Polyclonal rabbit gamma globulins against a human cytotoxic CD4 T cell clone. II. Use in prevention of rejection in kidney transplantation: a pilot study

Antiblast globulins (GAB) were prepared by immunization of rabbits with activated T lymphocytes (AT) derived from a rejected kidney allograft. AT consisted of a CD4+ (CD3+, CD2+ TCR alpha+ beta+) clone cytotoxic for HLA DR8-positive targets. The immunizing cells were adapted to industrial growth conditions by repetitive stimulations with an EBV-transformed line from the kidney donor and recombinant IL-2. In the pilot study, GAB (1.0-1.5 mg/kg/day) was given in 12-hr infusions, in association with prednisone (Pred) 1 mg/kg/day and azathioprine (Aza) 2 mg/kg/day, as prophylactic treatment of rejection in 12 kidney-transplanted patients during the first 2 weeks postgrafting. GAB dosage was further adapted according to the level of circulating E-rosette-forming T cells (ERFT). Cyclosporine A (8 mg/kg/day) was given at day 14 as a monotherapy after Pred and Aza were progressively tapered. No patient died, but one kidney was lost from surgical complication. No rejection occurred under GAB treatment; 41% of patients had at least one episode in the first 3 months and 16% from 3 to 9 months. GAB side effects were minor (skin rash: 2, low grade fever: 4) except for one acute serum sickness. Platelet and white blood cell counts were unchanged, but there was a significant decrease in hemoglobin during the 2 weeks of GAB infusions. Few infectious episodes occurred (3 bacterial, 2 viral). GAB monitoring showed a dramatic drop in T11+, T3+, T4+, and T8+ circulating T cells (less than 10% of normal values between days 3 and 14), whereas EFRT cells had a delayed and somewhat lower decrease (less than 10% after day 6 only). Consequently, mean GAB doses had to be raised to 1.3 mg/kg/day at day 4 and 1.6 at days 8 and 14. This pilot study suggests that this new bioreagent should be of major interest in the prophylaxis and treatment of rejection in allograft recipients. A controlled study is in progress.

[Platelet phenotyping and study of alloantibodies using flow cytometry]

In this study, we describe a flow cytometric technic for the detection and characterization of platelet allo antibodies and for platelets grouping in the platelet group PLA. This new technique is a variant of the platelet suspension immuno fluorescence test. It is rapid, simple, sensitive and specific. So it is very useful in the cases of neonatal thrombocytopenia and posttransfusion purpura. Moreover, anti-HLA antibodies don't obstruct the detection of anti-PLA1 antibodies.

HLA class II genes polymorphism in DR4 giant cell arteritis patients

We have previously reported a significant increase of HLA-DR4 antigen frequency in giant cell arteritis (GCA). This finding suggested an important role of immunogenetic factors in this syndrome. Recent data suggest that inherited susceptibility to several autoimmune diseases was associated with specific DR4 associated DQ beta alleles. DNAs from 27 DR4 positive patients with GCA were digested with Taq I and Bam HI, analysed on 0.7% agarose gel and hybridized with DR beta, DQ alpha and DQ beta probes. DR beta hybridization produced no variant detectable within DR4. DQ beta probe confirmed two clusters among DR4 associated DQW3 alleles: DQW 3.1 (Bam HI 360 Kb) and DQw 3.2 (Taq I 1.9 Kb and Bam HI 11 Kb). Among our 27 DR4 positive patients, 34% were DQW 3.1 and 66% were DQW 3.2. These frequencies are the same as those observed in healthy controls.

Definition of DRw10 specificity by restriction fragment length polymorphism

The purpose of this study was the RFLP characterization of the DRw10 specificity. Twenty-two DRw10 cells were tested: the DNAs were digested by seven restriction enzymes and hybridized with DR beta, DQ beta and DQ alpha probes. Hybridization with DR beta revealed a pattern particular to the DRw10 specificity, with a specific TaqI 12.5Kb fragment. Hybridization with both DQ-specific probes showed that DRw10 is always associated with a special DQw1 subtype: DQw5. Furthermore, at DR and DQ levels, the 22 DRw10 cells behaved homogeneously.

Prognostic value of Langerhans cells in the epidermis of HIV patients

We measured the number of Langerhans cells in clinically normal epidermis and the number of T4 lymphocytes in the plasma in 24 patients infected with HIV, and related these to the stage of the disease. A correlation is demonstrated between the numbers of Langerhans cells and T4 lymphocytes. Numbers of Langerhans cells were lower in patients with disease stages III and IV than in those with disease stage II. Thus Langerhans cell numbers could be of prognostic value in this disease.

