Influence of HLA compatibility on renal graft survival using live unrelated & cadaver donors in India

BACKGROUND & OBJECTIVES

Living unrelated donor (LURD) renal transplantation has shown a rising trend over the last 5 yr at our center following the passing of The Transplantation of Human Organs Act by the Government of India in 1994. In this paper, the results of LURD and cadaver (CAD) donor renal transplantation are compared. We have also looked into factors that have a bearing on graft survival such as the extent of HLA mismatch (MM), infections, acute rejections (AR), donor age and sex.

METHODS

A total of 42 LURD and 25 CAD renal transplants performed between March 1994 and February 1999 has been included in the study. HLA typing, panel reactive antibody (PRA) screening and T and B cell cross match assay were performed by the complement dependent cytotoxicity (CDC) method for all patients.

RESULTS

The graft survival rates were generally higher in the LURD category as compared to the CAD group and were significant at 6 month period (90 vs 56%, P = 0.002). A follow up of the patients up to 60 months revealed a matching effect since the 3, 4 allele MM group had better survival rates as compared to the 5, 6 MM group. Twenty six of the 67 recipients (39%) experienced episodes of acute rejection (AR). Patients with 3, 4 MM had fewer such episodes than those with 5, 6 allele MM (P < 0.05). Of the 32 deaths, 20 were those with a functional kidney, of which 15 were caused by severe infections.

INTERPRETATION & CONCLUSION

Better HLA matching ensures fewer episodes of rejection and better long term graft survival in comparison to the poorly matched grafts. The graft survival for LURD recipients was appreciably higher than that of CAD recipients.

Results of renal transplantation on conventional immunosuppression in second decade in India: a single centre experience

BACKGROUND

In-spite of many renal transplant (RT) centres in the country, there is paucity of data on the survival results in India. Furthermore, there is hardly any data of results in second decade. In this study we present the results of RT in second decade at our centre.

METHODS

RT at our hospital is being done since 1972. First eight years saw occasional RT and complete data is not available in these patients. So, we have excluded these patients from the study. We have included rest all 144 patients who had RT between Jan. 1981 to Dec. 1989, so as to have at least 10 years of follow-up or more. All these patients were on conventional immunosuppression.

RESULTS

Of the 144 patients, 126 (87.5%) were males and the mean age was 29.5 +/- 8.5 years (range 14-54). Basic disease was presumed chronic glomenulonephritis (CGN) in 79.9%, vesicouretenic reflux (VUR) in 8% and diabetic nephropathy in 1.4% patients. Mean number of haemodialysis (HD) and blood transfusion before RT were 44 +/- 24.7 and 8.9 +/- 4.7 (range 0-25), respectively. Mean donor age was 40.9 +/- 10.1 year (range 18-62). HLA matching was haploidentical in 74.5% cases, HLA identical in 3% cases and 11.5% were less than two-antigen match. Of the 63% patients, who had at least one acute rejection (AR) during their follow-up, 78.8% cases had this AR within first three months after the renal transplant. During 10 years of follow up, 65 patients died (23 with normal graft function and 42 with chronic rejection) and 17 lost to follow-up. Eight patients lost their graft but were surviving at 10 years and 54 had functioning graft till the time of analysis. With mean follow-up of 83.9 +/- 61.2 (range 1-216) months, 10-year actuarial patients and graft survival was 53% and 47%, respectively. Graft half-life in these patients is 92 months. In multivariate analysis of the donor age, number of blood transfusion (BT), degree of HLA matching and AR, only AR was found to be statistically correlated with the graft outcome (p=0.004).

CONCLUSION

Our study concludes that in our set-up during eighties, on conventional immunosuppression, actuarial patient and graft survival at 10 year is 53% and 47%, respectively with graft half-life being 92 months. Only acute rejection has been found to affect the graft outcome in these patients.

