Influence of the renal endothelin system on the autoregulation of renal blood flow in spontaneously hypertensive rats

The renal endothelin (ET) system has been claimed to play an important role in the regulation of renal blood flow (RBF) and sodium excretion in primary hypertension. The aim of the present study was to investigate the contribution of the endogenous ET system in the autoregulation of total RBF, cortical blood flow (CBF), pressure-dependent plasma renin activity (PRA) and pressure natriuresis in spontaneously hypertensive rats (SHR) by means of the combined (A/B) ET-receptor antagonist, bosentan. In anesthetized rats, RBF was measured by transit-time flow probes and CBF by laser flow probes. During the experiments, the rats received an intrarenal infusion of either bosentan (1 mg/kg/h) or vehicle. Renal perfusion pressure (RPP) was lowered in pressure steps of 5 mm Hg with a servo-controlled electropneumatic device via an inflatable suprarenal cuff. Bosentan had no effect on resting RPP, CBF, PRA and renal sodium excretion, whereas RBF was lowered by 30% (p < 0.05). Furthermore after bosentan the rats revealed a complete loss of RBF autoregulation. In contrast no changes in autoregulation of CBF, pressure-dependent PRA and pressure natriuresis were observed. Our findings demonstrate a significant impairment in total RBF autoregulatory ability during renal ET-receptor blockade which is not confined to the cortical vessels. These data suggest that the renal ET system plays an important role in the dynamic regulation of renal blood flow in SHR.

Wegener's granulomatosis: a meta-analysis of 349 literary case reports

We report the results of a meta-analysis of 349 patients with Wegener's granulomatosis (WG) that were described in the literature from 1979 onward. We describe the patients in terms of diagnosis (granulomas present or absent in biopsy samples from various organs, results of the anti-neutrophil cytoplasmic antibody [ANCA) test) and of the clinical impact of renal involvement. Furthermore, we report the incidence of histopathologic lesions that were found in 134 renal biopsy samples. Before and after the development of the ANCA test, the percentage of patients in whom WG was diagnosed with histologically proven granulomas is the same. However, after 1987 the diagnosis of the group without granulomas is frequently supported by a positive ANCA test result. For the entire group we found that patients without renal involvement (N = 82) were reported to have lower erythrocyte sedimentation rate (ESR), lower white blood cell count (WBC), less anemia, less hypertension, less occurrence of joint symptoms, and less multi-organ involvement than patients with renal involvement (N = 267). The most frequently reported lesion in the renal biopsy samples was extracapillary proliferation (70%), followed by fibrinoid necrosis of the glomerular tuft (54%). Renal granulomas were reported in only 7 biopsy samples.

In vitro sensitivity to prednisolone may predict kidney rejection after steroid withdrawal

A maintenance immunosuppressive regimen of cyclosporine and steroids after renal transplantation has proven to be a successful policy to obtain long-term graft survival. However, serious side-effects are associated with this therapy; these include an increased risk for infections, cancer, and cardiovascular morbidity and mortality. Therefore, this pilot study was conducted to investigate the possibility of reducing the immunosuppressive load after transplantation. To this end, we tried to develop an in vitro assay to predict graft rejection after withdrawing steroids from the immunosuppressive therapy. Patients who had stable renal function at least one year after transplantation were randomly divided into a group that continued to receive standard immunosuppression of cyclosporine and steroids and a group to be withdrawn from steroid therapy, the latter group being the subject of the present study. Patients withdrawn from steroids were monitored closely and when a biopsy-proven rejection occurred, steroid treatment was reestablished. Blood was collected from patients preceding steroid withdrawal and at fixed time points thereafter. In case of suspected rejection, blood was also taken before biopsy, before steroid treatment was reestablished. In the in vitro limiting dilution analysis-assays cytotoxic T lymphocyte precursor frequencies directed against kidney donor HLA-antigens were determined, in the absence or presence of cyclosporine and several concentrations of prednisolone and the combination of these agents. Confirming earlier results, we found that the number of cyclosporine-resistant cytotoxic T lymphocytes increased prior to a rejection crisis, while they did not change or even decreased in patients who retained normal graft function after steroid withdrawal. More importantly, the results show that 10(-7) M prednisolone in vitro differentially affected donor-specific cytotoxic T lymphocyte precursor frequencies in patients who experienced a rejection crisis after steroid withdrawal, compared with those who remained to do well. This heterogeneity could be detected before the start of steroid withdrawal. Therefore, we conclude that the present data justify a prospective clinical trial to investigate the possible application of this in vitro assay to predict for which patients steroid withdrawal might be considered.