Lymphocyte subsets, phytohaemagglutinin responsiveness of blood lymphocytes, and interleukin 2 production in sarcoidosis

To test the possibility that T lymphocyte subset imbalance and interleukin 2 (IL2) play a part in the impairment of cellular immune response in sarcoidosis, the proportion of T lymphocyte subsets in peripheral blood and alveolar lavage fluid from 21 patients with sarcoidosis was studied, monoclonal antibodies OKT3, OKT4, and OKT8 being used. Lectin induced production of IL2 and phytohaemagglutinin (PHA) responsiveness of peripheral blood lymphocytes were investigated. The percentage of both OKT3+ and OKT4+ T lymphocytes was significantly lower in peripheral blood from patients with sarcoidosis than in control subjects (control 63% and 46%), more so in patients with chronic sarcoidosis (44% and 23%) than in patients with recent sarcoidosis (56% and 38%). PHA induced IL2 production from peripheral blood lymphocytes did not differ between patients with sarcoidosis and control subjects. There was a significant positive correlation between PHA responsiveness and the percentage of blood OKT3+ and OKT4+ cells. Peripheral blood lymphocyte PHA responsiveness was decreased only in patients with an OKT4/OKT8 ratio of less than 1.5. Finally, late addition of exogenous IL2 to the culture medium on day 5 increased 3(H)Tdr incorporation by PHA stimulated blasts in peripheral blood lymphocytes from normal subjects, but not from those of patients with sarcoidosis. The data suggest that the impairment of cellular immune response in patients with sarcoidosis could in part reflect a decrease in the percentage of blood T helper lymphocytes and impaired IL2 receptors at the surface of stimulated lymphocytes.

[Populations of circulating T lymphocytes in patients with alcoholic cirrhosis]

The characteristics, the origin and the role in the determinism and/or in the course of hepatocellular necrosis of immune disorders in patients with alcoholic liver cirrhosis still remain unclear. In this study, the T-lymphocyte population was determined by sheep-rosette formation and labelling with OKT3-monoclonal antibodies. T-cell subsets were investigated using OKT4 and OKT8 monoclonal antibodies in the peripheral blood of 40 alcoholic patients with cirrhosis (CA) and of 23 non-cirrhotic alcoholic (ANC) patients. The results were compared to those in 34 healthy volunteers. A decrease in the percentage of T-lymphocytes in the two groups of alcoholic subjects was noted. However, this decrease was significant only in the CA group and only when OKT3 antibodies were used as markers. The lymphocyte-subset identified by OKT4 antibodies was decreased as well in the CA and ANC groups; however the OKT8+ subset was significantly decreased in the CA group only (p less than 0.001). No correlation was found between this decrease in OKT8+ subpopulation or between the increased OKT4/OKT8 ratio and all biochemical parameters of hepatic function measured in this study. The significance of this T-cell imbalance in CA has still to be elucidated, concerning both the functional activity of the reduced pool of OKT8+ cells (suppressor or cytotoxic?) and the mechanism of this decrease.

Influence of HLA-A, B, and DR matching on the outcome of kidney transplant survival in preimmunized patients

The outcome of 893 prospectively typed (HLA-A, B, and DR) and matched cadaveric kidney transplants--all first grafts, with patients being transfused before transplantation--was studied using actuarial survival methods. The effect of HLA-A, B and DR matching was only found to be significantly beneficial to graft survival in the group of 289 presensitized recipients: 70% and 43% graft survival at two years in the case of best-matched (4-6 HLA-A, B, and DR) identities versus mismatched (0 and 1 HLA-A, B, and DR) identities, respectively (P = 0.05). Although a cumulative effect of matching for antigens belonging to the 3 HLA-A, B, and DR series was observed among the group of preimmunized recipients, a trend arose in favor of the prominent role of the HLA-B alleles. No significant difference related to HLA matching was observed in the group of nonsensitized recipients. These results confirm previous observations and support efforts to give priority for matched kidneys to preimmunized patients.

HLA DR4 and giant cell arteritis

We reported the data of HLA-DR frequencies in a new series of 40 unrelated patients suffering from giant cells arteritis (Horton's disease). As previously reported by us, a large increase of HLA-DR4 antigen frequency is noted in patients compared with 146 healthy controls. Moreover, gathering together these 40 patients with the 48 other patients of our first published data, increase of the DR4 frequency is largely confirmed with a Pc less than 0.001.