Opening Pandora's box: parental anxiety and the assessment of childhood murmurs

BACKGROUND

Most family physicians and pediatricians recognize the induction of parental anxiety when a newly diagnosed childhood murmur is discussed with a child's parent.

OBJECTIVES

To assess parental anxiety before and after consultation with a pediatric cardiologist for assessment of a childhood murmur. The study investigated the relationship between anxiety and parental understanding of murmurs, and assessed the possible role of the primary physician's initial diagnosis of the child's murmur on the anxiety level of parents.

SUBJECTS AND METHODS

One hundred ninety-five consecutive parents who presented with their child to the Alberta Children's Hospital Cardiology Clinic, Calgary, Alberta, were recruited. The children were referred for an initial consultation with a pediatric cardiologist for assessment of a heart murmur noted previously by the referring physicians. Before consultation, the patients were divided into three murmur groups for diagnosis: innocent, pathological and unknown. Anxiety questionnaires, as well as questionnaires assessing basic parent understanding of childhood murmurs, were administered to one of the parents pre- and postconsultation.

RESULTS

The initial diagnosis given to the caregiver by the primary care physician as the reason for referral did not seem to affect the level of parental anxiety within groups. As expected, postconsultation anxiety levels were significantly higher in parents whose children received a pathological diagnosis from the pediatric cardiologist. A significant drop in parental anxiety post-consultation was seen in all parent groups, including parents of a child diagnosed with a significant cardiac problem or pathology requiring further investigation and/or cardiac follow-up. There was a consistent correlation between higher scores on parental understanding and lower levels of parental anxiety.

CONCLUSION

The present study confirms that the finding of a childhood murmur by the family doctor or pediatrician induces significant parental anxiety, even when the presumptive diagnosis is that of an 'innocent' murmur. Pediatric cardiology consultation decreases parental anxiety, even in parents whose child has been given a diagnosis of pathology. The correlation between poor understanding of murmurs and high parental anxiety suggests that further study is required on the role of the referring physician in augmenting parental understanding of the term 'heart murmur' and the referral process.

A three-step strategy for targeting drug carriers to human ovarian carcinoma cells in vitro

To improve tumor-to-tissue ratios of anticancer agents in radioimmunotherapy, a three-step targeting approach was used to deliver biotinylated liposomes to human ovarian cancer cells (NIH:OVCAR-3, SK-OV-3) in vitro. Targeting was based upon the use of two antibodies specific for the CA-125 antigen that is highly expressed on NIH:OVCAR-3 cells but not expressed on SK-OV-3 cells. Briefly, the approach consists of prelabeling target cells with biotinylated anti-CA-125 antibody and FITC-labeled streptavidin (SAv) prior to administration of biotinylated liposomes containing a marker dye for visualization by confocal laser scanning microscopy (CLSM). In addition, the two anti-CA-125 antibodies (B27.1 and B43.13) were labeled with FITC and incubated with ovarian cancer cells at 37 degrees C from 30 min to 24 h to study binding and uptake kinetics. Shedding kinetics of bound antibody from tumor cells was performed using radiolabeled B27.1. Results demonstrated that both B27.1 and B43.13 specifically bound to the cell surface of OVCAR-3 cells but not to SK-OV-3 cells. Biotinylation, FITC-labeling and radiolabeling of the antibodies did not compromise immunoreactivity. Less than 6% of the bound B27.1 was shed from tumor cells by 4 h following incubation, and the antibody-antigen complex resided predominantly on the cell surface by 4 h at 37 degrees C with slow internalization by 12-24 h. Biotinylated, conventional liposomes were specifically and effectively delivered to OVCAR-3 cells prelabeled with biotinylated B27.1 and SAv. The slow internalization and shedding properties of these antibodies are useful for multistep pretargeting methods. Thus, a modified targeting strategy, utilizing a bispecific antibody and liposomes, may be feasible for radioimmunoliposomal therapy of ovarian cancer.

