Relations of HL-A and Rh Systems to Immune Reactivity

[Cellular mechanisms implicated in anti-erythrocyte alloimmunization]

In many clinical situations patients are dependent on blood transfusions. Occurrence of alloimmunization to blood group antigens (BGA) complicates the transfusion strategy and may be involved in clinical transfusion stalemate situations. B cell differentiation into antibody-secreting plasma cells is triggered by antigen and requires helper T cells which produce cytokines. Although antibodies implicated in BGA alloimmunization have been studied for many years, little is known about helper T cell responses that drive their production. Few studies on BGA specific T cell responses have been published today. This review summarizes the new developments in the field of cellular mechanisms implicated into antibody production. The definition of immunodominant peptides derived from RhD and Jk(a) BGAs, the cytokine patterns induced and the HLA class II molecules implicated in their presentation are analyzed. A tolerogenic route for RhD immunodominant peptides is experimented. Identification of such immunodominant peptides, the cytokine patterns induced and the HLA class II molecules implicated in their presentation, would facilitate the design of new therapeutic strategies including the specific control of alloimmunization with peptide antigen tolerogens or the ex-vivo induction of regulatory T cells.

Monoclonal anti-D development programme

Administration of anti-D immunoglobulin to D- women after delivery of a D+ infant has dramatically reduced the number of immunised women and cases of haemolytic disease of the fetus and newborn. The use of monoclonal anti-D might alleviate some of the pressures on maintaining adequate supplies of plasma sourced anti-D. Two human monoclonal antibodies, BRAD-3 (IgG1) and BRAD-5 (IgG3), with proven activity in in vitro functional (immunological) assays with cells bearing IgG Fc receptors (Fc gammaR) were selected for clinical studies. They were prepared by purification of IgG secreted by culture of the Epstein-Barr virus-transformed B cell lines in hollow fibre bioreactors. The mean half-lives of BRAD-3 and BRAD-5 in D- subjects were 10.2 and 22.2 days, respectively. The clearance of D+ red cells injected into D- subjects was accelerated by prior injection of the monoclonal antibodies, both individually and blended (3:1, BRAD-5/BRAD-3). The clearance rate was related to the amount of anti-D on the red cells. Clearance of the D+ red cells coated with BRAD-3 was more rapid in subjects homozygous for Fc gammaRIIIa-F/F158 than in those expressing the Fc gammaRIIIa-V158 allele. The subjects were protected from Rh D immunisation. A large multi-centre study evaluated the BRAD-3/5 blend for its ability to prevent Rh D immunisation in 95 D- subjects given 400 microg i.m. 24 h after injection of 5 ml D+ red cells. Challenge injections of D+ red cells alone were given 24 and 36 weeks later, and blood samples were taken every 4 weeks from the subjects throughout the study for detection of anti-D responses. There was one definite and one possible failure of protection; in one subject the plasma anti-D level rose from week 12 onwards, and in another individual rapid seroconversion was observed at week 28. Considering the relatively large dose of red cells and the number of subjects studied, it was concluded that the failure rate was much lower than in routine Rh D prophylaxis. The responder rate was 13% by week 36 and 24% by week 48. There was no relationship between HLA haplotype and Rh D immunisation. The low percentage of responders and the modest levels of endogenous anti-D produced suggested that administration of monoclonal anti-D had induced long-term specific suppression of anti-D responses in these subjects. The most likely mechanism of action was considered to be inhibition of B cells resulting from co-cross-linking antigen receptors with inhibitory Fc gammaR when the B cells contacted red cells that had bound passive anti-D.

Role of HLA antigens in Rh (D) alloimmunized pregnant women from Mumbai, Maharashtra, India

Immunogenetic studies in various diseases provide potential genetic markers. We have studied the incidence of HLA A, B, C, DR and DQ loci antigen in Rh (D) antigen isoimmunized mothers compared to those nonimmunized isoimmunized Rh negative mothers. Seventy six mothers who were immunized to Rh (D) antigen due to pregnancy (responders) and fifty four mothers who did not develop Rh (D) isoimmunization despite positive pregnancies (nonresponders) were selected for the study. Standard methods of serological HLA typing, ABO and Rh (D) groups, and screening for Rh D antibodies were used. 392 unrelated individuals from the population were compared as controls. In addition 45 unrelated individuals from the same population were typed for HLA DRB and DQB gene using PCR-SSP kits. The genotype frequencies of HLA A2, A3, A28, B13, B17, B35, B52, B60, Cw2, Cw6, DR4, and DQ3 were significantly increased, while the frequencies of the HLA A11, A29, A31, B7, B37, B51, Cw1 and DR9 were decreased in the responder women when compared to the non-responder women. HLA A30 (19) split antigen was not identified in immunized women while HLA A23 (9) split antigen was not identified in non immunized women. HLA A3, B17, Cw2 and DR4 showed a significant relative risk among the immunized responder women. When compared with Rh immunized women (responders) reported from USA, England and Hungary the phenotype frequencies of HLA A11, A24, A28, B5, B17, B40, DR2 and DR5 were increased while HLA A23, B8, B18, and DR6 were decreased in the Indian Rh immunized women. Two locus haplotype frequency analysis observed among the responders women revealed that among the significant haplotypes expressed A2-B5, B7-Cw1, DR2-DQ1 were highly significant haplotypes in positive linkage, while A1-B5, and A1-B7 were in significant negative linkage disequilibrium. The haplotype frequencies were <or= one when these common hapoltypes were compared with control population. Thus in the present study it is evident that the inheritance of HLA A3, B17, Cw2 and DR4 increases the relative risk factor by 2.6 times among Indian Rh isoimmunized women. Further, it is evident that there are significant differences in the observed HLA antigen frequencies and two locus haplotypes in Rh isoimmunized women when compared to women from USA, UK and Hungary due to extreme HLA polymorphism in different populations of the world.