The renal histopathology in systemic vasculitis: an international survey study of inter- and intra-observer agreement

In order to relate histopathological findings of the kidney in systemic vasculitis to renal outcome, scoring of various morphological parameters is necessary. Therefore, we conducted a standardization study for evaluating renal biopsies from patients with systemic vasculitis. Four experienced renal pathologists from four European centres joined in the study. A scoring protocol was devised that required the observers to score an extensive number of histopathological lesions either quantitatively (as a percentage of the total number of glomeruli) or dichotomously (on a present/absent scale). Twenty renal biopsies were scored individually by all the observers, from which the inter-observer variability was analysed. Ten randomly chosen biopsies were scored again, in order to obtain the intra-observer variability. For inter-observer agreement, the evaluation of the quantitative variables was satisfactory for both rounds (0.55 < or = Kendall's W < or = 0.95 and 0.59 < or = W < or = 0.96, respectively, with all P < 0.05). However, the inter-observer agreement for the dichotomous data was poor (kappa < or = 0.30 in more than half of the parameters in both rounds). Also the data on intra-observer agreement showed more favourable results for the analysis of the quantitative data (Pearson's r > 0.45 in more than 85% of the variables in both rounds) than for the dichotomous scoring system (kappa < or = 0.30 in more than half of the variables). It is concluded that even between experienced renal pathologists discrepancies occur in scoring kidney biopsies. Inter- and intra-observer agreement is greater if a quantitative method for reviewing the biopsies is applied that requires the observers to score the tissue specimens systematically.

Pharmacokinetics of the conventional and microemulsion formulations of cyclosporine in pancreas-kidney transplant recipients with gastroparesis

Cyclosporine (CsA) is an immunosuppressive drug requiring dose individualization and regular control due to its highly variable pharmacokinetics. Since gastroparesis may influence the absorption of CsA, a randomized cross-over study was performed to assess the pharmacokinetics and tolerability of a novel microemulsion CsA formulation in comparison with the standard CsA dosage form in six stable pancreas-kidney transplant recipients with scintigraphically proven gastroparesis. The absorption of CsA was investigated during three 2-hr study days during each treatment period, and a full pharmacokinetic profile was done for each formulation. No adverse events or differences in tolerability/safety parameters between the treatments were found. The average AUC (0-->2 hr) was 150% higher after the novel formulation. The coefficient of variation in AUC (0-->2 hr) for both formulations was comparable (37% after the microemulsion and 40% after the standard formulation). The median time at which blood CsA levels exceeded the preceding trough level by 20% was 30 min (range: 30 -> 718 min) after the standard formulation. With approximately the same average dose, the AUCss tau after the microemulsion was 81% higher than the standard formulation, while predose and 12-hr trough levels were similar. The average maximal CsA plasma level after the microemulsion was 396 ng/ml (95% CI: 71-722 ng/ml) higher than after the standard formulation. The median time at which the highest blood levels were observed was 90 min (range: 150 -> 718 min) after the standard formulation. The time profiles of the CsA metabolites followed those of the parent compound. The microemulsion resulted in a higher systemic exposure to CsA than the standard formulation in pancreas-kidney transplant patients with diabetic gastroparesis, but substantial variability in blood concentrations remained.