Antibiotic therapy in coronary heart disease--where do we currently stand?

A casual association between Chlamydia pneumoniae infection and atherosclerosis remains unresolved but plausible. Evidence comes from sero-epidemiological data, pathological specimen examinations, animal models and in vitro experiments. A number of prospective antibiotic intervention trials targeted against C. pneumoniae infection in patients with coronary heart disease are now underway. We remain wary that C. pneumoniae infection can persist in cell lines (associated with atherosclerosis) despite antibiotic therapy and also that reactivation of infection can occur. Issues such as delineating the patient group that could be targeted for treatment, choice of optimal antibiotic regimens, duration of therapy and effective methods of monitoring treatment response remain controversial and, as yet, unresolved. The relevance of persistence of C. pneumoniae infection and potential antimicrobial resistance will require equal consideration.

Atypical manifestation of dural arteriovenous fistula

A case of secondary dural arteriovenous fistula presenting as infantile stroke, in a fifteen month old boy, is reported. The initial impression on CT scan in this case was misleading, due to the atypical appearance of the pathological periventricular blood vessels, interpreted as periventricular calcification.

Epidermal grafting for vitiligo in adolescents

Vitiligo is a significant problem in children. Many fail to respond to medical treatment and require melanocyte replenishment with one of the various surgical methods. Epidermal grafting using the tops of suction blisters has been found to be the most effective surgical procedure. However, the results of this procedure have never been delineated separately in adolescents and children. There are certain procedural and outcome differences in epidermal grafting among children and adolescents as compared to adults. We performed epidermal grafting in 15 recalcitrant patches of stable vitiligo in 10 children. Thirteen of 15 patches (86.66%) in 8 of the 10 patients (80%) showed more than 75% pigmentation. The results were much better than the overall response rate of 62% in 142 patients (adults as well as children) found in an earlier study. Literature analysis revealed the same trend in other studies.

Generalized lymphadenopathy caused by Trichosporon asahii in a patient with Job's syndrome

Of the six species of Trichosporon known to cause human infections, T. asahii is the main agent of invasive trichosporonosis. We describe an unusual case of generalized lymphadenopathy due to T, asahii in a 10-year-old boy with Job's syndrome (markedly elevated IgE with eosinophilia). The diagnosis was based on the presence of blastic conidia and hyphal elements breaking into arthroconidia in biopsied tissue of the cervical lymph node and isolation of the causal agent T, asahii in pure culture. The patient responded initially to amphotericin B therapy, but the infection recurred within 4 weeks and did not respond to therapy of liposomal amphotericin B and 5-fluorocytosine for 10 days. The patient left the hospital against medical advice.

Hepatitis C virus related cryoglobulinemic glomerulonephritis

A 46 years male presented with skin rash and acute nephritic syndrome. He had history of jaundice four months back. Rheumatoid factor and cryoglobulins were present in the serum. Although anti-HCV antibodies were negative, HCV RNA was detected by polymerase chain reaction. Kidney biopsy showed membranoproliferative glomerulonephritis and thrombi in the lumen of the glomerular capillary loops. His renal functions improved with steroids.

Rising incidence of genital herpes over two decades in a sexually transmitted disease clinic in north India

