Comparative study of influenza virus H2 (Asian) hemagglutinins isolated from human and avian sources

The hemagglutinin of an influenza virus isolated from a wild duck (Pintail, Anas acuta) in the USSR in 1976 had been found to be antigenically indistinguishable from the hemagglutinin of H2N2 viruses of human origin isolated in 1957. The hemagglutinins from viral preparations of the A/Anas acuta/Primorie/695/76 (H2Nav2) and A/Singapore/1/57 (H2N2) strains were purified by SDS gel chromatography as the subunits HA1 and HA2. Comparison of amino acid compositions and peptide maps of tryptic peptides containing [14C]-carboxymethylcysteine showed a striking degree of similarity between the H2 hemagglutinins.

Adenovirus-associated virus structural protein sequence homology

Adenovirus-associated virus (AAV) structural proteins (VP1, VP2, and VP3) have been examined to determine if areas of sequence homology exist between these three virion proteins. Tryptic and chymotryptic maps have been produced which demonstrate extensive areas of sequence homology common to all three proteins. The amino acid compositions of the proteins were also determined and were found to be very similar. These data are consistent with the hypothesis that all three virion proteins arise either from a common precursor of similar transcripts.

Hypoxemia during exercise in patients with chronic obstructive pulmonary disease

Arterial oxygenation at rest and during maximal treadmill exercise was studied in a group of 17 patients with chronic obstructive pulmonary disease. Patients who developed exertional hypoxemia (subgroup 1) were compared to others who did not (subgroup 2). There was no significant difference between the 2 subgroups at rest in terms of mixed venous PO2, cardiac output, or venous admixture. Subgroup 1 had more severe respiratory impairment than subgroup 2, but there was marked overlap of their respective lung volumes and flows. Both subgroups showed the same extent of desaturation of mixed venous blood during maximal treadmill exercise, so that exertional hypoxemia cannot be explained on the basis of low mixed venous O2. The marked difference between subgroup 1 and subgroup 2 was that the latter showed decreased venous admixture on exercise. Because of the relative constancy of mixed venous blood desaturation, arterial saturation was closely correlated with venous admixture both at rest (r = 0.931) and during exercise (r = 0.985).

Macrophage-related suppressor cells in human renal transplant recipients

In this study 66 renal transplant recipients were studied by in vitro immunologic monitoring assays in an attempt to delineate some immune reactivity parameters which migh explain the successful long-term survival of HLA incompatible allografts. Ninety percent of the recipients were found to be responsive to their specific donors in one-way mixed lymphocyte culture assays, indicating the presence of antigen reactive proliferating T cells. In contrast, studies of the in vitro generation of cytotoxic T cells showed that 73% of the long-term recipients demonstrated a marked hyporesponsiveness to the donor in cell-mediated lympholysis (CML) assays. Longitudinal studies indicated that specific CML hyporesponsiveness to the donor developed after transplantion. In the majority of recipients, CML hyporesponsiveness could be related to a suppressor cell phenomenon, since recipient mononuculear cells specifically suppressed the CML reactivity of third-party cells to the donor. Recipient CML hyporesponsiveness to the donor could be abrogated by removal of recipient adherent cells, most of which were monocytes or macrophages. The suppressor cell effect on CML is postulated to be related to macrophages which are either acting independently or under the regulation of suppressor T cells. These studies are among the first to suggest that suppressor cell regulation of relevant effector T cell activity may be important in the facilitation of successful human renal transplantation.

Restrospective correlation of clinical and histologic findings of 189 exchanged kidneys

Tissues samples from 189 unsuccessful renal allografts, 47 recovered at autopsy and the others removed surgically, were examined histologically by light microscopy. Tissues samples were obtained from cadaver kidneys that had been exchanged regionally for transplantation. Each allograft tissue sample was rated as to extent of pathologic changes denoting rejection and was classified accordingly. Surgical and autopsy reports, as well as clinical data, were then obtained and these were compared with the retrospective pathologic findings of this study. Our pathologic findings agreed with the original pathologic diagnosis as to presence or absence of rejection changes in 180 cases, but disagreed with the clinical diagnosis of rejection in 28 of the 63 cases with minimal or no histologic evidence of rejection. There was less disagreement with the clinical diagnosis for the 87 cases with histologic evidence of rejection which had been judged as sufficient to cause allograft loss, 70 having been clinically diagnosed as rejected. Disagreement occurred most often where the allograft had never functioned or had been lost within 3 months. Retrospective analysis did not disclose any association between rejection histology and preformed antibodies or length of kidney perfusion time. Sufficient allografts appeared to have been lost for reasons other than rejection to cast doubt on the validity of interpreting renal allograft data only by graft survival statistics.