Differential effects of angiotensin II and transforming growth factor beta on the production of heparan sulfate proteoglycan by mesangial cells in vitro

This study approaches the question of whether angiotensin II (AngII) and transforming growth factor beta (TGF-beta) are important mediators for mesangial heparan sulfate proteoglycan (HSPG) production. This might explain the beneficial effects of angiotensin-converting enzyme inhibitors observed in several kidney diseases independent from their hemodynamic effects. Metabolic-labeling studies revealed that AngII induced a decrease of HSPG synthesis with decreases in N-sulfation of the glycosaminoglycan side chains. ELISA measurements with a heparan sulfate (HS)-specific monoclonal antibody confirmed that AngII decreased HS production. AngII increased TGF-beta production in a dose-dependent fashion. Specific mRNA for the large basement membrane HSPG (perlecan) decreased, whereas mRNA for TGF-beta increased after incubation with AngII. Blockade of the Subtype 1 Ang-II receptor (ATR1) reversed both the effects of AngII on HSPG and TGF-beta production. Coincubation of the mesangial cells with neutralizing antibodies against TGF-beta significantly reduced the production of HS as compared with control and AngII. These results indicate that the decrease in HS synthesis induced by AngII is not mediated by an increase in TGF-beta, but on the contrary, the increase in TGF-beta partially counteracts the inhibition of HS production by AngII. Considering the important role of HSPG in maintaining the glomerular charge barrier, cell proliferation, and matrix interaction, downregulation of the production of this molecule by increased local AngII concentrations could have important consequences, such as albuminuria and matrix expansion.

Rejection treatment and cytomegalovirus infection as risk factors for Pneumocystis carinii pneumonia in renal transplant recipients

Pneumocystis carinii pneumonia (PCP) is an infection of immunocompromised patients. The purpose of our study was to estimate the risk of PCP in renal transplant recipients in relation to number, timing, and type of rejection treatments and to cytomegalovirus (CMV) infection. In a case-control study, 15 renal transplant recipients with proven PCP were compared with 95 controls. The relative risks of PCP for 1, 2, and > or = 3 rejection treatments vs. no such treatment were 1.7 (95% CI, 0.2-12.5), 4.8 (95% CI, 0.9-25.5), and 9.5 (95% CI, 1.6-56.4). The relative risk of PCP for renal transplant recipients with negative pretransplantation CMV serology was 3.2 (95% CI, 1.0-10.2), and for the combination of recipient-negative and donor-positive pretransplantation CMV serology it was 5.7 (95% CI, 1.4-22.3). The relative risk of PCP for patients with CMV infection was 5.0 (95% CI, 1.6-15.8). The risk of PCP in renal transplant recipients was positively related to the number but not the timing or type of rejection treatments. The risk of PCP was also increased in cases of CMV infection, irrespective of the number of rejection treatments.

Increased urinary excretion of monocyte chemoattractant protein-1 during acute renal allograft rejection

BACKGROUND

Acute rejection is characterized histologically by infiltration of the interstitium by mononuclear cells. Monocyte chemoattractant protein 1 (MCP-1) has recently been identified as a monocyte chemotactic factor. This study examined the possible role of MCP-1 in renal transplantation.

METHODS

The concentration of MCP-1 in urine and serum of 19 renal transplant patients was investigated using an inhibition radioimmunoassay. The patients were divided into a non-rejection (NRj) and a rejection (Rj) group. Normal healthy volunteers were included as controls. Immunoperoxidase staining for MCP-1 and CD14, as a marker for macrophages, was performed in renal biopsies of transplant patients with rejection and six biopsies from histologically normal kidneys, as controls. The size of urinary MCP-1 was determined by gel filtration chromatography and in a number of fractions assessed for monocyte chemotactic activity using a modified Boyden chamber assay.

RESULTS

Urinary excretion of MCP-1 in the Rj group ranged between 250 ng/mmol Cr and 3148 ng/mmol Cr with a median of 612 ng/mmol Cr. This is significantly higher than the results in the NRj group, ranging between 47 ng/mmol Cr and 288 ng/mmol Cr with a median of 229 ng/mmol Cr. In the normal control group, urinary MCP-1 levels ranged between 38 ng/mmol Cr and 74 ng/mmol Cr with a median of 50 ng/mmol Cr. The fractional excretion of MCP-1, calculated on the basis of MCP-1 and creatinine clearances, was found also to be significantly higher in the Rj group as compared to the NRj group. However, there was no significant difference in the serum levels of MCP-1 between the Rj, NRj, and normal control group. The intensity of MCP-1 staining in tubular epithelial cells and the degree of CD14+ cells in the interstitium was significantly higher in renal allograft biopsies than in the normal kidneys. In addition, MCP-1 isolated from urine of renal transplant patients with rejection was filtered with apparent molecular weight of 13 kDa and 11 kDa. Both sizes are chemotactically active for monocytes.

