Photochemical donor pretreatment in clinical kidney transplantation--preliminary report

Extended experimental experience with the efficacy of pretreating the kidney donor and the allograft by means of photochemotherapy (photosensitizer + UVA irradiation = PUVA) was adopted in clinical kidney transplantation. In a preliminary unrandomized study similar patient populations were treated by generally uniform methods. Thirty-three PUVA-pretreated kidneys (group A) were compared with the experience regarding 26 non-pretreated kidney allografts (group B). The number of rejection episodes was significantly lower in the first 3 months in group A (p less than 0.05 vs group B) and fewer grafts failed because of irreversible rejection (2 vs 5). Furthermore, in group A the rate of infectious complications was lower (18% vs 34%). The cumulative allograft survival at 3 months was improved from 65% in group B to 81% in group A and at 12 months from 65% 76%, respectively. These differences were not significant. Therefore, our preliminary clinical experience with a photochemical donor pretreatment is encouraging and further use in a randomized study seems to be necessary.

Inhibited efficiency of kidney mitochondria isolated from rats treated with cyclosporin A

The effect of cyclosporin A (CYA) on the respiration and phosphorylation in rat kidney mitochondria was studied. When CYA (50 mg/kg/day) was subcutaneously administered to rats for 4 days, the state 3 respiration and uncoupled respiration of succinate and glutamate/malate respiration was decreased. The respiratory control index was decreased in glutamate/malate respiration. These ex vivo effects of mitochondrial dysfunction are discussed as CYA effects on kidney mitochondria occurring in the intact cell. The nephrotoxic effect of CYA could be demonstrated by increased excretions of urinary enzymes.

31P-NMR spectroscopy and ultrastructural studies on nephrotoxicity of cyclosporine A

NMR-spectroscopy and electron microscopy were applied in order to find out whether nephrotoxic effects of cyclosporine A in combination with ischaemia on rat kidney are of significance for the energy metabolism of the organ. CSA was administered in daily doses of 15 mg/kg rat over 20 days. Use was made of the particular advantage of 31P-NMR-spectroscopy to follow up the dynamics of high-energy phosphate concentrations in the same tissue. Ultrastructural changes were observed in the region of the proximal tubule. Some mitochondria showed degenerative changes, others increased density of cristae. The total number of mitochondria was increased. This observation together with the coexistence of vacuolarly degenerated mitochondria and mitochondria with increased activity after CSA treatment is interpreted as expression of a compensatory mechanism that keeps constant the totality of high-energy phosphates despite damage to some mitochondria.

BLV receptor activity in plasma membranes from tumorous lymph nodes of BLV-infected cows

Plasma membranes of cells from lymph nodes of bovine leukaemia virus (BLV)-free cattle and of cells from tumorous lymph nodes of BLV-infected cattle have been investigated for their reactivity with iodine labelled BLV antigens gp51 and p24. It has been found that only the plasma membranes from cells of tumorous lymph nodes bound gp51 and p24. The binding could be abolished by addition of nonlabelled antigens. It has been calculated from Scatchard plot analysis that 10(5) molecules of gp51 or 10(4) molecules of p24 can be bound per tumour cell. The findings led to the conclusion that tumour cells of BLV-infected cattle are endowed with receptors for the BLV antigens gp51 and p24.

Diagnostic significance of some urinary enzymes for detecting acute rejection crises in renal-transplant recipients: alanine aminopeptidase, alkaline phosphatase, gamma-glutamyltransferase, N-acetyl-beta-D-glucosaminidase, and lysozyme