Relationship of B cell alloantibodies to renal allograft survival

To define the relationship of donor-specific B lymphocyte alloantibodies to renal allograft survival, longitudinal serum samples obtained pre- and post-transplantation were examined for antibodies cytotoxic to donor B lymphocytes. Ten of 17 renal allograft recipients had antibodies to donor B lymphocytes but not T lymphocytes either pre- and/or post-transplantation. Three patients underwent successful transplants despite preformed B cell antibodies; however, seven who developed B cell antibodies only after transplantation are either undergoing chronic rejection (4) or have had severe rejection crisis (3). Seven patients with no B cell antibodies have functioning grafts. In all cases, B cell antibodies were detected before biochemical and clinical evidence of rejection. Similar findings were noted when sera of 38 renal transplant recipients were examined for B cell antibodies cytotoxic to an unrelated panel of B lymphocytes. These results demonstrate that the development of B cell alloantibodies after transplantation is often associated with rejection and that successful renal transplantation can be performed across a positive B cell crossmatch.

Immunological monitoring as a guide to the management of transplant recipients

Immunological monitoring assays are of current value in the management of transplant recipients. These assays allow the pre-transplant quantitation of both donor-recipient histocompatibility and recipient "responder status." In addition, these assays allow the individualization of immunosuppression, permitting a more uniform and effective immunosuppression in the difficult early post-transplant period. Individualized modulation of recipient immune reactivity avoids the documented pitfalls of conventional stereotyped suppression and permits better abrogation of acute rejection responses and lesser rates of serious infections consequent to excessive immune suppression. Immunological monitoring of long-surviving recipients permits early detection of immune reactivity which often culminates in clinical chronic rejection, as well as permits the quantitation of immune facilitory mechanisms (reduced capability to generate anti-donor cytotoxic T cells and/or cellular suppressor mechanisms) that indicate an immune milieu conductive to long-term graft survival. The primary limitations to the more widespread use of immunological monitoring assays at present are the need for more consensual validations of the utility of these assays in different laboratories, more standardization and better controls of techniques, and improvement in the technology of the assays to permit rapid, reproducible, and accurate results with a lesser expenditure of laboratory time and money and greater economy in demands for recipient blood and donor tissue. Finally, immunological monitoring assays are notable for the great promise they offer in terms of immunobiological probes to dissect mechanisms of rejection, mechanisms of graft facilitation, mechanisms of action of immunosuppressive agents, and mechanisms by which empirical technology of recipient pre-treatment may condition the host to better acceptance of an incompatible graft.

Pretransplant monitoring of donor-recipient compatibility

In these studies, pretransplant testing of donor-recipient compatibility was performed in 10 related donor and 26 cadaveric renal transplants using a variety of cell-mediated immunity tests. Mixed lymphocyte culture results did not correlate with acute rejection (AR), acute irreversible rejection, or chronic rejection (CR). Lymphocyte-mediated cytolysis also did not correlate with AR, acute irreversible rejection, or CR. Cell-mediated lympholysis correlated with AR but not with acute irreversible rejection or CR. Antibody-dependent cell-mediated cytolysis (ADCMC) was positive pretransplant in 13 (36%) of the recipients. Of the positive patients, 4 had early severe AR and 9 developed typical CR. Of these 13 patients, 9 or 69% lost graft function to rejection whereas only 3 of 20 (15%) of ADCMC-negative patients lost graft function because of rejection (P less than 0.05). In summary, cell-mediated lympholysis testing demonstrated a capability to predict AR episodes. The most useful pretransplant monitoring assay in this patient series was the ADCMC assay. A positive ADCMC against donor cells pretransplant indicates a relatively poor prognosis for long-term graft survival.

