Lymphokine (MIF) production by glomerular T-lymphocytes in experimental glomerulonephritis

Glomerular T-lymphocyte infiltration has recently been demonstrated to precede glomerular macrophage influx in a pre-immunized model of anti-glomerular basement-membrane antibody-induced glomerulonephritis (antiGBM-GN). In the current study, the functional role of these glomerular T-lymphocytes in directing macrophage localization was sought by measuring their production of macrophage migration inhibition factor (MIF). MIF activity in supernatants from cultured isolated glomeruli was measured in a conventional capillary tube bioassay. Glomerular T-lymphocytes (OX19 positive cells) were maximal (1.95 +/- 0.19 cells/glomerular cross section, c/gcs) 24 hours after injection of antiGBM antibody into sensitized animals. Seventy-two hours after antibody injection, T-lymphocyte numbers were reduced (1.02 +/- 0.14 c/gcs) while macrophage accumulation was maximal (at 24 hrs 4.2 +/- 1.3 macrophages/glomerulus (m/g), at 72 hrs 19.8 +/- 3.7 m/g). MIF activity was only detected in supernatants from T-lymphocyte infiltrated glomeruli (12 hrs 40.81 +/- 4.32% migration inhibition, 24 hrs 45.11 +/- 4.11% migration inhibition, 48 hrs 38.24 +/- 3.53% migration inhibition, 72 hrs 20.86 +/- 3.85% migration inhibition, all P less than 0.05). Control glomeruli from normal animals, pre-immunized animals given normal sheep globulin, pre-immunized animals given anti-GBM antibody and Cyclosporin A, and non-pre-immunized animals given antiGBM antibody did not contain glomerular T-lymphocytes, and their supernatants contained no MIF activity. This data indicates that the glomerular T-lymphocytes in pre-immunized antiGBM-GN are sensitized cells which release MIF and thus may direct glomerular macrophage localization in this model of antibody-induced glomerulonephritis.

A comparison of fibrinolytic and defibrinating agents in established experimental glomerulonephritis

The effect of fibrinolysis with Streptokinase and defibrination with Ancrod on the progression of established fibrin-related glomerular injury was assessed in rabbits developing anti-glomerular basement membrane antibody-induced glomerulonephritis. Untreated rabbits developed renal failure and a severe crescentic nephritis with prominent fibrin deposition after 5 days. Rabbits with established injury and glomerular fibrin deposition were treated with Streptokinase or Ancrod over the last 4 days of this model. Both treatments resulted in significant protection from loss of renal function and reduced crescent formation by day 5. Glomerular fibrin deposition was also significantly reduced by both agents, although Streptokinase produced a greater reduction than Ancrod. Two further groups of rabbits with advanced disease, were treated over the last two days of this model. Although treatment reduced glomerular fibrin deposition, no protection from loss of renal function was observed. These studies indicate that both treatments were effective, if used early, in preserving renal function in established fibrin related glomerulonephritis, but they did not effect the outcome of more advanced disease. Both agents prevented further glomerular fibrin deposition, although only early treatment with Streptokinase reduced glomerular fibrin to below pre-treatment levels.

Pulmonary manifestations of the clinical syndrome of acute glomerulonephritis and lung hemorrhage

The pulmonary manifestations at the time of initial diagnosis were reviewed in 45 patients with the clinical syndrome of acute glomerulonephritis and lung hemorrhage. Initial pulmonary radiographic appearances encompassed a wide variety of abnormalities, and alveolar hemorrhage could not be reliably differentiated from other causes of pulmonary infiltration. The diseases underlying the syndrome included antiglomerular basement membrane (anti-GBM) disease (8/45), a systemic vasculitis (25/45), and idiopathic glomerulonephritis with idiopathic lung hemorrhage (12/45). A variety of acute pulmonary complications were seen, the most common being acute respiratory failure (13/45). Mortality directly due to pulmonary disease was uncommon (3/45 died from fulminant lung hemorrhage). Most deaths were from extrapulmonary manifestations of the underlying disease or infection. Follow-up studies in 22 patients 6 months after initial presentation indicated that although respiratory symptoms (3/22) or pulmonary radiologic abnormalities (5/22) were uncommon, the majority of patients had residual abnormalities on pulmonary function testing (16/22). Thus, the syndrome of alveolar hemorrhage with nephritis is associated with several distinct categories of underlying disease process. The initial chest radiograph is of limited value in differential diagnosis. Although a variety of acute and chronic respiratory complications may be anticipated and contribute significantly to morbidity, mortality is predominantly due to extrapulmonary progression of disease or infection complicating immunosuppressive therapy.

The participation of macrophages, glomerular procoagulant activity, and factor VIII in glomerular fibrin deposition. Studies on anti-GBM antibody-induced glomerulonephritis in rabbits

The temporal relationships of macrophage accumulation, glomerular fibrin deposition, the expression of glomerular procoagulant activity (PCA), and Factor VIII antigen deposition were studied in rabbits in which antiglomerular basement membrane antibody-induced glomerulonephritis (anti-GBM GN) developed. The initiation of injury coincided with the accumulation of glomerular macrophages. Glomerular fibrin, assessed by immunofluorescence and by deposition of 125I-fibrinogen, paralleled the development of glomerular crescents and renal impairment. Macrophage ingress clearly preceded the deposition of 125I-fibrinogen within glomeruli. Augmented levels of PCA were present in glomeruli prior to the initiation of fibrin deposition, and peak levels coincided with the peak glomerular macrophage presence. Factor VIII related antigen was apparent late in the disease and was present mainly at the margins of fibrinous crescents. These data demonstrate that accumulation of glomerular macrophages precedes glomerular fibrin deposition in anti-GBM GN. The augmentation of PCA, coincident with the appearance of glomerular macrophages, suggests a role for macrophage PCA in the initiation of fibrin deposition within the glomerular tuft in this model.

Quantitation of the intrarenal uptake of immunoglobulin aggregates by macrophages in diffuse proliferative glomerulonephritis

The intrarenal processing of circulating immune-complex-like-material is traditionally attributed to resident glomerular mesangial cells. To assess the contribution of infiltrating mononuclear cells to macromolecule processing by diseased glomeruli we have utilized an isolated perfused kidney system (IPK) to quantify the specific glomerular uptake of heat-aggregated immunoglobulin (AIgG) (as micrograms of aggregated IgG per 10(4) glomeruli (microgram 10(4)glom)). Mononuclear cell infiltrated glomeruli from animals with diffuse proliferative glomerulonephritis had a significantly augmented uptake of AIgG (48.9 +/- 3.8 micrograms/10(4)glom; normal 11.8 +/- 0.6 micrograms/10(4)glom; P less than 0.01). Specific blockade of mononuclear cell function by perfusion with anti-macrophage-serum (AMS) prevented increased AIgG uptake (12.8 +/- 1.2 micrograms/10(4)gloms; P less than 0.01), but had no effect on the AIgG uptake of normal kidneys (13.1 +/- 1.2 micrograms/10(4)glom). Thus, in diffuse proliferative glomerulonephritis the observed increase in the glomerular clearance of AIgG was due to phagocytosis by mononuclear cells. This study suggests that infiltrating, bone-marrow derived mononuclear cells may significantly contribute to the glomerular handling of circulating immune complexes by nephritic glomeruli.