We compared the diagnostic validity of five urinary enzymes--alanine aminopeptidase (EC 3.4.11.2), alkaline phosphatase (EC 3.1.3.1), gamma-glutamyltransferase (EC 2.3.2.2), N-acetyl-beta-D-glucosaminidase (EC 3.2.1.30), and lysozyme (EC 3.2.1.17)--as indicators of acute rejection crises in renal-transplant recipients. In 82 patients (group A), the excretion of each of these five enzymes was measured daily from transplantation until discharge from hospital. In another 69 patients (group B), enzyme determinations were made when the patient came for regular checkups (about every four to eight weeks). We used an "activity ratio" (the activity measured at a particular time compared with the activity on the preceding determination) value of 1.5 as the decision point. In group A, use of this discrimination point for alanine aminopeptidase, gamma-glutamyltransferase, and N-acetyl-beta-D-glucosaminidase yielded a specificity and sensitivity of about 90%. In group B, only alanine aminopeptidase had a greater diagnostic sensitivity than creatinine alone. Evidently, measurement of alanine aminopeptidase can be a helpful indicator of acute rejection crises, when interpreted in combination with other available relevant clinical, biochemical, and immunological data.

Diagnostic significance of some urinary enzymes for detecting acute rejection crises in renal-transplant recipients: alanine aminopeptidase, alkaline phosphatase, gamma-glutamyltransferase, N-acetyl-beta-D-glucosaminidase, and lysozyme

We compared the diagnostic validity of five urinary enzymes--alanine aminopeptidase (EC 3.4.11.2), alkaline phosphatase (EC 3.1.3.1), gamma-glutamyltransferase (EC 2.3.2.2), N-acetyl-beta-D-glucosaminidase (EC 3.2.1.30), and lysozyme (EC 3.2.1.17)--as indicators of acute rejection crises in renal-transplant recipients. In 82 patients (group A), the excretion of each of these five enzymes was measured daily from transplantation until discharge from hospital. In another 69 patients (group B), enzyme determinations were made when the patient came for regular checkups (about every four to eight weeks). We used an "activity ratio" (the activity measured at a particular time compared with the activity on the preceding determination) value of 1.5 as the decision point. In group A, use of this discrimination point for alanine aminopeptidase, gamma-glutamyltransferase, and N-acetyl-beta-D-glucosaminidase yielded a specificity and sensitivity of about 90%. In group B, only alanine aminopeptidase had a greater diagnostic sensitivity than creatinine alone. Evidently, measurement of alanine aminopeptidase can be a helpful indicator of acute rejection crises, when interpreted in combination with other available relevant clinical, biochemical, and immunological data.

Synergistic effect of donor pretreatment with 8-methoxypsoralen and ultraviolet irradiation of the graft plus azathioprine and prednisolone therapy in prolonging rat renal allograft survival

Pretreatment of the kidney donor with 8-methoxy-psoralen (8-MOP) and direct longwave ultraviolet (UVA) irradiation of the kidney graft (PUVA therapy) significantly prolonged survival in allogeneic recipients. 40% of the recipients survived more than 100 days with normal transplant function. The addition of standard clinical immunosuppressive agents azathioprine and prednisolone (both at dosages of 15 mg/kg body weight/day for 21 days) to the PUVA therapy further improved graft survival rate, with a recipient survival rate of 62.5%. The two drugs alone were less effective in prolonging graft survival rate (28.5%). A synergistic effect of PUVA therapy and standard immunosuppressive treatment with azathioprine and prednisolone was demonstrated. This suggested a possible clinical application of this type of immunosuppression and immunoregulation.

[Saralasin test in the differential diagnosis of essential and renal hypertension]

In a multicentric prospective study should be tested clinically the effectiveness and the tolerance of an angiotensin-II-antagonist (Saralasin-IWF) developed by the Institut für Wirkstofforschung der Akademie der Wissenschaften, its position in the differential-diagnostic step programme of the arterial hypertension should be analysed and with it should be performed pathogenetic investigations for hypertension after kidney transplantation. Taking into consideration international studies our results confirm that the Saralasin test, taking into account strongly standardized methodical prerequisites, is suited to objectify a participation of the RAAS in the hypertension pathogenesis, without, however, thus making an absolutely reliable evidence concerning the etiology of hypertension. The Saralasin test may represent an important diagnostic criterion for an optimization of the therapy of "volume-resistant" hypertension under the conditions of haemodialysis and in connection with selective renin determinations it possesses a high value in the screening diagnostics of the arterial stenosis after allogenic kidney transplantation.