Genital herpes, which was considered to be a minor sexually transmitted disease (STD) in the past in developing countries, is rapidly increasing; in contrast, bacterial STDs are declining. This changing trend of various STDs prompted us to analyze our data retrospectively to see whether a similar change is occurring in this part of India as well. The records of sexually transmitted diseases (STDs) clinic attendees from January 1977 to December 2000 were analyzed. The demographic profile of patients with genital herpes was also considered for analysis. STDs were diagnosed clinically and by appropriate laboratory tests wherever applicable. VDRL test was done in all patients, and HIV antibody detection was performed from 1987 onwards. The incidences of chancroid, donovanosis, and gonorrhea were 12.2%, 6.3%, and 16.9%, respectively, from January 1977 to December 1985. The figures for the same decreased to 2.5%, 0.9%, and 2.3%, respectively, from January 1993 to December 2000. The decreasing incidence of the above bacterial STDs is statistically significant (p<0.001). However, there was an approximately two-fold increase in the incidence of genital herpes in recent years (20.5%) in comparison to the figures from the late 70s (11.4%). Molluscum contagiosum also showed an upward trend (1% in 1977-85 vs. 9.8% in 1993-2000). Condylomata accuminata remained almost unchanged (21.4% in 1977-85 vs. 20% in 1993-2000). To conclude, a significant increase in the number of viral STDs and a decline in the bacterial diseases were observed in recent years in comparison to the figures from the late 70s. This may be due to awareness of HIV, success of control programs, syndromic management of STDs, and adoption of safer sexual practices, which prevent bacterial STDs more efficiently than viral ones.

Emergence of rotavirus G4P8 strain among children suffering from watery diarrhea in Calcutta, India

Rotavirus RNAs from the fecal samples were hybridized with cDNAs specific for G1 and G2 genotypes. 59 out of 138 samples (42.7%) did not hybridize with either probe. The cDNAs coding for VP7 and VP4 from one such sample, SC134, were synthesized by combined reverse transcriptase/polymerase chain reaction (PCR) using specific oligonucleotide primers and were used as probes to screen those local isolates which did not hybridize with either G1 or G2. 26/59 (44%) of fecal RNA hybridized with these cDNAs indicating a possible emergence of this strain in this part of India. The VP7 and VP4 genotype specificity of SC134 was found to be G4P8 by multiplex PCR. The VP7 gene of SC134 was cloned and characterized in detail by restriction enzyme digestion and DNA sequence analysis. Comparison of nucleotide and predicted amino acid sequence of the VP7 gene of SC134 with other serotypes revealed that the VP7 gene of SC134 was closely related to G4. However, amio acids within the VP7 sequence differed in seven positions with that of both the subtype 'A' and 'B' of the G4 serotype. To establish the relation of this emerging strain with the other reported G4 strains, a phylogenetic tree was constructed and SC134 was found to be more closely related to the ST3 strain isolated in England and included in the tetravalent vaccine formulation along with two Japanese strains, although all four were distinct and did not form any cluster as was evident by the horizontal distance separating them. The VP7 gene sequence of SC134 was submitted to EMBL and was assigned the accession number AJ278217.

Transport of Bose-Einstein condensates with optical tweezers

We have transported gaseous Bose-Einstein condensates over distances up to 44 cm. This was accomplished by trapping the condensate in the focus of an infrared laser and translating the location of the laser focus with controlled acceleration. Condensates of order 10(6) atoms were moved into an auxiliary chamber and loaded into a magnetic trap formed by a Z-shaped wire. This transport technique avoids the optical and mechanical access constraints of conventional condensate experiments and creates many new scientific opportunities.