CONCLUSIONS

These data suggest that urinary excretion of MCP-1 can be used as a marker for the episodes of acute rejection. The increase of urinary excretion of MCP-1 most likely is the result of local production by tubular epithelia cells. MCP-1 produced locally may, at least in part, be responsible for the influx of macrophages into the interstitium during rejection.

Interstitial rejection, vascular rejection, and diffuse thrombosis of renal allografts. Predisposing factors, histology, immunohistochemistry, and relation to outcome

Histological and immunohistochemical analyses were made of biopsy specimens from 50 consecutive patients who experienced putative graft rejection. The mean age of the patients was 44.5 years (range, 17-69 years) and 26 were men. There were 67 evaluable allograft specimens, which were grouped according to the histological diagnosis: group 1, acute tubulointerstitial rejection (n = 42); group 2, acute vascular rejection (n = 18); and group 3, diffuse thrombosis (n = 7). Over a follow-up period of 21-57 months, the mean number of rejection episodes was 1.7, 2.8, and 3.3 in groups 1, 2, and 3, respectively. Allograft loss occurred in 7 out of 30, 10 out of 16, and 4 out of 4 patients in groups 1, 2, and 3, respectively. The following histological parameters differed significantly (P < 0.05) among the groups: interstitial edema, congestion of peritubular capillaries, glomerular thrombosis, and glomerular ischemia (group 3 > group 2 > group 1). Interstitial bleeding was seen more often in group 2 and 3 tissues than in group 1 specimens (P < 0.01). Immunohistochemical analyses showed that vascular rejection was associated with WT14 staining for monocytes and macrophages around the tubuli and with interstitial deposition of complement factor 3. With regard to serology, positive anti-endothelial cell antibody-dependent cellular cytotoxicity was associated with vascular rejection and thrombosis of the graft in all patients tested, and with graft loss in 75%. Pre-existent positive anti-IgG immunofluorescence on peritubular capillaries in pretransplant biopsy specimens incubated with patient serum was found in only 3 of the 50 patients, but was associated with graft loss in 2 of the 3. Cytomegalovirus infection was associated with a higher percentage of graft loss. There were significant intergroup differences in panel reactive antibodies before transplantation (P < 0.001), with higher titers in groups 2 and 3. The findings in relation to interstitial rejection are compatible with cellular rejection, while the data on vascular rejection support a humorally mediated pathogenesis.

Proteinase 3, the major autoantigen of Wegener's granulomatosis, enhances IL-8 production by endothelial cells in vitro

Proteinase 3 is the major target antigen of antineutrophil cytoplasmic autoantibodies (ANCA) in Wegener's granulomatosis and is contained in the azurophilic granules of polymorphonuclear neutrophils, the dominant cell type in vascular lesions during the early stages of systemic vasculitis. This study questioned whether neutrophil lysosomal enzymes, once released at the site of inflammation, are able to potentiate the influx of additional neutrophils by enhancing the production of the chemotactic cytokine interleukin-8 (IL-8) by endothelial cells. Therefore, human umbilical vein endothelial cells in culture were incubated with varying concentrations of highly purified proteinase 3, human neutrophil elastase, and cathepsin G for different time periods. The supernatants were subsequently assessed for IL-8 antigen by using a sandwich ELISA. The presence of both proteinase 3 and elastase resulted in an increased production of IL-8, up to 15.6- and 4.2-fold, respectively, in a dose- and time-dependent fashion. Cathepsin G did not influence IL-8 production. Although the addition of an alpha 1-proteinase inhibitor completely abrogated elastase-mediated IL-8 production, it did not significantly influence the effect of proteinase 3. Both proteinase 3-and elastase-mediated production of IL-8 was inhibited by cycloheximide, indicating de novo synthesis. This was supported by the finding of increased IL-8 mRNA levels in proteinase 3-treated human umbilical vein endothelial cells by using Northern blot analysis. Taken together, the neutrophil lysosomal enzymes proteinase 3 and human neutrophil elastase may contribute to a self-perpetuating process of neutrophil recruitment in acute inflammation by increasing de novo synthesis of IL-8 by endothelial cells. The studies presented here also show that proteinase 3 mediates its effect independently of its enzymatic activity, indicating a hitherto unknown mode of action on endothelial cells.