Evidence for direct renal injury as a consequence of glomerular complement activation

An isolated perfused kidney (IPK) preparation was used to study the functional consequences of antibody-initiated glomerular complement activation in an environment devoid of circulating inflammatory cells. Control IPK, with antibody bound to the glomerular basement membrane (GBM) (mean +/- SEM, 165.0 +/- 5.7 micrograms globulin/g renal cortex), were perfused with a 5% albumin solution. Control urinary protein excretion was 0.306 +/- 0.112 mg/min, renal vascular resistance (RVR) was 4.72 +/- 0.69 mgHg/ml/min, and the glomerular filtration rate (GFR) was 0.41 +/- 0.01 ml/min/g. To produce glomerular complement activation, IPK with equal quantities of bound antibody (167.0 +/- 6.1 micrograms/g) were perfused with fresh plasma. Glomerular complement activation was associated with linear deposition of C3 on the GBM, a significant increase in protein excretion (3.317 +/- 1.077 mg/min; p less than 0.001) and RVR (10.15 +/- 1.85 mmHg/ml/min; p less than 0.001), and a decline in GFR (0.38 +/- 0.01 ml/min/g; p less than 0.05). Equivalent IPK perfused with decomplemented plasma demonstrated neither glomerular complement deposition nor augmented renal injury. By using both complement repletion and depletion techniques, this study demonstrates that antibody-initiated glomerular complement activation produces direct, neutrophil-independent renal injury. Thus, activated complement components may directly contribute to antibody-induced immune renal injury, in addition to their well established role in the recruitment of circulating inflammatory cells.

Evidence for direct renal injury as a consequence of glomerular complement activation

An isolated perfused kidney (IPK) preparation was used to study the functional consequences of antibody-initiated glomerular complement activation in an environment devoid of circulating inflammatory cells. Control IPK, with antibody bound to the glomerular basement membrane (GBM) (mean +/- SEM, 165.0 +/- 5.7 micrograms globulin/g renal cortex), were perfused with a 5% albumin solution. Control urinary protein excretion was 0.306 +/- 0.112 mg/min, renal vascular resistance (RVR) was 4.72 +/- 0.69 mgHg/ml/min, and the glomerular filtration rate (GFR) was 0.41 +/- 0.01 ml/min/g. To produce glomerular complement activation, IPK with equal quantities of bound antibody (167.0 +/- 6.1 micrograms/g) were perfused with fresh plasma. Glomerular complement activation was associated with linear deposition of C3 on the GBM, a significant increase in protein excretion (3.317 +/- 1.077 mg/min; p less than 0.001) and RVR (10.15 +/- 1.85 mmHg/ml/min; p less than 0.001), and a decline in GFR (0.38 +/- 0.01 ml/min/g; p less than 0.05). Equivalent IPK perfused with decomplemented plasma demonstrated neither glomerular complement deposition nor augmented renal injury. By using both complement repletion and depletion techniques, this study demonstrates that antibody-initiated glomerular complement activation produces direct, neutrophil-independent renal injury. Thus, activated complement components may directly contribute to antibody-induced immune renal injury, in addition to their well established role in the recruitment of circulating inflammatory cells.

Clinicopathological associations in mesangial IgA nephropathy

On hundred and fifteen renal biopsies performed in 112 patients with mesangial IgA nephropathy were reviewed and the histological disease patterns correlated with the clinical features at the time of initial biopsy. To determine the significance of macroscopic haematuria in this disease, specific comparisons were made between patients with a history of episodes of macroscopic haematuria and those with only microscopic haematuria. The mean age at initial biopsy was 38.3 years (90 males, mean 40.3 years; 22 females, mean 30.2 years). Histological examination showed 9 patients (8%) with class I disease (mesangial matrix expansion alone); 43 patients (38%) with class II disease (diffuse mesangial proliferation); 60 patients (54%) with class III disease (focal and segmental proliferation), including subsets of 20 patients (16%) with segmental sclerosis and/or synechiae and 23 patients (21%) with crescent formation. Class III disease and crescent formation correlated with an increased frequency of capillary loop IgA and glomerular fibrin deposition and with the presence of subendothelial and subepithelial deposits. The degree of renal impairment and the incidence of hypertension were increased in class III disease. Macroscopic haematuria patients were younger (mean 31.1 vs. 43.0 years; p less than 0.001), had less severe renal impairment (mean creatinine 116.2 vs. 213.3 mumol/l; p less than 0.001) and less class III disease (48 vs. 58%; p less than 0.05). The incidence of crescentic disease was equal in macroscopic (17%) and microscopic (23%) haematuria. Eventual progression to end-stage renal failure occurred in 12 patients (11%) and correlated with crescentic disease, renal impairment, hypertension and heavy proteinuria at the time of diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Idiopathic Goodpasture's syndrome. Fatal pulmonary haemorrhage and crescentic glomerulonephritis in the absence of immune-reactant deposition

A 58-year-old woman was hospitalized with acute renal failure and unilateral pulmonary consolidation. Ten days later she developed massive pulmonary haemorrhage with diffuse pulmonary consolidation. Renal biopsy revealed 100% crescentic nephritis without immunofluorescence (IF) or electron microscopic evidence of immune reactant deposition. Circulating anti-glomerular basement membrane (antiGBM) antibody was not detectable by radioimmunoassay. Despite aggressive therapy pulmonary haemorrhage eventually proved fatal. IF of lung tissue revealed no immune-reactant deposition. This report represents a case of idiopathic Goodpasture's syndrome, both from an aetiological and an immunopathological viewpoint. It emphasizes that Goodpasture's syndrome (i.e. pulmonary haemorrhage and glomerulonephritis) occurs in a variety of situations which are not mediated by antiGBM antibody deposition and that alveolar haemorrhage should be considered in the differential diagnosis of all radiological pulmonary infiltrates, including unilateral opacities, when abnormalities of renal function coexist.