Biology of natural killer cells

Studies of cytotoxicity by human lymphocytes revealed not only that both allogeneic and syngeneic tumor cells were lysed in a non-MHC-restricted fashion, but also that lymphocytes from normal donors were often cytotoxic. Lymphocytes from any healthy donor, as well as peripheral blood and spleen lymphocytes from several experimental animals, in the absence of known or deliberate sensitization, were found to be spontaneously cytotoxic in vitro for some normal fresh cells, most cultured cell lines, immature hematopoietic cells, and tumor cells. This type of nonadaptive, non-MHC-restricted cellmediated cytotoxicity was defined as “natural” cytotoxicity, and the effector cells mediating natural cytotoxicity were functionally defined as natural killer (NK) cells. The existence of NK cells has prompted a reinterpretation of both the studies of specific cytotoxicity against spontaneous human tumors and the theory of immune surveillance, at least in its most restrictive interpretation. Unlike cytotoxic T cells, NK cells cannot be demonstrated to have clonally distributed specificity, restriction for MHC products at the target cell surface, or immunological memory. NK cells cannot yet be formally assigned to a single lineage based on the definitive identification of a stem cell, a distinct anatomical location of maturation, or unique genotypic rearrangements.

Some methodological problems in the assessment of complementary therapy

The increased interest of the public and the medical profession in complementary forms of therapy introduces an urgent need for proper assessment of efficacy. This growth in popularity suggests that complementary therapies are effective in some circumstances, but without objective assessment neither the public nor the medical profession can be sure. Rigorous scientific assessment is required, but the nature of complementary therapy is such that double-blind randomized controlled trials, as usually conducted, are rarely applicable, and alternative approaches are needed. At its best, complementary therapy is designed individually for each patient, and few treatments can readily be applied 'blind'. These are the main problems in trial design but complementary therapists are also aware of the importance of body-mind interactions: they see the 'placebo effect' as an integral part of treatment which needs investigation, and they question the validity of clinical trials in which the patient's will is not fully engaged through lack of information, and of those not asking the patients if they feel better. The problems are examined and alternative approaches suggested. The paper raises the question of whether they are only problems for complementary medicine.

HLA-B35 is associated with red cell alloimmunization in sickle cell disease

HLA-A, -B, -C, and DR antigens were determined in 33 patients with sickle cell disease (SCD), who had received red blood cell (RBC) transfusions. Twenty-one patients formed red cell alloantibodies after transfusions (responders) while 12 multitransfused SCD patients did not form any RBC antibodies (non-responders). We found that 67% of the SCD responder participants had HLA-B35 versus 25% of the non-responders (chi 2 = 5.3079, P = 0.0212). The frequency of B35 in non-responder SCD patients was similar to that of a normal healthy Black population consisting of 139 individuals. Calculation of the relative risk showed that sickle cell patients with B35 are six times more likely to form RBC alloantibodies after transfusion than those lacking that HLA antigen. We found no significant increase or association between any HLA-DR antigens and sickle cell disease.

Natural killer funciton in systemic lupus erythematosus

Peripheral blood lymphocytes from patients with systemic lupus erythematosus (SLE) demonstrated significantly less cytotoxicity against two different lymphoblastoid cell lines and one myeloid cell line than peripheral blood lymphocytes from normal individuals. Short-term culture and other attempts to remove interfering immune complexes failed to restore low natural killer (NK) function. Six day culture in fetal calf serum resulted in increased cytotoxicity by mononuclear cells from normal individuals and some SLE patients, but this effect was shown to be dependent on Fc-, not Fc+, effector cells. Suppressor cells were not demostrable as a cause for decreased NK activity.