Chronic sun exposure and age are inversely associated with nevi in adult renal transplant recipients

In 126 adult renal transplant recipients who had survived their transplantation for at least 8 years, we determined whether numbers of nevi and the presence of clinically atypical nevi were related to chronic sun exposure. On the basis of a skin examination, three groups were defined: patients with at least one clinically a typical nevus; patients with only clinically normal nevi: and patients without any nevi. The prevalence odds ratio of having any clinically atypical nevi as compared to having only clinically normal nevi was calculated in a logistic model, in relation to gender, skin type, age, sun exposure, and number of keratotic skin lesions present. Similarly, the prevalence odds ratio of having 30 or more nevi compared to fewer than 30 nevi was calculated. We found an inverse association between chronic sun exposure and age with numbers of nevi in adult renal transplant recipients. The presence of clinically atypical nevi was also inversely associated with chronic sun exposure, but this association disappeared after adjustment for age. We did not observe an association of nevi with the number of keratotic skin lesions, nor with humoral immune responses against human papillomavirus and the presence of certain HLA antigens, which are factors associated with nonmelanoma skin cancer in renal transplant recipients. Chronic sun exposure and age appeared to be strong determinants for decreased numbers of nevi in adult renal transplant recipients. Infection with human papillomaviruses does not appear to play an important role.

[Results of kidney transplantation in Leiden, 1966-1994, and prognostic factors]

OBJECTIVE

Evaluating prognostic determinants and results of renal transplantation.

DESIGN

Descriptive study.

SETTING

Leiden University Hospital, The Netherlands.

METHODS

Follow-up of all 1289 patients who had a kidney transplantation in Leiden University Hospital between March 1966 and December 1994. The following determinants were investigated: age and sex of donors and recipients. HLA matching, type of immunosuppression, presensitization, presence of diabetes mellitus, and living or post-mortem donor.

RESULTS

Renal transplantation was very successful during the first few years, one-year graft survival dropped to 50% during the second decade and gradually increased to almost 90% during the last years. 5-year and 10-year graft survival were 65% and 50% respectively. The mean age of recipients increased from 32.8 years to 45.7 years, that of donors from 24.9 to 37.9 years. Duration of dialysis before transplantation increased from 19.7 months to 35.7 months. The introduction of cyclosporine and matching on the HLA-DR locus were responsible for better transplantation results. Other favourable prognostic factors were absence of diabetes mellitus, absence of panel reactive antibodies, kidney from a living donor, male donor and donor age between 20 and 50 years.

CONCLUSION

Both short term and long term results of renal transplantation improved in spite of a strong increase of mean donor age and mean recipient age and an increase of co-morbidity of the recipients. Introduction of HLA-DR matching and cyclosporine immunosuppression contributed to better graft survival.

Effects of high glucose on the production of heparan sulfate proteoglycan by mesangial and epithelial cells

Changes in heparan sulfate metabolism may be important in the pathogenesis of diabetic nephropathy. Recent studies performed on renal biopsies from patients with diabetic nephropathy revealed a decrease in heparan sulfate glycosaminoglycan staining in the glomerular basement membrane without changes in staining for heparan sulfate proteoglycan-core protein. To understand this phenomenon at the cellular level, we investigated the effect of high glucose conditions on the synthesis of heparan sulfate proteoglycan by glomerular cells in vitro. Human adult mesangial and glomerular visceral epithelial cells were cultured under normal (5 mM) and high glucose (25 mM) conditions. Immunofluorescence performed on cells cultured in 25 mM glucose confirmed and extended the in vivo histological observations. Using metabolic labeling we observed an altered proteoglycan production under high glucose conditions, with predominantly a decrease in heparan sulfate compared to dermatan sulfate or chondroitin sulfate proteoglycan. N-sulfation analysis of heparan sulfate proteoglycan produced under high glucose conditions revealed less di- and tetrasaccharides compared to larger oligosaccharides, indicating an altered sulfation pattern. Furthermore, with quantification of glomerular basement membrane heparan sulfate by ELISA, a significant decrease was observed when mesangial and visceral epithelial cells were cultured in high glucose conditions. We conclude that high glucose concentration induces a significant alteration of heparan sulfate production by mesangial cells and visceral epithelial cells. Changes in sulfation and changes in absolute quantities are both observed and may explain the earlier in vivo observations. These changes may be of importance for the altered integrity of the glomerular charge-dependent filtration barrier and growth-factor matrix interactions in diabetic nephropathy.