[Frequency of infection with cytomegaloviruses (CMV) following kidney transplantation and initial experiences with CMV gamma globulin prevention]

In a retrospective study we investigated 364 patients who had received cadaveric kidney transplants between 1978 and 1984 as to cytomegalovirus (CMV) infections using complement-fixation test and indirect immunofluorescent test (IgM, IgG). Before transplantation, 194/364 patients were seropositive and 170/364 were seronegative. After transplantation, seroconversion or an increase in titre (greater than or equal to 4 fold) was found in 26% of seropositive recipients and in 30% of seronegative recipients. In contrast to the secondary infections (approximately 40% asymptomatic or oligosymptomatic), the primary infections were regularly connected with a clinical symptomatology. As to the recipient's and donor's pre-transplant antibody status the highest infection rate (62%) was seen in the group of seronegative recipients of kidneys from seropositive donors. Preformed CMV antibodies seem to be useful in preventing severe CMV-diseases. Therefore, in April 1985 we started a randomized study in order to investigate the efficacy of an i.v. cytomegalovirus-immunoglobulin (CMV-Polyglobin/Cutter). There were no side effects. Already 4 h after infusion we were able to detect CMV-IgG-antibodies (IFT) in peripheral blood. This passive immunization, however, was not capable to prevent a CMV infection in each case; there were 5/8 seroconversions and 4/8 symptomatic CMV infections. Nevertheless, we think the application of CMV immunoglobulin has a beneficial effect.

Prolongation of rat renal allograft survival time by donor pretreatment with 8-methoxypsoralen and longwave ultraviolet irradiation of the graft (PUVA therapy)

Pretreatment of the kidney donor with 8-methoxypsoralen (8-MOP) and ex vivo longwave ultraviolet irradiation (UVA) of the kidney prolonged the subsequent survival on allogeneic recipients. The efficacy of this treatment seems to be dependent on the time and dose of UVA irradiation rather than on the dose of 8-MOP. In conclusion, PUVA treatment is effective in reducing the immunogenicity of the rat kidney allograft, although the mechanism remains unclear. These experimental findings are new and preliminary results in clinical human kidney transplantation are favourable.

Extracorporeal microsurgical repair of injured multiple donor kidney arteries prior to cadaveric allotransplantation

To prevent the complications of ureteral and parenchymal ischemia it is important to revascularize all accessory and main branches of the renal arteries in kidney transplantation. 11 allografts underwent ex vivo microsurgical repair of injured polar arteries prior to allotransplantation, and 1 patient had an in situ repair. Three extracorporeal reconstructive techniques are used that are applicable to most of the vascular injuries presented by multiple renal arteries. These are simple and effective methods that avoid subjecting the allograft to prolonged warm ischemia. There were no operative complications, and only one late arterial stenosis occurred; five transplants currently are functioning. The 1-year graft survival in this group, which is 50%, does not differ significantly from those of all transplants (58%). As a result of our policy, 10.5% more allografts were utilized.

[Fc IgG carrying T lymphocytes in healthy adults and patients following kidney transplantation]

In 28 healthy adults aged 19 to 52 years, normal values of the TG lymphocytes amount to 17.8 +/- 2.3% and 253.1 +/- 96.1 per microliters respectively and the non TG/TG ratio to 4.72 +/- 0.82. When compared with normal controls, patients on dialysis had a disturbed non TG/TG ratio (4.72 +/- 0.82 vs. 6.00 +/- 1.94, p less than 0.05). During the first posttransplant month the total TG cell count was significantly reduced, but the relative TG cell count did not significantly differ from the normal as well as praeoperative TG cell count. In connection with rejection crises we could not observe any changes in the TG subset. Beside this general dynamics we observed two different kinds of changes of the non TG/TG ratio in the individual posttransplant course. Either the non TG/TG ratio were lower than praetransplant or higher. In 9 out of 9 cases the lowering of the non TG/TG ratio (that means a relative or absolute increase of Fc-IgG receptor bearing T cells) were connected with a good graft function. In 4 out of 6 cases a postoperative increase of the non TG/TG ratio were connected with an early graft failure. A change of T subsets for the benefit of TG cells which includes suppressor cells seems to be favourable with regard to the graft survival. Therefore, we think the determination of the prae- and posttransplant non TG/TG ratio is of some prognostic value.