Chlamydia pneumoniae and atherosclerosis -- what we know and what we don't

The clinical manifestations of atherosclerosis include coronary artery disease (CAD), stroke, abdominal aortic aneurysm and peripheral vascular disease. World-wide, CAD and stroke are the leading causes of death and disability. The recognition of atherosclerosis as an inflammatory disease in its genesis, progression and ultimate clinical manifestations has created an interesting area of vascular research. Apart from those well-known traditional risk factors for atherosclerosis, novel and potentially treatable atherosclerotic risk factors such as homocysteine (an amino acid derived from the metabolism of dietary methionine that induces vascular endothelial dysfunction) and infections have emerged. In fact, the century-old 'infectious' hypothesis of atherosclerosis has implicated a number of micro-organisms that may act as contributing inflammatory stimuli. Although cytomegalovirus, Helicobacter pylori and Chlamydia pneumoniae are the three micro-organisms most extensively studied, this review will focus on C. pneumoniae. Collaborative efforts from many disciplines have resulted in the accumulation of evidence from seroepidemiological, pathological, animal model, immunological and antibiotic intervention studies, linking C. pneumoniae with atherosclerosis. Seroepidemiological observations provide circumstantial evidence, which is weak in most prospective studies. Pathological studies have demonstrated the preferential existence of C. pneumoniae in atherosclerotic plaque tissues, while animal model experiments have shown the induction of atherosclerosis by C. pneumoniae. Finally, immunological processes whereby C. pneumoniae could participate in key atherogenic and atherothrombotic events have also been identified. Although benefits of the secondary prevention of atherosclerosis have been demonstrated in some antibiotic intervention studies, a number of negative studies have also emerged. The results of the ongoing large prospective human antibiotic intervention trials may help to finally establish if there is a causal link between C. pneumoniae infection and atherosclerosis.

Plasmodium falciparum: in vitro interactions of artemisinin with amodiaquine, pyronaridine, and chloroquine

In the scenario of drug-resistant Plasmodium falciparum malaria combination therapy represents an effective approach. Artemisinin and its derivatives are of special interest because they represent the most effective group of compounds against multidrug-resistant malaria with a rapid onset of action and a short half-life. Interactions of artemisinin with amodiaquine, pyronaridine, and chloroquine were therefore investigated against three strains of P. falciparum using a 48-h in vitro culture assay. Two of the strains were chloroquine sensitive and one was partially chloroquine resistant. Observed effective concentrations (O) of the combined compounds at different concentration ratios were calculated for different degrees of inhibition (EC50, EC90, EC99) and compared to expected calculated effective concentrations (E) using a probit method. Synergism with mean O/E EC90 values of 0.25 and 0.8 were found with the combination of artemisinin and the two Mannich bases, amodiaquine and pyronaridine, respectively, whereas chloroquine showed addition with a mean value of 1.2. Although both amodiaquine and chloroquine are 4-aminoquinolines, their interaction with artemisinin appears to be different. The combination of artemisinin with amodiaquine represents an important option for the treatment of falciparum malaria.

A novel scoring system for evaluation of results of autologous transplantation methods in vitiligo

Autologous transplantation of melanocyte/melanocytes bearing epidermis for vitiligo can be done by mini-punch grafting (MPG), suction blister epidermal grafting (SBEG), thin split -thickness skin grafting (TSTG), transplantation of basal cell layer enriched suspension and cultured epithelial/melanocyte transplantation. To date no comparative study of these transplantation procedures has been published. Comparison of different studies carried out at different centers may be difficult in the absence of uniform evaluation criteria. In most of the published studies, the results were evaluated in terms of extent of pigmentation. Complictions and color match were evaluated separately. This approach, however, may not give a fair idea about the results. We have developed a scoring system with holistic approach considering the extent of pigmentation, color match and the complications of both the donor and the recipient areas, all taken together. In the scoring system, the score for individual criteria was multiplied with a factor, the value of which was decided on the basis of relative importance of each criteria. The use of this scoring system is exemplified in twelve patients who underwent TSTG, SBEG and MPG. In the scoring system the results were judged as excellent and fair in 3 patients each, as good in 4 patients and as poor in 2 patients.

A fatal case of systemic brucellosis

A 65 years man presented with fever, drenching sweats, progressive dyspnoea, backache and weight loss. On examination, he had wide pulse pressure, clubbing, retinal hemorrhages, aortic and mitral regurgitation, hepatosplenomegaly, lower spinal tenderness and bilateral basal crepitations. Transthoracic 2D-echocardiography showed a large vegetation on the aortic valve. Antibody titers for brucella were positive. X-ray spine was suggestive of brucella spondylitis. Early surgical intervention was planned and the patient was given combination antibiotic therapy. The course was complicated by renal failure and the patient succumbed while being taken up for surgery.