Both IgG- and C1q-receptors play a role in the enhanced binding of IgG complexes to human mesangial cells

The presence of immunoglobulin G (IgG) in the mesangial area in kidneys of patients with different forms of glomerulonephritis suggests a role for IgG in the inflammatory process. This study investigates whether IgG is able to bind to cultured human mesangial cells (MC) in vitro. Incubation of MC with 125I-aggregated IgG(125I-AIgG), as a model for immune complexes (IC), at 4 degrees C resulted in a time- and dose-dependent binding of 125I-AIgG to MC. The binding of 125I-AIgG to MC was inhibited by excess AIgG or Fc-fragments and not by F(ab')2-fragments or human serum albumin (HSA). Scatchard analysis revealed the presence of 2.8.10(6) receptors/cell with an affinity of 9.7.10(7) M-1. Incubation of MC with 125I-C1q resulted in a time- and dose-dependent binding of 125I-C1q to MC. The binding of 125I-C1q was inhibited by excess C1q or C1q talls and not by HSA. Scatchard analysis revealed the presence of 3.2.10(7) binding sites/cell with an affinity of 1.4.10(7) M-1. Immunoprecipitation of 125I-labeled MC membrane proteins with C1q or monoclonal antibodies directed against human C1q-R revealed a single 66 to 68 kd band under reducing conditions. Fluorescence-activated cell-sorter analysis revealed an average of 60.1% +/- 5.4% of the cells positive with a mean channel of fluorescence of 592. A cooperative effect between C1q-R and Fc gamma-R in the binding of 125I-AIgG to MC, was assessed by incubation of 125I-AIgG in the presence of increasing concentrations of C1q, C1q talls, or delta C1q. Only intact C1q showed a 6- to 11-fold enhancement in binding of 125I-AIgG to MC. These studies demonstrate the occurrence of C1q-R and Fc gamma-R on MC and indicate that binding of IC is enhanced after interaction of IC with C1q.

Differential expression of complement components in human fetal and adult kidneys

Various studies have shown that complement components are synthesized by renal cells and that mRNA for a number of complement components is detectable in renal tissue. The present study shows that complement proteins are present both in fetal and adult human kidneys. The localization of the complement components was compared with the localization of other proteins for which specific expression in defined renal cell types is known from the literature. In adult human kidneys C3, factor B and factor H were detected in the mesangial area by immunohistochemistry, whereas C2 and C4 were present in the proximal tubuli. In fetal kidneys C3 and factor B were expressed in glomeruli of kidneys of 11 weeks of gestation. In kidneys of 13 to 19 weeks of gestation no staining for C3 was found in the glomerulus, whereas for factor B glomerular staining was found in all fetal kidneys examined. Factor B was also detected in fetal tubuli and in the interstitium. Factor H was expressed in fetal tubuli starting at 13 weeks of gestation. For both C3 and C2 weak tubular staining was found in all fetal kidneys investigated. C4 could not be detected in any of the fetal kidneys. While not all the complement proteins investigated were detectable by immunohistochemistry, by RT-PCR analysis, mRNA expression for C3, factor B, factor H, C2 and C4 was found in all adult and fetal renal tissue. The finding of mRNA for the complement components in the fetal and the adult kidneys indicates that local synthesis of complement occurs both in the adult and in the fetal kidney. Next to the in situ expression of complement components in fetal kidneys the synthesis of complement proteins in vitro by fetal renal cells was investigated. Four different primary mesangial cell lines were shown to synthesize all complement proteins investigated. Although a specific role for complement during the development of the kidney is not known, it is possible that certain complement components may play a role during renal differentiation.