Effect of antilyphocyte-globulin potency on survival of cadaver renal transplants. Prospective randomised double-blind trial

71 recipients of cadaver primary and secondary renal transplants were investigated in a prospective randomised double-blind study. Patients were given one of two rabbit antilymphocyte globulin (A.L.G.) preparations made by similar techniques but differing in potency as measured by skin-graft prolongation in rhesus monkeys. Patient selection and management were otherwise similar. A statistically significant difference (P less than 0-05) in graft survival (78% vs. 42%) developed between the two groups at a mean follow-up of 18-4 months and patient entry into the study was terminated. After a 3-5 year interval from the start of the trial the double-blind code was broken. It was found that the high-potency-A.L.G. group had better graft survival and fewer rejection episodes (P less than 0-05) than the moderate-potency group. The results suggest that preclinical testing of A.L.G. by the primate skin graft test can be a valid indicator of the potential efficacy of an A.L.G. preparation in renal-transplant recipients. It is suggested that quality-control standards may improve the clinical results of A.L.G. therapy.

Renal artery occlusion in transplant recipients

Five cases of renal artery occlusion occurring in kidney transplant recipients are reported--an incidence of 1.4%. Two patients recovered moderate renal function after thrombectomy in spite of the estimated occlusion time of four hours and 12 hours, respectively, under normothermic conditions. Three cases of occlusion were associated with pre-existing renal artery stenosis. This experience reinforced the optimistic and aggressive approach to treatment of renal artery thrombosis. Renal artery occlusion may simulate acute rejection in the transplant recipient.

Cryptococcosis in renal transplant patients

First, cryptococcal infections in transplant patients can be readily diagnosed and successfully treated; aggressive, innovative uses of currently available drugs should accomplish this. Second, some drug related toxicity, mostly nephrotoxicity and hematologic, is inevitable, and patients must be carefully monitored so that these effects may be minimized. Third, anti-fungal drug assays are available and can be performed and drug levels should be monitored, with the object of obtaining levels which are both reasonably safe and maximally effective in terms of known in vitro susceptibilities of the offending pathogen.

Effective monitoring and modulation of immune reactivity in allograft recipients

This study demonstrates that current techniques of immune monitoring and modulation are available, which have potential to reduce early cadaver allograft loss from rejection to 5% or less. The techniques center on the monitoring of T lymphocyte levels and T lymphocyte reactivity, using relatively simple and reproducible assays, which give results within 4-72 hrs, depending upon the tests used. In addition, these techniques include modulation of T cell levels and reactivity using quality-controlled anti-thymocyte globulin (ATG) in low doses during the post-transplant period. High potency ATG demonstrates a significant capability of preventing early (3 mos) graft rejection, as well as maintaining low levels and reactivity of T cells for 3 mos or longer, when intermittent low dose therapy is utilized. Evidence is presented that ATG has a relatively selective effect on T lymphocytes and this may result in a degree of selective immunosuppression not achieved in clinical transplantation to date.

Factors in the differential rate of arteriosclerosis (AS) between long surviving renal transplant recipients and dialysis patients

In this study, the incidence of clinical and autopsy arteriosclerosis (AS) was studied in over 300 renal transplant patients (RTP) followed in our clinic up to 13 years post-transplant. Of 45 RTP followed a mean of 10.45 years, the incidence of clinical AS was 6% or 0.58% per year at risk. The incidence of death from AS was 2.2% over 10 years or 0.22% per year at risk. There was no apparent tendency for increase of the risk incidence with increasing time post-transplantation up to 13 years. This incidence of clinical and death-related AS in long term RTP contrasts sharply with a quite high incidence of both clinical and death-related AS in long-term dialysis patients as reported by Scribner's group and both the European and U.S. Dialysis Registry. Of our RTP surviving a decade or more, 77% have normal serum triglycerides and 92% are normotensive, again contrasting sharply with a 70-80% incidence of hyperlipidemia and a 60-80% incidence of hypertension in long-term dialysis patients. These studies suggest that the high rate of accelerated AS in dialysis patients is largely reversed by successful renal transplantation, probably due to a lowering of both blood pressure and hyperlipidemia in the long-term RT patients. Practically, these results suggest that the superior survival of transplant patients over dialysis patients already evident at 10 year mark will widen further during the second post-transplantation decade.