Fibrinolytic therapy with streptokinase for established experimental glomerulonephritis

The efficacy of fibrinolytic therapy with streptokinase was assessed in rabbits developing anti-glomerular basement membrane antibody induced glomerulonephritis. Untreated animals developed renal failure (mean creatinine 615 +/- 120 microM/l) and a severe glomerulonephritis with prominent fibrin deposition. Streptokinase treatment of animals with established disease (creatinine 204 +/- 35 microM/l) reduced renal impairment (creatinine 256 +/- 68 microM/l, p less than 0.025) and fibrin deposition. Treatment of more advanced disease (creatinine 416 +/- 68 microM/l) did not preserve renal function (creatinine, 518 +/- 106 microM/l), although glomerular fibrin deposition was reduced. These studies indicate that fibrinolytic therapy with streptokinase reduces glomerular fibrin deposition and, if used early, protects from loss of renal function.

Anti-glomerular basement membrane antibody-induced experimental glomerulonephritis: evidence for dose-dependent, direct antibody and complement-induced, cell-independent injury

The immunopathogenesis of anti-glomerular basement membrane antibody-induced glomerulonephritis (anti-GBM-GN) involves the triad of antibody fixation to the glomerular basement membrane, local complement activation and polymorphonuclear leucocyte (PMN) infiltration. We sought to investigate the potential for contributions to renal injury from each component of this triad (i.e., antibody, complement, and PMN). This study compares the ability of antibody to induce injury in normal, PMN-depleted and dual (i.e., PMN + complement)-depleted rabbits by assessing the quantity of kidney-fixed antibody (KFA) necessary to induce proteinuria. (The KFA levels are expressed in micrograms of antibody bound per gram renal cortex.) Normal animals developed significant proteinuria at KFA 60 +/- 6 micrograms/g. PMN-depleted animals were injury free at KFA 60 +/- 6 micrograms/g, but developed heavy proteinuria at KFA 140 +/- 5 micrograms/g. The protection from injury by PMN depletion at lower KFA levels confirms the important contribution of PMN to injury in this model. Furthermore, the demonstration of a clearcut threshold for injury despite PMN-depletion indicates that glomerular antibody deposition and complement activation can cause direct PMN-independent injury. Dual depletion studies showed a significantly higher KFA threshold for injury in PMN + complement-depleted animals than in PMN-depleted, complement intact animals (195 +/- 10 micrograms/g, cf. 140 +/- 5 micrograms/g; p less than 0.01). The occurrence of injury despite dual mediator depletion demonstrates that antibody itself can produce direct, complement and PMN independent renal injury. Together the PMN depletion and dual depletion studies indicate that antibody-induced glomerular complement activation produces direct, PMN-independent renal injury that can be prevented by complement depletion. Thus each of the potential mediators studied is individually capable of producing renal injury in anti-GBM-GN. In addition to the well established injurious role of PMN, this study demonstrates that glomerular complement activation and anti-GBM antibody deposition may both produce neutrophil-independent components of renal injury. The relative contributions of the individual mediators to injury is dependent on the quantity of antibody deposited within the glomerulus.

Anti-glomerular basement membrane antibody-induced experimental glomerulonephritis: evidence for dose-dependent, direct antibody and complement-induced, cell-independent injury

The immunopathogenesis of anti-glomerular basement membrane antibody-induced glomerulonephritis (anti-GBM-GN) involves the triad of antibody fixation to the glomerular basement membrane, local complement activation and polymorphonuclear leucocyte (PMN) infiltration. We sought to investigate the potential for contributions to renal injury from each component of this triad (i.e., antibody, complement, and PMN). This study compares the ability of antibody to induce injury in normal, PMN-depleted and dual (i.e., PMN + complement)-depleted rabbits by assessing the quantity of kidney-fixed antibody (KFA) necessary to induce proteinuria. (The KFA levels are expressed in micrograms of antibody bound per gram renal cortex.) Normal animals developed significant proteinuria at KFA 60 +/- 6 micrograms/g. PMN-depleted animals were injury free at KFA 60 +/- 6 micrograms/g, but developed heavy proteinuria at KFA 140 +/- 5 micrograms/g. The protection from injury by PMN depletion at lower KFA levels confirms the important contribution of PMN to injury in this model. Furthermore, the demonstration of a clearcut threshold for injury despite PMN-depletion indicates that glomerular antibody deposition and complement activation can cause direct PMN-independent injury. Dual depletion studies showed a significantly higher KFA threshold for injury in PMN + complement-depleted animals than in PMN-depleted, complement intact animals (195 +/- 10 micrograms/g, cf. 140 +/- 5 micrograms/g; p less than 0.01). The occurrence of injury despite dual mediator depletion demonstrates that antibody itself can produce direct, complement and PMN independent renal injury. Together the PMN depletion and dual depletion studies indicate that antibody-induced glomerular complement activation produces direct, PMN-independent renal injury that can be prevented by complement depletion. Thus each of the potential mediators studied is individually capable of producing renal injury in anti-GBM-GN. In addition to the well established injurious role of PMN, this study demonstrates that glomerular complement activation and anti-GBM antibody deposition may both produce neutrophil-independent components of renal injury. The relative contributions of the individual mediators to injury is dependent on the quantity of antibody deposited within the glomerulus.

Glomerular permselectivity in the isolated perfused rat kidney

Glomerular permselectivity characteristics were studied in the Sprague-Dawley rat in vivo and in the isolated rat kidney perfused with an erythrocyte-free Krebs-Henseleit buffered 5% albumin solution (IPK). IPK permselectivity in vitro, assessed by fractional clearances of neutral dextran (FCND) and dextran sulfate (FCDS) with molecular radii 18-43 A, was essentially similar to that of the Sprague-Dawley rat in vivo. The negative charge barrier of the IPK glomerular filter was intact [e.g., FCND of 36 A = 0.10 +/- 0.01 (SE) vs. FCDS of 36 A = 0.01 +/- 0.00 (P less than 0.01)]. Dextrans of an intermediate size (26-34 A) had lower fractional clearances in the IPK than in vivo [e.g., FCND of 30 A in IPK = 0.23 +/- .04 vs. FCND of 30 A in vivo 0.40 +/- 0.01 (P less than 0.01)]. This decreased clearance of dextrans of an intermediate molecular size is predicted by pore theory, since the IPK has an increased afferent glomerular plasma flow rate. As glomerular permselectivity characteristics in the IPK simulate in vivo characteristics, such preparations are suitable in vitro models in which to study factors that modulate permselectivity. The demonstration that the glomerular filter in the IPK has a normal negative charge barrier indicates that the increased protein excretion in IPK systems cannot be attributed to abnormalities of this component of the filtration barrier.