The HLA system and leprosy in Thailand

To investigate immunogenetics of leprosy, 205 leprosy patients (26 with tuberculoid, 57 with borderline-tuberculoid, 21 with borderline, 31 with borderline-lepromatous, and 70 with lepromatous leprosy) have been typed for HLA antigens, and compared with 183 healthy controls from the same region (Northern Thailand). There was no significant difference between the overall group of leprosy patients or the three borderline classes and the controls. The two polar forms, tuberculoid and lepromatous leprosy, however, showed significant associations: HLA-A2 is decreased and HLA-Bw17 is increased in tuberculoid leprosy; HLA-B7 is increased in lepromatous leprosy. When both polar forms are compared with each other, HLA-A2 is significantly higher, HLA-Bw40 lower in patients with lepromatous than in those with tuberculoid leprosy. The results are discussed with respect to the different immune responsiveness in the two polar forms of leprosy.

Human natural cytotoxicity in the blood and lymphoid organs of healthy donors and patients with malignant disease

Natural cytotoxicity against CLA-4 and D6 target cells was determined in the peripheral blood of healthy donors and women with mammary carcinoma (localized to the breast and axilla), and in human normal and regional tumour lymph nodes. The NK cell activity in the blood of women with clinically localized mammary carcinoma showed a wide range of reactivities but was similar to the pattern detected in healthy controls. The NK cell activity in human normal lymph nodes also showed a wide range and was the same irrespective of the anatomical site of origin of the lymph node. Lymph nodes draining a variety of solid tumours had a similar spectrum of NK cell activity, there being no obvious correlation between the level of NK cell activity and such parameters as size and histological type of tumour, hyperplasia or metastatic spread in the regional node. Trypsin treatment of lymphocyte suspensions from the various lymphoid compartments suggested that the cell responsible for natural cytotoxicity in blood was probably different from the NK cell in tonsil and lymph nodes.

Gross-virus-induced lymphoma in the rat. V. Natural cytotoxic cells are non-T cells

The cytotoxic cells from the spleens of normal rats, which lyse Gross-virus-induced lymphoma target cells in a short-term 51Cr release test, are predominantly small to medium-sized cells sedimenting at 4-5 mm/h as shown by velocity sedimentation analysis. Their cytotoxic activity is relatively resistant to gamma-radiation, 50% surviving 1,000 rads and 30% remaining after 5,000 rads, and to heat, since 20 min incubation at 48-51 degrees C is required for its abolition. In these properties the natural killer (NK) cells are very similar to the cytotoxic T cells from tumour-immune rats, and they share in addition a requirement for Ca++ ions for cytolysis. They differ in that they are non-T cells as defined by their resistance to anti-T-cell antiserum and complement, and by their presence in T-cell-deprived rats. They lack detectable surface Ig, Fc receptors and phagocytic or adherence properties and belong therefore to that small proportion of lymphoid cells lacking the surface markers of T or B lymphocytes, as do the comparable NK cells of mice. Cytotoxicity appears to involve an autonomous, papain-sensitive recognition structure on the surface of NK cells, rather than acquired cytophilic antibody operating through an antibody-dependent mechanism.

Spontaneous human lymphocyte-mediated cytotoxicity againts tumour target cells. I. The effect of malignant disease

Spontaneous human lymphocyte-mediated cytotoxicity (SLMC) against tumour-cell targets was examined in a series of patients with localized or malignant disease, both treated and untreated, and patients with untreated chronic lymphocytic leukemia (CLL). The level of SLMC was assessed by means of two previously established assay systems; the xenogeneic assay involving the mouse mastocytoma line P815, and the allogeneic assay in which the human chronic myelogenous leukemia-derived line, K562, was used. The assay systems involve the use of Ficoll-Isopaque-separated, iron-plus-magnetism-purified lymphocytes in an overnight 51chromium release assay, and reflect the cytotoxic ability of human non-T, complement receptor-, Fc receptor-positive lymphocytes. In the present paper, lymphocytes from all normal donors tested showed significant activity in the SLMC assay, with some variation from day to day. This variation was markedly reduced when different normal donors were tested on the same day and under identical experimental conditions. In contrast, lymphocytes from many patients with malignant disease had decreased SLM activity, and this decrease was highly significant in patients with treated or untreated metastatic disease, or untreated CLL. This was also the case when the data were expressed relative to the number of cytotoxic cells in the normal control population, or in comparison to the relative SLMC activity of lymphocytes from patients with other conditions. Markedly decreased SLMC was observed in some patients in spite of normal T and B lymphocyte proportions, or the presence of the ability to mount a vigorous delayed hypersensitivity reaction to PPD. A comparison of the xenogeneic and allogeneic assays showed that the same information with respect to whether SLMC was normal or abnormal was obtained with both assays in the majority of cases. The significance of the data is discussed with respect to the possible role of SLMC in vivo and the relevance of SLMC to the assessment of specific cell-mediated cytotoxicity in malignant disease.