Leucocyte migration inhibitory activity of concanavalin-A-stimulated human lymphocytes. Modification by dipyridamole, lysine-acetylsalicylate and heparin

The in vitro effects of heparin, dipyridamole (DIPY) and lysine-acetylsalicylate (LASA) on human peripheral blood leucocyte migration and upon production/release and effect of leucocyte migration inhibitory activity (LMIA) from lymphocytes stimulated with concanavalin-A (con-A) have been studied. The final concentration of each drug was of the same order of magnitude as during clinical treatment. The leucocyte migration under agarose was significantly increased by DIPY at a concentration of 100 mug/ml. The release/production of LMIA was inhibited by DIPY at 1 mug/ml and by LASA at 0.3 mug/ml. Heparin had no influence on LMIA release, even at 10 IU/ml. The LMIA of supernatants from con-A-stimulated lymphocyte cultures was inhibited by DIPY at a concentration of 10 mug/ml, by LASA at 3 mug/ml and by heparin at 10 IU/ml. The findings suggest that DIPY and LASA could have a dual role as modifiers of inflammation: 1) the well known role as antiaggregants tending to limit and impede thrombosis, and 2) as antagonists to the lymphocyte-mediated (type IV) immune reaction through a depressive action on lymphokine production/release and activity.

Efficacy of methylprednisolone pulse therapy in steroid-resistant nephrotic syndrome

Steroid-resistant nephrotic syndrome (SRNS) in children is intractable, and the optimal treatment regimen is not known. We investigated the efficacy of methylprednisolone pulse therapy (MPT) in SRNS patients. Using only MPT plus heparin, we have treated ten pediatric SRNS patients that were resistant to cyclophosphamide (CPM) or cyclosporin A (CsA) and predicted to have a very poor prognosis. Administration of 30 mg/kg per day methylprednisolone with heparin for 3 days was taken as one course, and this was given 14 times over 2 years. One patient discontinued MPT because of peritonitis. Of the remaining nine patients, complete remission was achieved by four patients, persistent mild proteinuria remained in three patients, and no effect was observed in two patients. All patients that had been diagnosed with minimal change (MC) pathology ( n=3) at the initial renal biopsy achieved complete remission. Observed adverse events were peritonitis in one patient and a transient decrease in pulse rate only during MPT in one patient. These results demonstrate that MPT with heparin can induce remission in children with SRNS, even when the patient is resistant to CPM and CsA.

Amelioration by beraprost sodium, a prostacyclin analogue, of established renal dysfunction in rat glomerulonephritis model

Effects of beraprost sodium, a chemically stable prostacyclin analogue, on renal dysfunction in an experimental rat model of glomerulonephritis were investigated. Beraprost sodium (30, 100 and 300 microg/kg) was orally given twice daily from the late stage of nephritis in which renal dysfunction was already developed. Beraprost sodium treatment inhibited the increase in urinary protein, serum creatinine and blood urea nitrogen, and the decrease in creatinine clearance. The elevation of serum creatinine was also inhibited by predonisolone (1 mg/kg). However, captopril (25, 50 and 100 mg/kg) and dipyridamole (20 and 60 mg/kg) failed to inhibit the elevation of serum creatinine. In the beraprost sodium-treated nephritic rats, the increase in mRNA levels for monocyte chemoattractant protein-1 (MCP-1) and collagen in the kidney was inhibited. These results suggest that beraprost sodium ameliorates developed renal dysfunction and is possibly an effective agent for the treatment of human glomerulonephritis.

Inhibition of active oxygen generation by dipyridamole in human polymorphonuclear leukocytes

The effect of dipyridamole on active oxygen generation by human polymorphonuclear leukocytes (PMN) was investigated. Dipyridamole inhibited the production of oxidative metabolites from human PMN stimulated by opsonized zymosan and formyl-methionyl-leucyl-phenylalanine dose and time dependently. To determine whether dipyridamole directly inhibits the production of oxygen metabolites by human PMN, human PMN were preincubated with dipyridamole washed prior to stimulation. Dipyridamole was found to directly inhibit human PMN from generated active oxygen metabolites at therapeutic concentrations. Dipyridamole may possibly be a potential scavenger of active oxygen metabolites since it inhibited active oxygen metabolite production from human PMN very rapidly. Dipyridamole was also found to directly affect the scavenging of active oxygen metabolites generated by opsonized zymosan-stimulated human PMN at therapeutic concentrations. This action of dipyridamole was also noted to be exerted against hydroxyl radicals and superoxide anions produced biochemically by an electron spin resonance spectrometer. It thus follows that dipyridamole may inhibit human PMN active oxygen metabolite generation and affect directly the scavenging of active oxygen metabolites at therapeutic concentrations.

