microscopy a pattern of MPGN, have been studied by immunofluorescence. 10 cases showed dense intramembranous deposits. Fluoresceinated antisera against IgG, IgA, IgM, C3, fibrinogen, IgD, IgE, C4, C1q, properdin and C3A were employed. Granular depostis of C3 were observed in all cases; IgG, IgM, properdin, C1q and C4 were found in 2/3 cases; IgA, IgE and C3A were rarely found. The localization of these deposits was parietal and often also mesangial. On the basis of glomerular deposition of C3 with or without immunoglobulins (Ig), we separated the cases into three groups: 1) C3 + Ig (59 cases), 2) predominant C3 (19 cases), 3) isolated C3 (12 cases). Most patients with dense deposits disease were classified in the third group. Deposits of C1q and C4 were found only in the first two groups. The localization of C3 deposits showed a more frequent mesangial extension in the second and third groups. Patients in these 3 groups also had different serum complement profiles. No significant differences in the major clinical features could be found in the 3 groups. Variable immunofluorescence patterns, in agreement with other serological parameters, confirm the heterogeneity of pathogenetic mechanisms in patients with MPGN.

Acute renal failure in systemic lupus erythematosus

Acute anuric renal failure complicating systemic lupus erythematosus does not usually respond to treatment with corticosteroids and immunosuppressive agents. We describe four cases treated by dialysis, corticosteroids, and heparin in anticoagulant doses in which there was remarkable improvement in renal function after prolonged anuria. One patient died later from a gastric haemorrhage. The other three were alive and well 55, 54, and 30 months from the onset of anuria. In two cases a second renal biopsy showed a striking improvement in the lesions. Large doses of corticosteroid and heparin may be the best treatment in acute anuric lupus nephritis.