Preparative two-step purification of human IL-2 by HPLC and hydrophobic affinity chromatography

Interleukin 2 (IL-2) has been purified by a protocol using gel filtration high performance liquid chromatography (HPLC) and hydrophobic affinity chromatography with blue-trisacryl M. Peripheral blood lymphocytes or tonsillar lymphocytes were stimulated with phytohemagglutinin (PHA). Serum free conditioned medium (CM) containing IL-2, other lymphokines and residual PHA molecules was analyzed after 3 variations of ammonium sulfate (AS) precipitation: (1) precipitation of CM with 50% AS yielded a precipitate containing most of the residual PHA but also a fraction of IL-2. (2) Precipitation with direct 80% AS of crude CM yielded both IL-2 and residual PHA. (3) A double step procedure (50% AS followed by 80% AS) yielded a precipitate containing IL-2 but free of residual lectin. HPLC purification of these various AS-precipitated materials or of lyophilized crude CM yielded 2 peaks with mitogenic activity as assayed with the CTLL2 murine clone or IL-2-dependent human Con A-stimulated lymphoblasts. IFN was easily separated from IL-2 and PHA, but BCGF still copurified with IL-2. Peak I (25 kDa) was enriched 400-fold for IL-2 while peak II (68 kDa) contained the residual PHA. The IL-2-containing fractions eluted from HPLC were further purified by blue-trisacryl M chromatography. The IL-2 eluted with 0.4 M NaCl. The entire protocol (HPLC followed by blue-trisacryl) led routinely to 8000-fold IL-2 enrichment. Preparative HPLC directly applied to lyophilized crude (CM) enriched IL-2 activity 400-fold with yield averaging 60% of the IL-2 input. The final material was free from interferon and IL-1, but BCGF still copurified with IL-2. The 2-step purified material (HPLC and blue-trisacryl) gave 2 bands in SDS-PAGE both of which contained IL-2.

[Test of differential anti-T and anti-B lymphocyte compatibility in renal transplantation. A partial solution to the problem of hyperimmune patients]

In view of their beneficial effect on the functional survival of transplanted kidneys, pretransplantation blood transfusions of haemodialysed patients have become routine procedure. At the same time, the number of hyperimmune patients awaiting transplantation has been increasing, as these are often excluded on account of positive cross-match. Cross-matching is usually done by testing recipients' sera against total donor's lymphocytes, so that positive cross-match due to specific anti-T cell cytotoxic antibodies cannot be differentiated from that due to anti-B cell antibodies. Differential anti-T cell and anti-B cell cross-matching showed no significant difference between the survival of 34 transplants with B cell-positive cross-match and that of 126 transplants with B cell-negative cross-match (67% and 60% respectively at 12 months). It also showed that anti-B cell antibodies had no adverse effect on the survival of transplants. The presence of antibodies or auto-antibodies with optimal cytotoxicity at 4 degrees C did not appear to correlate with a significantly longer transplant survival as compared to other transplanted patients. Finally, a high degree of a anti-T cell immunization or a strongly positive B cell cross-match on transplantation day did not seem to jeopardize transplant survival in a B-cell-positive cross-match population of transplanted patients. The differential cross-matching method has made it possible to successfully transplant a substantial number of hyperimmune patients: at least 62% of patients with B cell-positive cross-match also had positive total lymphocyte cross-match which would have precluded renal transplantation.

HLA-AB and -DR types in patients with infectious mononucleosis (IM)

The frequency of HLA-A, -B and -DR antigens in 48 infectious mononucleosis (IM) patients was studied and the antigen frequencies were compared with those of a local panel. The resulting data do not confirm the association of IM and HLA-B35 as reported in a previous work. A high and significant frequency of blank HLA-DR phenotypes was noticed in IM population during the acute phase, but HLA-DR phenotypic expression was restored after recovery. This lack of expression could be the result of modified HLA-DR expression on circulating EBV infected B lymphocytes.

Plasma exchange in early kidney graft rejection associated with anti-donor antibodies

Patients with early rejection of kidney allografts associated with anti-donor antibodies have been randomized in two groups which received, respectively, either the conventional corticosteroid/azathioprine treatment or extensive plasma exchanges (PE) plus the conventional treatment. Data on the monitoring of anti-T or anti-B donor lymphocytes, as well as anti-panel or autoreactive cytotoxicity are described. Although the titer of anti-donor antibodies is decreased in the PE-treated group there is no sustained improvement of graft function compared to the control group. Thus, in these stereotyped rejection episodes, which are likely to be antibody mediated, there is no significant effect of extensive and early plasma exchange.

[Effects of blood transfusions on kidney transplants]

In a retrospective study involving 24 transplantation centres and 858 cadaveric kidney recipients, a number of transfusion factors affecting transplant survival were identified. The best results were observed with the most intensive transfusion schedules including at least one transfusion per month. The optimal number of transfusions varied from 6 to 20. However, it was impossible to determine whether a minimal interval was required between the last perfusion and transplantation, or whether the effect of each transfusion was limited in time. Qualitatively, it appeared that whole blood and packed red cells gave better results than leucocyte-deprived blood. Moreover, fresh blood taken less than 3 days before the transfusion clearly proved more effective than blood stored for more than 5 days. All this suggests that live leucocytes and platelets may be important factors. The mechanism by which blood transfusions improve the outcome of kidney transplants remains unknown.