[Anti-Thomsen-Friedenreich (anti-T) antibody titer in kidney transplant recipients]

In 43 recipients of allogenic cadaver kidneys before and three times a week after transplantation to the discharge from the hospital care the antibody titre against the Thomsen-Friedenreich-antigen (Anti-T) was determined and the score value was calculated from the agglutination intensity. A prognostic significance of the value got before operation could not be found. No changes of the titre appeared under the influence of the postoperatively performed immunosuppression as well as in connection with rejection crises. In 9 patients with clinically manifest systemic infections (8 cytomegalovirus infections, 1 bacterial infection) unequivocal (greater than or equal to 8 fold) increases of the anti-T-titre could be proved. These findings speak for an infection-induced formation of these cross-reacting anti-T-antibodies.

Postprandial hyperoxaluria and intestinal oxalate absorption in idiopathic renal stone disease

Calcium and oxalate were studied in daily, fasting and postprandial urine specimens from healthy subjects and patients with idiopathic renal calcium stones in response to a test meal free of oxalate, and supplemented with calcium and 14carbon-oxalic acid. The data showed that the amount of oxalate in fasting urine of patients with stones did not differ from that in controls. Generally, patients with stones had considerable postprandial hyperoxaluria in terms of excretion and concentration, associated with a significantly higher degree of supersaturation with regard to calcium oxalate compared to controls. These findings were paralleled by decreased intestinal absorption of 14carbon-oxalate and by unchanged 24-hour urinary oxalate. Although the source of increased postprandial oxalate in patients with stones is not clear the possibility of enhanced de novo synthesis from oxalate precursors is discussed. In patients with different types of calciuria the 2 main risk factors (hyperoxaluria and hypercalciuria) for the process of stone formation are recognizable more readily in the postprandial urine specimens than in fasting or daily urine specimens.

Increased serum gamma-glutamyltransferase activity in renal transplant recipients: liver damage or microsomal enzyme induction?

To investigate the reason for the increased activities of gamma-glutamyltransferase in the serum of renal transplant recipients, the activity of this enzyme was determined together with the alanine aminotransferase and alkaline phosphatase activity in serum (as an index of liver damage) and the urinary excretion of D-glucaric acid (as an index of microsomal enzyme induction) in 63 renal transplant recipients. Forty-one patients had increased activities of gamma-glutamyltransferase. Increased D-glucaric acid excretion was found only in ten patients having elevated alanine aminotransferase and/or alkaline phosphatase in seven cases and gamma-glutamyltransferase in eight cases. Therefore, the increased gamma-glutamyltransferase activities in renal transplant recipients can be primarily considered as a consequence of hepatobiliary dysfunction and not of enzyme induction.

Multiple forms of alanine aminopeptidase, alkaline phosphatase and gamma-glutamyltransferase in urine of healthy persons, patients suffering from kidney diseases and patients with kidney transplants

The catalytic activities of alanine aminopeptidase, alkaline phosphatase and gamma-glutamyltransferase were determined in the soluble and particulate fractions of urine, after ultracentrifugation. In healthy adults the fractional catalytic activities in the supernatants were 0.53, 0.56 and 0.24, respectively. Nearly the same proportions were found in children. In patients suffering from chronic kidney diseases there was a tendency for the proportion of catalytic activity in the soluble fraction to increase. However, the separation into the multiple forms gave no higher diagnostic reliability than the determination of total catalytic activity of the respective enzymes. The determination of multiple forms has no clinical significance in the detection of rejection episodes in renal transplant recipients.