Dietary fish oil in renal transplant recipients treated with cyclosporin-A: no beneficial effects shown

This study aimed to determine whether dietary supplementation with fish oil has a beneficial effect on graft function and the incidence of rejection in renal allograft recipients treated with cyclosporin A (CsA). Renal function, blood pressure, the incidence of acute rejection episodes, graft survival, and renal histology and immunochemistry were investigated. In a randomized, placebo-controlled, double-blind trial, groups of 25 recipients of primary cadaveric renal allografts who had been treated with CsA took fish oil (30% C20:5 omega-3 and 20% C22:6 omega-3) or coconut oil (63% C8:0 and 36% C10:0) at 6 g/day for 3 months. There were no differences between the two patient groups with regard to HLA matching, panel-reactive antibody titers, or the demographic characteristics of donors or recipients. The GFR and effective RPF were determined at 1, 3, and 12 months after transplantation by simultaneous measurement of (125I-)iothalamate and (131I-)hippuran clearances. At 1 yr after transplantation, patients treated with fish oil showed better renal function than did the control patients, but this difference was not statistically significant. Blood pressure and antihypertensive drug use were similar in both groups. The number of rejection episodes was also similar, and renal histopathological and immunohistochemical studies showed no significant differences between the fish-oil group and the control patients. It is concluded that fish oil, at a dose of 6 g/day, has no beneficial effect after renal transplantation within the time scale of the study.

Autoregulation of renal blood flow and pressure-dependent renin release in autosomal dominant polycystic kidney disease of rats

The Han:SPRD (PKD) rat is a new animal model of autosomal dominant polycystic kidney disease (ADPKD) which resembles many clinical and pathoanatomical features of human ADPKD. The aim of the present study was to analyse age-dependent changes in renal haemodynamics and renal renin secretion which could be of pathophysiological importance in the course of the disease. We investigated glomerular filtration rate (GFR), renal blood flow (RBF), renal vascular resistance (RVR), plasma renin activity (PRA), the autoregulatory behaviour of RBF and the pressure-dependent plasma renin activity in conscious PKD rats compared with age-matched controls. Experiments were performed in conscious chronically instrumented PKD rats (age: 3 and 9 months) and their age-matched genetic controls. GFR in 3-(0.52 +/- 0.07 ml/min/100 g; n = 9) and 9-month-old (0.42 +/- 0.03 ml/min/100 g; n = 21) PKD rats were significantly lower (P < 0.05) than 3- (0.92 +/- 0.07 ml/min/100 g; n = 17) and 9-month-old (0.67 +/- 0.05 ml/min/100 g; n = 17) controls. Nine-month-old PKD revealed a significant (P < 0.005) resetting of the breakpoint of RBF autoregulation towards lower pressures (85.5 +/- 4.4 mmHg; n = 10) than either age-matched controls (102.8 +/- 2.5 mmHg; n = 11) or young PKD (107.5 +/- 4.4 mmHg; n = 6). The basal plasma renin activity was significantly (P < 0.05) lower in 3-month-old PKD than in old PKD and age-matched controls. A significant shift of threshold pressure for pressure-dependent renin release to lower pressures was observed in PKD rats. The observed improvement of autoregulatory reserve, at least in the low pressure range, could be of pathophysiological importance in delaying the progression of chronic renal failure in ADPKD. The suppression of the renin angiotensin system in young PKD could explain the fact that we did not observe hypertension in PKD rats, which is a major difference between this animal model and human ADPKD.

Longterm low dose cyclosporine in patients with rheumatoid arthritis: renal function loss without structural nephropathy

OBJECTIVE

To investigate whether administration of low dose cyclosporine for 2 years induces structural changes in the kidneys of patients with rheumatoid arthritis (RA).