Macrophage-induced glomerular fibrin deposition in experimental glomerulonephritis in the rabbit

Glomerular fibrin deposition is important in the pathogenesis of renal failure and crescent formation in glomerulonephritis. The mechanisms of glomerular fibrin deposition are unknown. The current studies explored the role of macrophages in this process. Methods were developed for measuring glomerular fibrin deposition and glomerular procoagulant activity in a passive model of the autologous phase of antiglomerular basement membrane antibody-induced glomerulonephritis in rabbits. Significant fibrin deposition was observed to be associated with glomerular macrophage accumulation. Leukocyte ablation with mustine hydrochloride prevented both glomerular macrophage accumulation and fibrin deposition without affecting the coagulation system or the deposition of disease-inducing antibodies and complement. Repletion with mononuclear inflammatory cells produced significant fibrin deposition. To examine the role of tissue injury per se in glomerular fibrin deposition, a macrophage-independent model of glomerular injury (heterologous phase glomerulonephritis) was also studied. Although a similar degree of glomerular injury occurred, there was no significant fibrin deposition. This suggests that macrophages, rather than injury alone, are responsible for fibrin deposition. Lysates of isolated glomeruli containing macrophages demonstrated greatly enhanced procoagulant activity compared with lysates of glomeruli without macrophages. Thus macrophages appear to be directly responsible for glomerular fibrin deposition in antiglomerular basement membrane antibody-induced glomerulonephritis, and this appears to be due to their ability to express procoagulant activity rather than their propensity to cause glomerular injury.

Wegener's granulomatosis: clinical features and outcome in seventeen patients

Seventeen patients with Wegener's granulomatosis are reviewed. Eleven males and six females, with a mean age of 46.9 +/- 4.5 years, were followed for 35.7 +/- 9.0 months. Mean duration from time of onset of symptoms to diagnosis was 8.5 +/- 3.1 months. Constitutional symptoms (100%), lower respiratory tract involvement (93%), renal involvement (87%), and upper respiratory tract involvement (80%) were the most frequent clinical manifestations. Arthritis (60%), dermal vasculitis (60%), and inflammatory ocular disease (40%) were also common. Elevated ESR (94%), anemia (70%), and lymphopenia (77%) were frequent laboratory findings prior to treatment. Five patients had renal failure at presentation and two patients progressed from no renal involvement at presentation to renal failure at diagnosis, while five patients progressed from renal involvement without impairment at diagnosis to end-stage renal failure. Seven patients died; six of these deaths were related to active Wegener's granulomatosis. The patients with a severe systemic vasculitis, and renal involvement had a poor outcome while predominant respiratory disease had a good prognosis.

The mechanism of action of corticosteroids on glomerular injury in acute serum sickness in rabbits

Macrophages have recently been identified as the predominant mediators of the glomerular injury in acute serum sickness (AcSS) in rabbits. Corticosteroids have been shown to prevent this lesion, but the mechanism of this effect is unknown. As corticosteroids are potent anti-macrophage agents, the effect of prednisolone treatment (2 mg/kg/day) on glomerular macrophage accumulation and injury was assessed in rabbits developing AcSS. Eleven untreated animals all developed a proliferative endocapillary glomerulonephritis (mean 71.7 +/- 1.9 sem cells per glomerular cross section, c/gcs) with glomerular macrophage accumulation (46.3 +/- 5.7 macrophages per glomerulus, macs/glom) and proteinuria (555 +/- 379 mg/24 h). Eight animals were treated with prednisolone commencing not more than 48 h prior to immune elimination (IE). Glomerular injury was markedly attenuated with significantly less cellular proliferation (49.1 +/- 2.1 c/gcs, P less than .005), fewer macrophages within glomeruli (10.5 +/- 7.7 macs/glom, P less than .005) and minimal proteinuria (19.3 +/- 5.5 mg/24 h, P less than 0.01). Treatment did not alter the amount of circulating BSA-anti-BSA immune complex; its time of IE (11.1 +/- 0.4 days treated, 11.4 +/- 0.4 days untreated) its renal deposition (2.36 +/- 0.64 micrograms BSA/g renal cortex treated, 2.66 +/- 0.52 mg BSA/g renal cortex untreated) or its glomerular localization. These results indicate that prednisolone treatment can effectively reduce the glomerular injury of AcSS. This effect is not dependent on any alteration of immune complex formation or deposition, but involves reduction of macrophage accumulation at the inflammatory site.

T lymphocyte participation in antibody-induced experimental glomerulonephritis

Macrophage accumulation is a feature of some aggressive forms of human and experimental glomerulonephritis (GN). Both antibody Fc components and T cells may cause macrophage accumulation; however, there has been no previous demonstration of T cells at the site of injury in GN, although some indirect evidence of their possible participation has been reported. Specific monoclonal anti-rat T lymphocyte antibodies W3/13, W3/25, and Ox8 were used to demonstrate T cells within the glomeruli of rats with an augmented autologous anti-GBM GN, by indirect immunofluorescence. The injury in this model has been shown to be mediated by macrophages. The T cell infiltrate consisted mainly of T helper cells, was maximal 24 hr after induction of the disease and clearly preceded the peak influx of macrophages and glomerular damage. Suppression of T cell function using cyclosporin prevented T cell accumulation and the subsequent macrophage-induced injury. Glomerular T cells were not seen in passively induced GN. These studies support a role for cell-mediated immunity in attracting macrophages and initiating injury in experimental anti-GBM antibody-induced GN.

Effect of cyclosporin A on antibody-induced experimental glomerulonephritis

The effect of cyclosporin A (CYA) on the development of active and passive models of rat anti-glomerular basement membrane antibody-induced glomerulonephritis (anti-GBM-GN) was assessed. Active GN was induced by an intravenous injection of sheep anti-rat GBM globulin to preimmunized rats. After 5 days, a diffuse proliferative GN with proteinuria and linear GBM deposition of rat IgG was regularly observed. CYA treatment, commencing prior to preimmunization, significantly attenuated the glomerular lesion, reduced proteinuria, prevented linear deposition of rat IgG and reduced the serum titre of anti-sheep globulin antibody. However, treatment started after the antibody response was established failed to alter antibody production, its glomerular deposition or the outcome of the disease. CYA treatment did not effect passive anti-GBM-GN, occurring 24 h after intravenous administration of sheep anti-rat GBM globulin to unimmunized rats. Thus, CYA is able to block anti-GBM-GN when given prior to induction of disease, by preventing an active antibody response. However, it did not alter GN when the antibody response was well established, or when glomerular injury was passively induced.

"Long-term" survival in light-chain myeloma with dialysis therapy alone

We report a case of a 59 year old woman who presented in end-stage renal failure with lambda (lambda) light-chain myeloma (LLCM). Despite a large tumour burden, and refusal to accept cytotoxic chemotherapy, she was commenced on continuous ambulatory peritoneal dialysis (CAPD). With dialysis therapy alone she has shown considerable hematological improvement and remains well 18 months after diagnosis. The extremely poor prognosis attributed to light-chain myeloma is largely due to death from uremia. As the natural history of this disease in patients offered dialysis therapy is unknown, dialysis should not automatically be withheld from patients with LLCM.