Antibody-dependent cellular cytotoxicity and chronic renal allograft rejection

Antibody-dependent cell-mediated cytotoxicity (ADCMC) was studied retrospectively in 20 long-term (1.3-11 years) renal allograft recipients. The serum of all seven patients having persistent proteinuria greater than 1 g/24 hr exhibited positive ADCMC activity to donor lymphocytes. All 11 patients having a negative ADCMC test had normal levels of urinary protein (mean + 0.28 +/- 0.06 (SE) g/24 hr). Two patients had a positive ADCMC test but had normal urinary proteins and no evidence of chronic rejection. In the ADCMC positive group, the mean serum creatinine values were significantly higher and the mean creatinine clearance values were significantly lower than in the ADCMC negative group. There was no significant positive correlation between the presence of ADCMC and the number of HL-A mismatches identified or the response to donor lymphocytes in mixed lymphocyte culture tests in the two groups. Two patients had transplant nephrectomy and histologically showed both glomerular and arterial lesions of chronic rejection. Post-transplant ADCMC activity showed a significant correlation with proteinuria, decreased creatinine clearance, and elevated serum creatinine, and suggests that the chronic rejection syndrome may be related to ADCMC activity in the recipient.

Use of plasma protein fraction in preservation of cadaveric kidneys

We have compared 23 cadaver kidneys preserved with cryoprecipitated plasma (CPP) with 23 consecutive cadaver kidneys preserved with plasma protein fractions (PPF). In both groups the MOX-100 Waters machine was used. The PPF solution does not contain any fibrinogen or gamma globulin. The harvesting characteristics of both groups were comparable. Pulsatile perfusion time in the PPF group was up to 46 hours and in the CPP group was up to 44 hours. In the PPF group, 20 kidneys achieved immediate function upon transplant (85 percent). Two underwent periods of acute tubular necrosis (ATN) and one kidney never worked. In the CPP group, 18 kidneys achieved immediate function (78 percent). Two underwent periods of ATN and three never achieved satisfactory function. From this clinical experience, PPF is as effective as CPP for the preservation of kidneys up to 44 hours prior to transplant. The advantages of the PPF are easy availability, long shelf life, simple preparation, low cost, freedom from risk of hepatitis, and theoretical absence of antibody against the kidney. Graft and patient survival at 6 months showed no statistical difference.

Monitoring and modulation of immune reactivity in human transplant recipients

In this study parameters of humoral antibody (HA) and cell-mediated immunity (CMI) were measured before and after transplant in 44 renal transplant patients. The results indicated that, before transplant, CMI parameters but not HA measurements correlated with early graft rejection crises. In antithymocyte globulin (ATG)-treated patients, a striking loss of early rejection activity occurred which correlated with ablation of T cells in the peripheral blood. ATG-treated patients also had a marked loss of T cell reactivity, as measured by phytohemagglutinin (PHA) blastogenesis and these parameters also correlated with allograft reactivity. Concanavalin A (Con-A) reactivity, however, did not correlate well with early rejection activity. Triple drug therapy with ATG, but not prednisone-Imuran therapy, caused a marked fall of T cell levels and reactivity within hours of the first dose of ATG. None of the ATG-treated patients had irreversible or progressive rejection in the first month after transplant and only 32 percent of patients had rejections, of which more than 70 percent were Type I. A "permissive" level of T cells of about 20 percent of normal was associated with over 95 percent of acute rejection crises, whereas no correlation of a variety of humoral antibody parameters and rejection has been seen in our unit. These studies suggest a primary role of the T cell in early allograft reactivity and indicate that future immunosuppressive techniques for human transplantation should be directed toward effective monitoring and modulation of T cell levels and reactivity in the early post-transplant period.

The angiographic evaluation of human renal allotransplants. Functional graft deterioration and hypertension

The renal arteriogram is a highly reliable test in the differential diagnosis of early transplant anuria, graft rejection, and hypertension. The reliability of the renal arteriogram was 97.8% in either substantiating or disproving the presence of a suspected episode of graft rejection or renal artery stenosis. The earliest signs of acute humoral and acute rejection were a prolongation of arterial clearance time, diffuse edema with enlargement of the kidney, and progressive deterioration of the nephrogram. Renal artery stenosis may be a sharply localized septum or an elongated narrowing at or distal to the actual site of anastomosis. This was seen primarily in patients' arteriograms more than 60 days after transplantation, and it is important because it is a surgically correctable cause of hypertension.