METHODS

Renal biopsies were performed in 11 patients with RA who had been treated with cyclosporine [mean dose 3.3 mg/kg/day; mean maximum dose 4.4 (3.5-5.1) mg/kg/day; mean cumulative dose 2.8 (1.6-3.9) g/kg] [mean (range)] for a mean period of 26 (15-30) months. The renal biopsy specimens and specimens of autopsy material of 22 control patients with RA matched for age, disease duration, sex, and previous use of gold and/or D-penicillamine were scored by 2 renal pathologists according to a semiquantitative scoring system (absence of lesions to severe lesions).

RESULTS

In the patients taking cyclosporine, creatinine clearance decreased from 111 ml/min before cyclosporine to 82 ml/min (-26%) after 24 months. Seven percent of the glomeruli in the renal biopsy specimens compared to 13% of glomeruli in the autopsy specimens showed obsolescence. Minimal arteriolopathy (one hyaline deposition in one arteriole) was detected in 3 biopsy specimens and in one autopsy specimen. Moderate and severe lesions were not seen. Tubular atrophy was common but mild in both the biopsy specimens (10/11 patients) and the autopsy specimens (16/22 patients). Five of 11 renal biopsy specimens and 13 of 22 autopsy specimens showed minimal to slight interstitial fibrosis. All biopsy specimens were classified as Group I (minimal lesions) according to the advisory board of nephropathologists.

CONCLUSION

Longterm continuous treatment of RA with low dose cyclosporine does not result in more structural nephropathy than the disease process itself, in spite of substantial and persistent deterioration of the renal function.

Effect of sulphated glycosaminoglycans on albuminuria in patients with overt diabetic (type 1) nephropathy

Decreased expression of heparan sulphate has been shown in the glomerular basement membrane of patients with over diabetic nephropathy. Low- molecular-weight heparin (LMWH) is a highly sulphated glycosaminoglycan with strong structural and functional similarities to heparan sulphate. In a first study, we set out to assess if LMWH could decrease the urinary albumin excretion rate (AER) in diabetic patients with over nephropathy. Six patients entered a randomized, double-blind, placebo-controlled crossover study with treatment episodes of 1 month, separated by a 1-month wash-out. Patients self-administered prefilled syringes with either placebo or LMWH (enoxaparin 40 mg/0.4 ml) at bedtime. Baseline AER levels before either treatment period were similar. In contrast to placebo, AER significantly decreased from 447 (181-1102) to 295 (100-873) micrograms/min after 1 month treatment with LMWH (P < 0.05). Compared to placebo, the effect of LMWH did not reach statistical significance in these six patients after 1 month treatment (P = 0.16). Haemodynamic variables including glomerular filtration rate and filtration fraction did not change during enoxaparin treatment. We observed a favourable effect on AER during LMWH treatment in diabetic patients with over nephropathy. These data suggest that long-term treatment trials in a larger group of patients may potentially demonstrate a new therapeutic option for patients with over diabetic nephropathy.

Tissue antigens in tubulointerstitial and vascular rejection

We propose that tissue-specific alloantigens are of importance in interstitial and vascular rejection. To study this hypothesis we took the following approaches: multivariate analysis on our database (N = 482) was performed, the specificity of T cells cultured from kidneys with rejection was analyzed, and non-anti-HLA antibodies reactive with endothelium were studied. First we observed that in a cohort study of 482 patients receiving a cadaveric renal allograft 76 (15.8%) patients developed vascular rejection and 115 (23.9%) developed interstitial rejection. The incidence of vascular rejection was increased in patients with delayed graft function, HLA-DR mismatches, a prolonged cold ischemia period, and previous transplantations. Next we examined 40 graft infiltrating cell (GIC) lines cultured from renal biopsies taken during rejection episodes. Thirteen GIC lines reacted in a donor-specific fashion to proximal tubular cells (PTEC) but not to donor splenocytes. These GIC recognize polymorphic tissue-specific peptides in the context of allo-MHC Class I. Finally, we studied if non-conventional allo-antigen systems on endothelial cells could be the target of the humoral immune response during vascular rejection. We found the endothelial monocyte (EM) system, and another system that is present on endothelial cells and platelets, which can be tested in an antibody-dependent cellular cytotoxicity assay (ADCC).