Macrophage-induced glomerular injury. Cell transfer studies in passive autologous antiglomerular basement membrane antibody-initiated experimental glomerulonephritis

The current studies were designed to assess the ability of mononuclear inflammatory cells to mediate glomerulonephritis (GN) by studying the effects of replacement of mononuclear inflammatory cells in rabbits depleted of all circulating leukocytes and in which an antibody-initiated, macrophage-dependent model of glomerular injury was induced. GN was initiated by the injection of passive autologous rabbit antisheep gamma-globulin serum following the injection of sheep antirabbit glomerular basement membrane antibody. A proliferative endocapillary GN regularly occurred in which macrophages were the predominant infiltrating cell (mean 48.4 +/- 16.1 SD macrophages/glomerulus) and heavy proteinuria developed (590 +/- 152 mg/24 hours). This lesion was shown to be dependent on the presence of circulating leukocytes as prior treatment with nitrogen mustard producing panleukopenia completely prevented macrophage accumulation (0.4 +/- 0.1 macrophages/glomerulus), abnormal proteinuria (5.1 +/- 1.6 mg/24 hours), and histologic evidence of injury. When peritoneal mononuclear inflammatory cells were given intravenously (10(8] to nitrogen mustard-treated rabbits that were given the GN-inducing antibodies, a proliferative GN developed with significant macrophage accumulation (14.2 +/- 4.8 macrophages/glomerulus), and some rabbits became proteinuric (38.8 +/- 15.3 mg/24 hours). Electron microscopy indicated that glomerular endothelial cells underwent swelling and separation from the basement membrane in relation to macrophage accumulation. Control nitrogen mustard-treated animals given 10(8) mononuclear inflammatory cells without the injection of disease-initiating antibodies did not have glomerular macrophage accumulation (0.8 +/- 0.3 macrophages/glomerulus), abnormal proteinuria (6.1 +/- 2.1 mg/24 hours), or any histologic abnormality. Thus, macrophages can accumulate in glomeruli in direct response to the deposition of antibody and produce a proliferative GN by both their own accumulation and their effects on intrinsic glomerular endothelial cells.

Differential effects of steroids on leukocyte-mediated glomerulonephritis in the rabbit

The effects of steroids on the development of injury in two models of experimental glomerulonephritis (GN), (one mediated by neutrophils, the other by macrophages) were compared. The neutrophil-associated lesion [initiated by heterologous antiglomerular basement membrane (GBM) antibody] was characterized by the development of an exudative endocapillary GN with heavy neutrophil accumulation [mean, 6.9 neutrophils/glomerular cross section (N/GCS) +/- 2.9 SD], minor macrophage infiltration [7.9 macrophages/glomerulus (M/G) +/- 2.2 SD] and heavy proteinuria (1905 mg/24 hr +/- 520 SD). Steroid-treated (methylprednisolone, 2 mg/kg/12 hr i.v.) rabbits developed a marked monocytopenia, mild neutrophilia, and significant reduction in glomerular macrophage accumulation (0.3 M/G 0.02 SD). However, neutrophil accumulation (6.1 N/CGS +/- 2.5 SD), histological appearances, and proteinuria (1820 mg/hr +/- 490 SD) were unaffected. The macrophage-associated model of GN was induced by passive autologous rabbit anti-sheep IgG 15 hr after the injection of a subnephritogenic dose of the same anti-GBM antibody. The glomerular lesion was characterized by a diffuse endocapillary proliferative GN with heavy macrophage infiltration (54 M/G +/- 8 SD), insignificant neutrophil accumulation (0.8 N/GCS 0.02 SD), and the regular development of proteinuria (420 mg/24 hr +/- 80 SD). Steroid-treated rabbits developed a mild neutrophilia and a significant monocytopenia associated with abrogation of glomerular macrophage accumulation (2.3 M/G +/- 0.8 SD). This was associated with the prevention of the development of GN and proteinuria (22 +/- 9.5 SD). Thus, steroids produce monocytopenia and prevent glomerular macrophage accumulation and associated injury whereas neutrophil accumulation and injury is unaffected. These data suggest steroids may have widely varying effects on the outcome of leukocyte-associated experimental GN depending on the nature of the infiltrating cells.

Renal involvement in systemic lupus erythematosus

A review of 28 cases of biopsy-proven lupus nephritis seen in Prince Henry's Hospital, Melbourne, in the last 12 years from 1971 to 1982 is reported. The mean follow-up period was 51 months. Renal histopathological changes were categorized according to the WHO classification of lupus nephritis. The majority of our patient population fell into two of the seven possible histological subgroups - Class IV (diffuse proliferative) disease (53.6%) and Class IIb (mesangial proliferative) disease (28.5%). Treatment with prednisolone alone or with a prednisolone/azathioprine combination resulted in an equal five-year survival (82%) and a similar overall preservation of renal function. The major single cause of death was opportunistic infection (60%). Despite overrepresentation of the more severe forms of lupus nephritis in a nephrology-unit population, there was a satisfactory outcome from therapy with either prednisolone alone or with a prenisolone /azathioprine combination. However, there were significant rates of morbidity and death associated with immunosuppressive therapy, primarily from opportunistic infection.

Transplantation of kidneys from living related donors. Comparison with cadaveric kidney transplantation

In a series of 271 transplantations of renal allografts, performed over 10 years, the rates of graft survival, patient survival, and morbidity in the recipients of allografts from living related donors (47 allografts) have been compared with those in the recipients of cadaveric allografts (224 allografts). The one-year graft survival rates were 88% for allografts from living related donors (100%, if these were HLA-identical) and 55% for cadaveric allografts, while the patient survival rates were 97% and 87%, respectively, in the same period. Morbidity rates (expressed as the number of days spent in hospital) for recipients of allografts from living related donors were approximately 50% of those for recipients of cadaveric grafts. Complications in the living related donors were minimal, and acceptable. It is concluded that transplantation of allografts from living related donors has many advantages over transplantation of cadaveric kidneys, and is a valuable adjunct to a cadaveric renal transplantation programme. Greater use of living related kidney donors should be encouraged in Australia.

A radioimmunoassay for the detection of circulating anti-glomerular basement membrane antibodies

A fluid phase radioimmunoassay (RIA) has been established for the detection of circulating anti-glomerular basement membrane (GBM) antibodies. Antibodies were detected by binding with a collagenase solubilised, immunochemically purified, radiolabelled extract of human particulate GMB. Sera from 108 patients with a variety of histological types of glomerulonephritis (GN) were assessed for the presence of antibodies. Likely positive sera were those from patients with clinical features of rapidly progressive glomerulonephritis (RPGN) with crescentic or diffusely proliferative GN and linear staining of their GBM's with IgG. Thirty one of 35 sera from such patients were positive in the RIA. Sera from 14 patients with RPGN but with granular IgG deposition (i.e. immune complex related GN) were all negative for anti-GBM antibodies as were sera from 59 patients with a variety of non-crescentic non RPGN without linear IgG. Comparison of the RIA with conventional indirect immunofluorescence (IIF) showed that the RIA had a higher detection rate of antibodies in likely positive sera (19/21 RIA: 16/21 IIF) lower false positive detection rate with sera from patients without GN (0/26 RIA: 2/26 IIF) and was three to four times more sensitive in serial dilution studies.