Inhibitory effect of a novel antianginal agent, E4080, on ST segment elevation induced by vasopressin in anesthetized guinea pigs

We compared the antianginal effect of E4080, a novel bradycardiac agent with coronary vasodilating properties, with those of a bradycardiac agent and some coronary vasodilators in vasopressin-induced anginal model of guinea pigs. An i.v.-administration of vasopressin (0.2 IU/kg) produced an ST segment elevation on electrocardiograms (ECG) of 0.30 +/- 0.05 mV from the baseline within 30 sec in anesthetized guinea pigs. The ST segment elevation on ECG was used as an index of myocardial ischemia. E4080 and other drugs were injected i.v. 5 min before the administration of vasopressin. E4080 at 5 mg/kg depressed the ST segment elevation induced by vasopressin to 0.06 +/- 0.01 mV (20% of control, n = 6, P < 0.001). However, alinidine (5 mg/kg), which produced the same bradycardic action (reduction of heart rate by 50%) as that of E4080, tended to inhibit the ST segment elevation, but this was not statistically significant. On the other hand, other vasodilators such as isosorbide dinitrate (0.3 mg/kg), nifedipine (0.1 mg/kg) and lemakalim (1 mg/kg) also significantly reduced the ST segment elevation to 0.16 +/- 0.03, 0.08 +/- 0.04 and 0.09 +/- 0.03 mV, respectively. These results suggest that the inhibitory effect of E4080 on the ST segment elevation induced by vasopressin is due to the coronary vasodilating effect rather than the bradycardiac effect, and that E4080 would be useful as an antianginal agent.

Transplantation in Australia--50 years of progress

OBJECTIVE

To review the history of clinical transplantation practice in Australia.

DATA SOURCES AND STUDY SELECTION

The first major source was published reports, chiefly in The Medical Journal of Australia (129 articles). The second source was personal communication with those involved in early and current transplantation programs.

DATA EXTRACTION AND SYNTHESIS

The first known transplant of each organ in Australia and the results of current programs have been documented.

CONCLUSIONS

Transplantation of the kidney, liver, heart, lung, pancreas, cornea, or bone marrow are available and accepted therapies for an increasing number of suitable patients, limited mainly by the number of donors.

Polyarteritis nodosa: chronic renal failure with spontaneous recovery

A 57-year-old male developed acute oliguric renal failure due to polyarteritis nodosa (PAN). He went on rapidly to chronic renal failure. After nine months of home hemodialysis, he recovered renal function with creatinine clearance of 30 ml/min. This patient was not treated with drugs of any type for his illness. He represents a spontaneous remission from severe renal PAN and underscores the need for further evaluation of the current recommended drug therapy for this disease.

Reversal of end-stage kidney failure in two scleroderma patients treated with anticoagulation

Two patients with progressive systemic sclerosis (scleroderma) developed renal failure which required thrice weekly hemodialysis. While receiving hemodialysis treatments and warfarin, their renal function improved and it was possible to discontinue hemodialysis after 9 mo in Case 1 and after 3 mo in Case 2. The recovery of renal function in these patients suggests therapy with warfarin may play a role in the treatment of scleroderma renal failure.

Hypercoagulation in glomerulonephritis

The clotting values of 50 patients with glomerulonephritis were examined. Three different coagulation groups were recognised: those with normal clotting values (group 1); those with high concentrations of factor VIII but otherwise normal clotting results (group 2); and patients who showed the presence of an activator of the intrinsic coagulation pathway, indicated by the presence of a short activated partial thromboplastin time or the ability of patients' plasma to shorten control clotting time in mixing studies (group 3). Patients in group 2 either had a uniform rise in all three components of the factor VIII molecule or a disproportionately higher concentration of factor-VIII-related antigen. In contrast, the level of VIII clotting activity in patients in group 3 was always higher than concentrations of either VIIIAg or VIIIWF. A significantly high incidence of thrombotic complications was observed in patients with group 3 but in none of the patients in either group 1 or group 2. Impaired renal function was more common in patients in groups 2 and 3, with higher mean serum creatinine concentrations in those with group 3. Patients with glomerulonephritis who have a short partial thromboplastin time with kaolin or who shorten control clotting time form a subgroup in whom hypercoagulation could adversely affect the course of their disease. The value of antiplatelet or anticoagulant treatment in these patients needs to be explored.