Studies of thymus-derived and bone marrow-derived lymphocytes in renal transplant patients

Serial studies of levels and responsiveness of T and B lymphocytes were performed in human renal allograft recipients. Patients given prednisolone-azathioprine immunosuppression had only mild falls in levels and responsiveness of T cells. Patients given a quality controlled ATG preparation had marked and relatively selective falls in levels of T cells associated with a marked fall in T cell responsiveness as measured by PHA and Con-A responsiveness. In vivo correlates of this severe T cell deficiency suggest that T lymphocytes are central to acute allograft rejection and that acute severe T cell deficiency is not associated with risk of infectious complications above and beyond those seen in patients suppressed with prednisone-azathioprine alone. These studies suggest that ATG, produced under quality control conditions and having rather selective anti-T cell activity, is a useful adjunctive immunosuppressive agent for human renal transplantation.

Cine-fluoroscopic studies of ureteral function in the human renal transplant

During a 14-month period 73 satisfactory fluoroscopic studies were done on 59 kidney transplant recipients. Ureteral peristalsis was seen in 90 per cent of these studies and there was no difference between patients receiving living related donor kidneys and those receiving cadaveric kidneys. When ureteral activity was studied during rejection episodes only 54 per cent of the studies showed activity. An effort was made to relate aperistaltic ureteral activity to renal function, warm ischemia time, urinary tract infection, number of rejection episodes and tissue matching but no positive correlation could be made except the concurrent clinical diagnosis of rejection.

Donor-specific IgG antibody and the chronic rejection of human renal allografts

Although many investigators have felt that humoral antibody was responsible for chronic rejection, attempts to detect it in the sera of recipients in the presence of functioning renal allografts have been largely unsuccessful. A modification of the mixed antiglobulin reaction has increased its sensitivity so that the development of low titers of immunoglobulin (IgG) antibody antibody specific for donor kidney cells can be detected in renal allograft recipients while renal function is still good. Donor-specific antibody was detected in the sera of 11 of 13 patients whose transplants had ceased to function from 5 to 43 months after transplantation. In five recipients the antibody was present prior to as well as after transplantation and in six recipients antibody developed after transplantation from 3 to 25 months prior to the cessation of function. In the patients with antibody, chronic rejection was characterized by hypertension which required treatment with multiple drugs, by proteinuria of greater than one gram per day, by a gradual, progressively rising serum creatinine, and by an absence of acute ologuric rejection episodes. Pathologically there was extensive intimal proliferation and occlusion of the intrarenal arteris. There also was significant glomerulonephritis which consisted of thickening of the basement membranes, mesangial cell proliferation, simplification of the capillary loops, and in some patients fibroepithelial crescent formation. These findings suggest that IgG antibodies directed against cell-surface antigens of the donor are the chief cause of chronic renal allograft rejection.

Humoral antibody responses following transplantation in man

Sequential titers of five different humoral antibodies (antirat erythrocyte, antisheep erythrocyte, isoantibodies, rheumatoid factors, and serum agglutinators) were simultaneously performed on 20 patients with renal transplants, 12 patients with skin transplants, and 2 patient populations (one hospitalized and one ambulatory). The results suggested that rises in titer of any of these antibodies could not be used as an indicator of acute rejection. Nevertheless, patients who lacked rejection episodes were unlikely to show humoral responses and always lacked antiglobulin responses. Heterophil responses always preceeded antiglobulin responses. These results suggest that heterophils are cross reacting antibodies and antiglobulins are auxillary immune responses.

Amaurosis fugax: diagnostic and therapeutic aspects

The three to eight-year follow-up study of 34 patients with unilateral amaurosis fugax (AF) suggests the following points: (1) A significant number of frequent unilateral AF patients suffer from small ulcerative plaques or irregular stenoses without any bruit in the neck or major changes in ophthalmodynamometry (ODM). The most important diagnostic test in these cases is angiography. (2) Surgery in patients with frequent unilateral AF seems to be more successful than anticoagulation. (3) No treatment cannot be considered a policy of "benign neglect" and may result in serious complications. (4) Cholesterol plaques, carotid bruits, and abnormal ODM are suggestive of carotid artery disease in unilateral AF. However, the absence of these signs is not helpful in differentiating carotid artery from cardiac origin of the emboli. (5) Heart disease may be the main etiological factor in a few patients with AF. It plays a major role in mortality regardless of the type of treatment.