Fc dependence of macrophage accumulation and subsequent injury in experimental glomerulonephritis

An IgG-initiated, macrophage-mediated model of experimental glomerulonephritis was induced in rabbits. Experiments were designed to determine the importance of the Fc portion of this disease-initiating IgG antibody in inducing macrophage accumulation and subsequent proteinuria and histologic injury. The model was a passive model of the autologous phase of anti-glomerular basement membrane antibody-induced glomerulonephritis. Leukocyte depletion with nitrogen mustard prevented the development of proteinuria, macrophage accumulation, and histologic injury, but decomplementation with cobra venom had no effect, confirming leukocyte dependence but complement independence of injury in this model. The effect of equimolar kidney binding quantities of the intact disease-initiating IgG and an F(ab')2 fraction of this same antibody were compared. Intact IgG deposition was associated with heavy proteinuria (630 mg/24 hr, mean +/- 106 SD). A diffuse endocapillary proliferative glomerulonephritis with prominent macrophage accumulation (54 +/- 21 macrophages/glomerulus) developed. Deposition of the F(ab')2 fraction was associated with only minimal proteinuria (28 +/- 7 mg/24 hr). Histologic appearances showed no significant glomerulonephritis, and macrophage accumulation (4.1 +/- 0.6 macrophages/glomerulus) was substantially prevented. Thus, macrophage accumulation and subsequent injury in this model are dependent on the Fc portion of the disease-initiating IgG molecule. These data suggest immune adherence is an important mechanism for macrophage accumulation in antibody-initiated glomerulonephritis. Furthermore, the prevention of the Fc-dependent macrophage accumulation and simultaneous abrogation of injury suggest the lesion is mediated by macrophages.

Fc dependence of macrophage accumulation and subsequent injury in experimental glomerulonephritis

An IgG-initiated, macrophage-mediated model of experimental glomerulonephritis was induced in rabbits. Experiments were designed to determine the importance of the Fc portion of this disease-initiating IgG antibody in inducing macrophage accumulation and subsequent proteinuria and histologic injury. The model was a passive model of the autologous phase of anti-glomerular basement membrane antibody-induced glomerulonephritis. Leukocyte depletion with nitrogen mustard prevented the development of proteinuria, macrophage accumulation, and histologic injury, but decomplementation with cobra venom had no effect, confirming leukocyte dependence but complement independence of injury in this model. The effect of equimolar kidney binding quantities of the intact disease-initiating IgG and an F(ab')2 fraction of this same antibody were compared. Intact IgG deposition was associated with heavy proteinuria (630 mg/24 hr, mean +/- 106 SD). A diffuse endocapillary proliferative glomerulonephritis with prominent macrophage accumulation (54 +/- 21 macrophages/glomerulus) developed. Deposition of the F(ab')2 fraction was associated with only minimal proteinuria (28 +/- 7 mg/24 hr). Histologic appearances showed no significant glomerulonephritis, and macrophage accumulation (4.1 +/- 0.6 macrophages/glomerulus) was substantially prevented. Thus, macrophage accumulation and subsequent injury in this model are dependent on the Fc portion of the disease-initiating IgG molecule. These data suggest immune adherence is an important mechanism for macrophage accumulation in antibody-initiated glomerulonephritis. Furthermore, the prevention of the Fc-dependent macrophage accumulation and simultaneous abrogation of injury suggest the lesion is mediated by macrophages.

Abrogation of macrophage-dependent injury in experimental glomerulonephritis in the rabbit. Use of an antimacrophage serum

Macrophages were shown by the use of glomerular cell culture and morphologic techniques to be present in large numbers within the glomeruli of rabbits with acute serum sickness (AcSS) and in a passive model of the autologous phase of antiglomerular basement membrane (GBM) antibody-induced glomerulonephritis (PAGBMN). To determine the part played by these cells in the glomerular injury, animals were treated with a sheep anti-rabbit macrophage serum (AMS) or normal sheep serum (NSS). NSS administration had no effect on the development of either model of glomerulonephritis. The use of AMS reduced the number of circulating monocytes and prevented the accumulation of macrophages within glomeruli in both models (AcSS/NSS, mean 126/glomerulus, range 40-251; AcSS/AMS, mean 8, range 1-44; PAGBMN/NSS, mean 52, range 27-69; PAGBMN/AMS, mean 5, range 2-7). The AMS-treated rabbits had only minor histologic lesion and profound reduction in proteinuria (AcSS/NSS, mean 516 mg/24 h, range 200-991; AcSS/AMS, mean 41, range 3-161; PAGBMN/NSS, mean 335, range 55-975; PAGBMN/AMS, mean 10, range 2-24). Similar studies in the heterologous phase of glomerular injury induced by the same anti-GBM antibody revealed no effect of the AMS on this polymorphonuclear leukocyte-related phase of injury, demonstrating the selectivity of the antisera. Complement depletion, with cobra venom factor, did not affect the development of glomerulonephritis nor the accumulation of macrophages in either model. Inhibition of macrophage accumulation can largely prevent these forms of experimental glomerulonephritis, thereby implicating macrophages as mediators of glomerular injury and consequent proteinuria.

Histochemistry of glomerular cells in animal models of crescentic glomerulonephritis

A histochemical enzyme profile has been used to determine the origin of the cells of glomerular crescents in rabbit and sheep models of rapidly progressive crescentic glomerulonephritis. Crescentic glomeruli were examined for beta-glucuronidase, esterase and acid phosphatase, the characteristic phagolysosomal enzymes of the monocyte-macrophage series and its transformed tissue counterpart, the epithelioid cell. More than 50% of the cells of the glomerular crescents of animals with experimental crescentic glomerulonephritis contained large amounts of all the enzymes, whereas the cells of normal glomeruli contained only trace amounts of acid phosphatase and esterase and no glucuronidase. These findings support the hypothesis that the major proportion of the cells of glomerular crescents are monocytes which have accumulated in Bowman's space rather than intrinsic glomerular cells which have proliferated.