The treatment of the hemolytic-uremic syndrome with inhibitors of platelet function

In four patients with clinical and laboratory manifestations of the hemolytic-uremic syndrome, the administration of aspirin and dipyridamole was associated with a dramatic and rapid increase in the platelet count. In three of the four patients there was also improvement in neurologic or renal function. No subject experienced bleeding or other untoward effects. We conclude that a trial of aspirin and dipyridamole therapy is warranted early in the course of the hemolytic-uremic syndrome.

The effect of fibrin on cultured vascular endothelial cells

The normal cobblestone monolayer architecture of cultured vascular endothelium becomes rapidly disorganized after contact of the cell layer with a fibrin clot. The cells of a confluent endothelial monolayer separate into individual migratory cells in 4--6 hr after contact with fibrin. The effect is reversible in that removal of the fibrin clot results in resumption of the normal morphology within about 2 hr. No other cell type tested exhibits the same change in organization when exposed to fibrin. A similar morphological change in endothelium does occur after the cell layer is overlaid with a collagen fibril gel but a gel of methylcellulose has no effect. It is proposed that the change in behavior of endothelial cells in response to contact with fibrin may represent a cellular component of fibrinolysis. The implications of this finding for the pathophysiology of disease states involving intravascular fibrin deposition are discussed.

Participation of kallikrein, coagulation/fibrinolysis parameters in the development of glomerulonephritis

Masugi nephritis was induced in dogs in which platelet count, fibrinogen, antithrombin activity, plasma prekallikrein and immediate plasmin inhibitors were coincidentally decreased immediately after the injection of nephrotoxin serum. It was found that the grade of decrease of urinary kallikrein excretion following these immediate reactions were parallel with the grade of renal damages. By the pretreatment with heparin or the defibrination with snake venom, however, the histological findings of Masugi nephritis showed rather severe damage. Based on the consumption of coagulation factors, kallikrein, kinin and their inhibitors in the development of this nephritis, it was postulated that inauguration of coagulation and activation of kallikrein contributed to the development of glomerulonephritis. The treatment or prevention of this coagulation process with heparin or snake venom, however, gave untoward effects on the pathological process in this experiment.

Delayed hypersensitivity in man: effects of systemic anticoagulation

Skin test reactivity, lymphocyte transformation, and mononuclear cell tissue factor generation were evaluated both before and during systemic anticoagulation in 24 volunteers. Anticoagulation with warfarin decreased skin test induration and tissue factor generation, but lymphocyte trnasformation remained unchanged. An intact coagulation mechanism, including tissue factor generation, appears to be important for the development of skin test induration in humans.

Severe glomerulonephritis complicated by coagulopathy: treatment with anticoaguland and immunosuppresive drugs

Serial determinations, using plasma fibrinogen gel chromatography as well as standard methodology, demonstrated that six children with severe glomerulonephritis, characterized on renal biopsy by glomerular necrosis and crescent formation, had persistent evidence of intravascular coagulation. Based on these observations, therapy with anticoagulants and azathicoagulants and azathioprine was instituted for one year; treatment with anticoagulants was continued for a second year. Anticoagulant therapy was initiated with heparin, followed by oral anticoagulation with phenindione and dipyridamole. In contrast to our earlier experience with similar patients, each of the present patients improved. Urinalyses returned to normal and glomerular filtration rates to near normal values in all patients at the end of the treatment period and have remained so for up to 3.9 years since treatment has been completed. Post-treatment biopsies showed remarkable improvement, with virtually no glomerulosclerosis even in patients who had had a high incidence of glomerular crescents before treatment. It is suggested that the therapeutic regimen favorably influenced the natural history of disease and that plasma fibrinogen chromatographic findings may be helpful in selecting patients likely to benefit from the use of anticoagulant therapy.

