Reciprocal skin grafts in a pair of twins showing blood chimaerism

Renal transplant surgery – Then and now

This year, Singapore General Hospital celebrates 50 years of renal transplantation. As we commemorate this historic milestone, we look back at the surgical journey and remember the pioneers, local as well as international, who have overcome myriad hurdles in performing kidney transplantations. These visionary surgeons have worked hand in hand with our nephrologists to establish renal transplantation as the renal replacement therapy of choice and our hospital as the oldest transplant program in Singapore.

Immunological tolerance during fetal development: from mouse to man

The development of the adaptive immune system has been studied in the mouse primarily because it is easier to access fetal tissues and because there exists a rich array of probes for analysis of various components of the immune system. While much has been learned from this exercise, it is also clear that different species show substantial temporal variation in the development of the immune system during early life. In mice, for instance, mature α/β T cells first appear in the periphery during the final stages of fetal gestation and only increase in number after birth (Friedberg and Weissman, 1974); in humans, on the other hand, the first mature α/β T cells are seen in peripheral tissues at 10-12 gestational weeks (g.w.) and are circulating in significant numbers by the end of the second trimester (Ceppellini et al., 1971; Haynes et al., 1988; Hayward and Ezer, 1974; Kay et al., 1970). Although the functional implications of these differences remain unclear, it is likely that there are significant biological consequences associated with the relatively early development of the peripheral adaptive immune system in humans, for example, with respect to the development of peripheral tolerance as well as to the response to antigens that might cross the placenta from the mother (e.g., cells bearing noninherited maternal alloantigens, infectious agents, food antigens, and the like). Here, we will review studies of immune system ontogeny in the mouse and in humans, and then focus on the possible functional roles of fetal T cell populations during development and later in life in humans.

Skin tolerance: in search of the Holy Grail

In 1943, Gibson and Medawar opened the modern era of transplantation research with a paper on the problem of skin allograft rejection. Ten years later Billingham, Brent and Medawar demonstrated that it was possible to induce selective immune acceptance of skin grafts in mice, a state of tolerance. After over six decades, however, the precise mechanism of skin allograft rejection remains still ill-defined. Furthermore, it has not been possible to achieve reliably clinical tolerance allowing the widespread application of skin allotransplantation techniques. The first successful applications of skin allotransplantation have included the hand and face. However, complications from the chronic immunosuppression regimens limit the application of these techniques. Induction of tolerance to skin (and the other tissues in the allograft) would be the most effective way to overcome all these difficulties, but this is yet to be achieved reliably, stimulating some to look for other ways to surmount the current limitations. This paper summarizes alternatives to enlarge the scope of skin allotransplantation techniques, current understanding of mechanisms of skin rejection, and the utility and limitations of animal models used to study skin rejection and tolerance induction. Finally, manipulation strategies to achieve skin tolerance are outlined.

Injection of allogeneic bone marrow cells into the portal vein of swine in utero

The ability to safely manipulate the immune system of the developing fetus carries the hope of effective treatment strategies for certain congenital disorders that can be diagnosed during gestation. One possible intervention is the induction of specific transplantation tolerance to an adult donor who could provide tissue after birth without the need for immunosuppression. Although the introduction of allogeneic stem cells to a developing immune system has been shown to result in hematopoietic chimerism, donor-specific transplantation tolerance has not been demonstrated in a large animal model. In previous reports of in utero stem-cell transplantation, the cells were injected into the fetus by an intraperitoneal route. We sought to improve upon this technique of cell transplantation by developing a method for the safe delivery of allogeneic stem cells directly into the hepatic circulation of fetal swine. In the second phase of our study, we determined if adult allogeneic bone marrow cells delivered to the fetus by this intravascular route could result in result in hematopoietic chimerism and donor-specific transplantation tolerance. A method of successful intravascular injection was designed in which a laparotomy was performed on a sow at midgestation (50-55 days) to administer 1 cc of inoculum into the portal vein of each fetus using transuterine ultrasound guidance and a 25-gauge spinal needle. In one sow, 10 piglets were injected with saline to test safety, and 8 piglets were born. For transplantation of stem cells to the fetuses, donor bone marrow was harvested from a genetically defined miniature swine. In one sow the marrow was injected without T-cell depletion resulting in abortion. In the third sow, the marrow was depleted of T-cells to less than 0.01% using magnetic beads conjugated to anti-CD3 monoclonal antibodies. No chimerism was detected in these offspring. Only in the fourth sow where the T-cell depletion was reduced to about 1% of the cells in the inoculum did one animal demonstrate chimerism. This piglet showed reproducible blood chimerism (0.95% donor cells) detected by flow cytometry measurement of monoclonal antibodies to the donor MHC. In addition, this animal demonstrated hyporesponsiveness to donor lymphocytes in an MLR assay while reacting strongly to third-party stimulator cells. A split-thickness skin graft from the donor was accepted, and a third-party graft was rapidly rejected.

Blood group chimeras. A review

More than 70 spontaneous chimeric propositi in man are known. This review attempts to summarize the information given by 32 twin chimeras, 32 dispermic chimeras and 11 chimeras of unestablished type.

Mixed lymphocyte reactions and tissue transplantation tolerance

The induction of tolerance of Lewis histocompatibility antigens in BN rats inoculated at birth with BNI Lewis F(1) hybrid bone marrow cells, as revealed by the prolonged survival of Lewis skin grafts, is accompanied by markedly decreased reactivity in the mixed lymphocyte interaction. Blood lymphocytes from animals inoculated with lymph node cell suspensions also display diminished proliferative reactivity to hybrid BN/Lewis cells in the interaction. However, these recipients are not tolerant of Lewis skin grafts. Blood lymphocytes from BN rats inoculated neonatally with Lewis thymocytes fail to display any level of unresponsiveness in vitro, and such animals are not tolerant of Lewis skin grafts. The results suggest that in rats skin and marrow cells have histocompatibility antigens that are absent or poorly expressed on lymph node cells and thymocytes.

THE CONTRIBUTION OF THE "CLINICAL TWIN METHOD" TO THE STUDY OF SEX ANOMALIES IN CHILDHOOD

First of all the Authors stress the importance of twin studies as a method of analysis of the pathological phenomena from a hereditary standpoint: to this aim, the Interzygotic Twin Method may be used in statistical studies, and the Clinical Twin Method in clinical ones. On this basis, the Authors report their observations, on a remarkable number of male twin pairs, affected by anomalies or syndromes including one or more genital dysfunctions, either in infancy or adolescence. Numerous cases of phimosis are thus presented, where the higher concordance in pairs of MZ twins stands for a hereditary conditioning; cases of hypospadias, showing a perfect symmetry of the malformation in the cotwins; cryptorchism, with various possibilities of presentation of the anomaly in the intrageminal comparison. The Authors also describe in detail, making an analytical intra-pair comparison of the symptoms and laboratory data, some cases of complex adiposogenital dystrophy, as well as one case of Laurence-Moon-Bardet-Biedl syndrome with different clinical manifestation in a DZ pair. The longitudinal study carried out over many years on some of the pairs affected by the above mentioned clinical pictures, and the clinico-statistical analysis of the cases under consideration allow the Authors to draw a number of positive conclusions concerning the variable, genotypic conditioning of the sex anomalies considered: in this field, as well as in many others of nosography, the Clinical Twin Method appears to be highly useful in practice, and unique by reason of its peculiarity.