Tissue culture of isolated glomeruli from patients with glomerulonephritis

To study aspects of glomerular cell response in varying types of glomerulonephritis, we evaluated isolated glomeruli from 101 normal and diseased adult human renal biopsy specimens in tissue culture. Glomerular cell outgrowths from normal glomeruli consisted of large stellate cells (type I) and smaller fusiform cells (type II). A very occasional cell (type III), which had the features of a macrophage, was seen. The cellular outgrowth from isolated glomeruli reflected the numbers and types of cells present in the diseased glomeruli. Reduced numbers of cells were found in the outgrowth of sclerotic, hypocellular glomeruli. Glomeruli from biopsy specimens with altered morphologic appearances but no increase in cellularity (minimal change nephropathy, membranous nephropathy) produced the same growth pattern as from glomeruli isolated from normal kidneys. In mesangial proliferative nephritis, increased numbers of type II cells were detected in the outgrowth. Large numbers of macrophages were found in the glomerular outgrowth of patients with crescentic glomerulonephritis. Macrophages were absent when crescentic glomeruli were sclerosed, indicating the importance of macrophages in the acute hypercellular phase of crescent formation.

The effect of defibrination on macrophage participation in rabbit nephrotoxic nephritis: studies using glomerular culture and electronmicroscopy

Recent studies in experimental crescentic glomerulonephritis, using the technique of glomerular culture, have shown that the macrophage is a major cell type present within the glomeruli and developing crescents. It has been suggested that their accumulation is a consequence of glomerular fibrin deposition. The effect of defibrination with ancrod on the cellular events occurring in experimental crescentic glomerulonephritis in the rabbit was therefore assessed in this disease using the techniques of culture of isolated glomeruli, electronmicroscopy or renal tissue, and light microscopy. Defibrinated animals developed only minimal renal impairment, virtually no fibrin deposition in Bowman's Space and only a mild degree of crescent formation, in contrast to the severe renal failure, fibrin deposition and crescent formation that occurred in the untreated animals. The culture of isolated glomeruli and electronmicroscopy of intact renal tissue demonstrated large numbers of macrophages within and emerging from glomeruli of both defibrinated and untreated animals. However, only in untreated animals were macrophages seen to migrate into Bowman's Space, phagocytose fibrin, transform into epithelioid cells and accumulate to form crescents. These studies suggest that fibrin deposition in Bowman's Space is the major stimulus to the macrophage migration from capillary loops and accumulation in Bowman's Space. However, fibrin deposition does not appear to be the stimulus to macrophage accumulation within capillary loops as this event was not affected by defibrination.

The macrophage in the development of experimental crescentic glomerulonephritis. Studies using tissue culture and electron microscopy

The role played by the macrophage in the development of injury in rabbit nephrotoxic nephritis (NTN) has been assessed by electron microscopy and glomerular culture of renal tissue obtained by several biopsies during the course of the disease. These observations have been correlated with the other immune, cellular, and biochemical events occurring in the glomerulus, ie, deposition of immunoglobulin and complement, proteinuria, polymorphonuclear leukocyte (PMN) exudation, fibrin deposition, crescent formation, and renal failure. A biphasic macrophage accumulation was detected, corresponding to the heterologous and autologous phases of the disease. In the autologous or crescentic phase, macrophages accumulated within the glomerular tuft from Day 5; their appearance coincided with the accumulation of PMN and development of proteinuria. Fibrin deposition in Bowman's space, which commenced on Days 6 and 7, was rapidly followed by the migration of macrophages from the glomeruli into Bowman's space. Within Bowman's space, macrophages were observed to phagocytose fibrin, transform into epithelioid and giant cells, and accumulate to form a substantial proportion of the cells forming the crescent. The inflammatory process of PMN exudation, macrophage accumulation, fibrin deposition, and crescent formation and the degree of renal failure reached a maximum by Days 12 to 14. Thereafter, resolution of the inflammatory process occurred so that by Day 40 macrophages had disappeared from the glomeruli. However, varying degrees of glomerular damage and renal failure persisted, occurring largely as a result of glomerulosclerosis and sclerosis of crescents. The tissue culture studies also demonstrated mesangial cell proliferation during the inflammatory process but did not show any abnormality of epithelial cell activity. This study demonstrates that the macrophages participate in NTN by accumulating in damaged glomeruli then migrating into Bowman's space (probably in response to fibrin deposition) where they undergo granulomatous transformation and accumulate, contributing to crescent formation.

Normal human glomerular cells in culture

Reproducible patterns of cell outgrowth have been observed from isolated normal adult, human glomeruli grown in tissue culture. Three morphologically distinct cell populations designated Types I, II, and III have been observed in culture from 15 normal human kidneys. Assessment of the morphology and behaviour of these cells has been made by phase contrast, time-lapse cinemicroscopic, transmission and scanning electron microscopic examination. The phagocytic capacity of these cells has been determined. The Type I cell appears in culture by migration from the capillary loops, its branched cytoplasm and ultrastructural features confirming its origin as a visceral epithelial cell. In keeping with the highly specialised nature of this cell, division was rare, movement was not observed, and differentiation was progressively lost in culture. The Type II cell was mobile and capable of active division. Ultrastructural features were those of mesangial cells. The Type III cell which was seen only rarely, had the features of a macrophage. Endothelial outgrowth was not observed.

A comparison of hemodialysis and transplantation in reversing the uremic disturbance of male reproductive function

A comparative study of the capacity of maintenance hemodialysis and renal transplantation to reverse the uremic damage to testicular function in 27 men with chronic renal failure was performed over a two year period. Despite two years of stable hemodialysis there was only minor improvement in sexual activity. Testosterone levels failed to improve and luteinising hormone (LH) levels remained high. Elevation of serum follicle stimulating hormone (FSH) together with severe spermatogenic damage persisted. Transplant patients showed a significant improvement in sexual activity, a return of testosterone to normal, and a significant fall in LH levels. Fertility, as assessed by sperm count, was improved in 50% of transplant patients. Thus while renal transplantation may restore reproductive function in men with chronic renal failure maintenance hemodialysis has no effect.

The effect of maintenance dialysis on lymphocyte function. II. Peritoneal dialysis

Lymphocyte function, as assessed by PHA-stimulated DNA synthesis, was studied in chronic renal failure patients maintained by peritoneal dialysis. In contrast to patients on haemodialysis, peritoneal dialysis patients had normal lymphocyte responsiveness pre-dialysis. There was no deterioration in the post-peritoneal dialysis plasma's ability to support control lymphocyte responsiveness as occurred after haemodialysis. Plasma dilution and reconstitution studies indicated that haemodialysis depleted the patients' plasma of nutrients and also added toxins, but peritoneal dialysis had neither effect.