Renal and cardiac complications of drug abuse

The case is presented of a young man who, after prolonged intravenous narcotic administration, developed subacute bacterial endocarditis involving the aortic valve, and rapidly progressive glomerulonephritis. After treatment of and recovery from renal failure, persistent proteinuria was shown to be caused by focal glomerulosclerosis. The association of these lesions with "mainlining" is reviewed.

[Experiments on the medicamental treatment of the noise-induced cochlear damage. Part I. The effect of dipyridamol and allopurinol on the RMP of the cochlea (guinea pig) after noise (author's transl)]

Dipyridamol has in addition to a coronardilatating effect an ati-thrombotic one too. Moreover it facilitates the release of O2 from haemoglobin by increase of the concentration of 2,3-diphosphoglycerate in the erythrocytes. Allopurinol causes a potential resynthesis of ATP in the cells by inhibition of the metabolism of uric acid. Both substances therefore seemed to be suitable for a medicamental therapy of the noise-induced cochlear damage. The expected favourable effect of Dipyridamol and Allopurinol on the organ of Corti after sound exposure (RMP-measurement before and after exposure to pure tone 120 dB SPL) however had not been confirmed by experiment on animals (guinea pig).

Circulating immunoglobulin complexes in Wegener's granulomatosis

Two cases of Wegener's granulomatosis are reported in which circulating immunoglobulin complexes detected during the active phase of the disease disappeared during induction of remissions of active pulmonary and renal disease by immunosuppressive agents. Elevated antiglobulin activity, urinary immunoglobulin L-chain concentration and evidence of activated coagulation mechanisms were also present during active disease, and returned toward normal with treatment. Studies showed that the serum complexes did not contain deoxyribonucleic acid (DNA) and demonstrated their immunoglobulin nature. Serum complement concentrations were normal, and no cryoglobulins were present. Immunofluorescent staining and electron microscopy of the kidney biopsy specimen of one patient showed marked fibrin deposition but no immunoglobulin or antigen-antibody deposits. Although the role of circulating immunoglobulin complexes in the pathogenesis of Wegener's granulomatosis remains uncertain, serial changes in the described parameters may provide an objective guide to activity of the disease and its response to treatment.

Heparin therapy in anti-basement membrane nephritis

The effect of heparin on the development and progression of a form of antiglomerular basement membrane nephritis was examined in the rat. Animals which received heparin before and throughout the period of immunological insult developed lesions which were as severe, and perhaps more severe, than rats which did not receive heparin. Inulin clearances were lower in heparin-treated animals than in untreated rats. Animals in both groups exhibited renal fibrin-fibrinogen deposition and had increased rates of urinary fibrin-fibrinogen related antigen excretion. These results indicate that heparin per se has no beneficial effect on the development of this form of glomerulonephritis in this species.

Management of acute renal failure

Acute renal failure has oliguria and uraemia as its cardinal manifestations. The syndrome may be due to acute tubular necrosis, glomerulonephritis, urinary tract obstruction and occlusive vascular disease.

The renal damage due to acute tubular necrosis is of uncertain aetiology. Renal cortical ischaemia and depression of glomerular filtration rate are important in the pathogenesis. Activation of the renin-angiotensin system and glomerular coagulation may prove to be important in these changes.

The differentiation between reversible oliguria and established renal failure is generally accomplished on clinical grounds and the response to a therapeutic trial of mannitol. Measurement of urinary sodium concentration and osmolality are valuable adjuncts.

The keystone of management is the prevention of symptomatic uraemia. Infection and haemorrhage have now replaced pulmonary oedema and hyperkalaemia as the major causes of death. The mortality rate remains high in acute tubular necrosis and a significant mortality occurs in the diuretic phase.

Immunologically reactive equivalents of fibrinogen in sera and urine of children with renal disease

Fibrin degradation products (FDP) were assayed by the tanned red cell haemagglutination inhibition technique in the sera and urine of children with renal disease, and their correlation with other parameters of proteinuria was examined. Urinary FDP were present in greater quantities in subjects with heavy and unselective proteinuria, and were not correlated with serum levels of FDP. FDP may derive from fibrinogen filtered through leaky glomeruli or from intravascular coagulation restricted to the kidney: the data presented are compatible with either hypothesis.