The effect of maintenance dialysis on lymphocyte function. I. Haemodialysis

The effect of haemodialysis on mitogen-stimulated lymphocyte DNA synthesis was determined in twenty-four uraemic patients. Lymphocytes pre-haemodialysis were significantly less responsive to phytohaemagglutinin (PHA) than were control lymphocytes and showed the same degree of impairment as uraemic lymphocytes. Intrinsic lymphocyte responsiveness improved immediately after each haemodialysis. Pre-haemodialysis plasma inhibited control lymphocyte responsiveness and this inhibition was even greater in post-haemodialysis plasma. This effect of haemodialysis on plasma lasted for 4--8 hr. Similar alterations of response were noted, despite the use of different dialysers and also when two other mitogens were substituted for PHA. This deleterious effect of haemodialysis on lymphocyte function is important for its possible immune consequences, and may indicate a deficiency in current haemodialysis technique.

Cell characteristics of cultured glomeruli from different animal species

A modified sieving technique has been developed to isolate pure glomeruli from monkey, sheep, dog, rabbit and rat kidney. Glomeruli from all these species have been grown in tissue culture and the glomerular cell outgrowth studied by light microscopy and time-lapse cinemicroscopy. The pattern of growth was the same for all the species studied. In all species, three cell populations have been identified with the features of epithelial cells, mesangial cells and macrophages, although the latter population is only rarely observed. The morphology and culture characteristics of each cell type in all species were similar, including the relative numbers present and rates of division.

Tissue culture of isolated human glomeruli

Glomerular cells have been grown in a reproducible manner from 5 normal human kidneys. A technique is described which combined mechanical disruption of renal cortex and microdissection, and provides large numbers of pure glomeruli within 30--45 mintues. Histological examination shows this technique produces intact glomeruli without cell disturbance. During tissue culture, glomeruli attach to the flask and the intrinsic cells migrate onto the flask and divide. Variations of culture conditions have shown that glomeruli are robust without fastidious culture requirements. Intact kidney tissue can be left at 4 degrees C for perios up to 24 hours prior to isolated of individual glomeruli without affecting subsequent cellular growth in culture. They grow in most commonly used media although the cells require 20% foetal calf serum for optimum growth. Their pH optimum is between 7.0 and 7.4 with temperature optimum of 37 degrees C. as glomeruli must attach prior to cell growth, minimum movement is critical to promote optimum growth. Under these optimum conditions a regular and predictable growth of cells of two distinct types, has been observed over 14 days; one of these types is probably epithelial.

Tissue culture of isolated glomeruli in experimental crescentic glomerulonephritis

As a means of studying mechanisms of response to injury in glomerulonephritis, glomeruli from normal sheep and rabbits and from sheep and rabbits with experimental crescentic glomerulonephritis have been isolated and grown in tissue culture. The cellular outgrowths from the normal and diseased glomeruli have been compared. The outgrowth of glomeruli from normal animals contained only two cell populations whose microscopic and ultrastructural appearances were of epithelial and mesangial cells. The same cells were also observed in the outgrowths of glomeruli from animals with crescenti nephritis but in addition a third population of cells was present in large numbers. These cells were identified as macrophages by their mobility, ultrastructure, phagocytic capacity, and presence of Fc receptors. Glomerular outgrowth from sheep with crescentic glomerulonephritis contained 170 +/- 20 (SEM) macrophages and outgrowths from rabbits with crescentic nephritis contained 64 +/- 6 (SEM) macrophages per glomerulus. We have previously observed large numbers of macrophages in the outgrowth of isolated glomeruli from humans with rapidly progressive crescentic glomerulonephritis. The predominance of the macrophage in cultures of glomeruli from both human and animal crescentic glomerulonephritis suggests that this is an important cell in the inflammatory reaction occurring in crescentic glomerulonephritis and may comprise a substantial proportion of the cells forming the crescent.

Immune and phagocytic function in patients on maintenance dialysis and post-transplantation

Immune, phagocytic and opsonic function was assessed in stabilized hemodialysis patients and compared with patients on maintenance immunosuppression following successful renal transplantation. Dialysis patients had a lymphopenia and a qualitative defect in lymphocyte function but opsonic and neutrophil metabolic function was normal. Post-transplant patients had normal intrinsic lymphocyte function but overall immunosuppression due to lymphopenia, selective T cell depletion, and drug inhibition. Neutrophil metabolic function was normal though there was a defect in opsonization.

Systemic herpes simplex infection with fulminant hepatitis post-transplantation

Immunosuppression for renal transplantation is associated with the risk of severe overwhelming infection with ubiquitous but normally relatively harmless micro-organisms. In recent years a number of adult cases of fatal hepatitis due to herpes simplex virus (HSV) infection have been reported. Nearly always immune deficiency was a significant factor. A case of fatal HSV infection with hepatitis following transplantation is reported. The case failed to respond to infusion with the antiviral agent cytosine arabinoside. The presentation, diagnosis and treatment of HSV fulminant hepatitis is discussed.

Prolonged antibiotic peritoneal lavage in the management of gross generalized peritonitis

Since there is a high mortality and morbidity with conventional therapy in generalized peritonitis, a treatment regime of prolonged continuous peritoneal lavage (two to 10 days) with the lavage solution containing kanamycin (40 mug/ml) and cephalothin (100 mug/ml) was undertaken in 14 cases of gross, well established, diffuse peritonitis. Antibiotics were also given systemically. In 11 cases, in which the causative lesion was definitively repaired, no intraperitoneal complications developed and convalescence was rapid. Three patients, in whom causative lesion was not definitively repaired at operation, subsequently died. Prolonged antibiotic peritoneal lavage appears to be beneficial for patients with gross and diffuse peritoneal soiling, after the causative lesion has been repaired.

The macrophagen in human rapidly progressive glomerulonephritis

Glomeruli from 18 "normal" patients and from 35 patients with glomerulonephritis have been maintained in tissue-culture and examined by time-lapse cinemicroscopy and electron microscopy. At least two distinct cell types with features of epithelial and mesangial cells emerge in the outgrowths from normal and non-crescentic glomeruli. 4 patients with rapidly progressive glomerulonephritis formed a distinct subgroup. Glomerular culture revealed that their crescents contained large numbers of macrophages. This suggests that, contrary to belief, the crescents in rapidly progressive glomerulonephritis consist of accumulated macrophages rather than proliferated epithelial cells.

Management of Candida peritonitis by prolonged peritoneal lavage containing 5-fluorocytosine

A 55 year old woman on chronic maintenance peritoneal dialysis developed Candida albicans peritonitis. This was successfully treated by continous five day peritoneal lavage containing 5-fluorocytosine. By this technique stable serum levels of the drug (58 mug/ml +/- 3.2 SEM) could be maintained. The peritoneal clearance of 5-fluorocytosine was found to be 7.5 ml/min (for peritoneal dialysis flow rate 1.2 1/hr) and the serum half-life 34 hours. The use of this drug in renal failure and its kinetics are reviewed.