Combined analysis of cytokine genotype polymorphism and the level of expression with allograft function in African-American renal transplant patients

Cytokine gene polymorphism and expression levels were evaluated in a group of African-American patients who had undergone renal transplantation. It was hypothesized that possession of specific cytokine alleles might be influential in predisposing the recipient to allograft rejection. Thus, we sought to establish a relationship between cytokine gene polymorphism, the levels of cytokine expression, and the outcome of allograft function. Cytokine genotypes and mRNA transcript levels of IL-2, TNF-alpha, TGF-beta1, IL-10, IL-6 and IFN-gamma were determined using peripheral blood cells. Genomic DNA samples from 77 transplant recipients and 77 controls were tested by a multiplex PCR with specific primers for the above cytokines. The frequency distributions of cytokines were analyzed in respect to the clinical characterization, including delayed graft function (DGF), rejection episodes (REs) and stable graft function (SGF). The mRNA transcript level was tested both at pre- and early post-transplantation (day 1 and day 4) with primers for coding regions of the above cytokines in a RT-PCR assay. The majority of recipients with successful graft function were matched with their donors for only three out of the six HLA alleles. We have shown that the TGF-beta1 T/C G/G high producer and IFN-gamma T/A intermediate producer genotypes were associated with allograft rejection, whereas low IFN-gamma producer and high IL-10 producer genotypes were significantly protective of the allograft. There was some correlation between the TGF-beta1 high producer genotype and DGF, but it was not statistically significant. Overall, 77% of those who experienced REs carried the TGF-beta1 T/C G/G, high producer genotype as compared with 52% who experienced DGF, 39% with SGF (P<0.01, RR=2.0), and 27.3% of controls (P<0.003, RR=2.6). The IFN-gamma T/A intermediate producer genotype was found in 69.2% of patients with REs as compared with 26.8% of patients with SGF (P<0.008, RR=2.85). The IL-10, ATA/ATA low producer genotype was found in 38.5% of recipients with REs and 14.6% of recipients without REs (P<0.04, RR=0.53). Expression levels of mRNA transcript were correlated with genotype data, except for the TGF-beta1 high producer genotype where there was no significant difference between the level of mRNA transcript at pre- and post-transplantation. Low DRbeta1 and high DPbeta1 expression by recipient peripheral blood mononuclear cells before transplantation was associated with more SGF, whereas high DRbeta1 and low DPbeta1 expression at pretransplantation was associated with more REs (DRbeta1, P<0.001 and DPbeta1, P<0.05, respectively). We concluded that, dual analysis of cytokine genotype and expression levels by peripheral cells may be an important clue to understanding the contribution of the recipient's immune response to an allograft pre- and post-transplantation. Identification of peripheral markers diagnostic of rejection could allow advance anticipation of clinical outcome, and might reduce the need for tissue biopsy.

Effect of poverty and other socioeconomic variables on renal allograft survival

BACKGROUND

Socioeconomic variables including low income and noncompliance impact negatively upon long-term renal allograft survival, especially in African Americans. We sought to determine whether other socioeconomic variables contributed to noncompliance and allograft survival.

METHODS

A detailed history of socioeconomic variables was made at the time of renal transplant evaluation in 450 consecutive candidates, 128 of whom (89 African American, 39 Caucasian) have thus far undergone transplantation. Variables evaluated included household income, zip code income, insurance coverage, years of education, literacy, marital status, pretransplantation compliance, and history of substance abuse as well as the usual pre- and posttransplantation demographics.

RESULTS

Immunologic graft loss occurred primarily in young African Americans with income below the federal poverty level, whereas nonimmunologic graft loss was distributed across racial, income, and other socioeconomic variables. Immunologic graft loss was also associated with a greater number of HLA mismatches, lower levels of education, and noncompliance with transplant medications and follow-up visits. Recipients with gross illiteracy, however, had excellent graft survival. Pretransplantation substance abuse, but not pretransplantation compliance, was predictive of posttransplantation noncompliance. By multivariate analysis, posttransplantation compliance emerged as the single most important factor predictive of graft survival.

CONCLUSIONS

Immunologic graft loss in our population is related to noncompliance with transplant medications, which occurred primarily in recipients with a pretransplantation history of substance abuse and is not related to an inability to pay for medications at the time of graft loss. A change in criteria for acceptance of transplant candidates with a prior history of substance abuse might significantly improve graft survival in this patient population.

Prospective pretransplant ultrasound screening in 206 patients for acquired renal cysts and renal cell carcinoma

BACKGROUND

Numerous studies have reported an increased prevalence of renal cell carcinoma in association with acquired cystic kidney disease (ACKD). In 1995, the clinical practice guidelines of the American Society of Transplant Physicians for evaluation of renal transplant candidates recommend not screening for ACKD and renal cell carcinoma, on the basis of the low frequency of cancer and reported regression of ACKD after transplantation. The objective of this study was to prospectively evaluate the prevalence of ACKD and renal cancer during renal transplant evaluation.

METHODS

A total of 206 consecutive adult patients evaluated for renal transplantation underwent a routine renal ultrasound. Patients with a suspicious ultrasound underwent a contrasted computed tomographic scan of the kidneys followed by excision of kidneys with solid, enhancing (>10 Hounsfield units) lesions.

RESULTS

Sixty-three (30.6%) of 206 patients had ACKD, with a greater proportion being male, African-American, and dialysis-dependent for a longer duration. Eight patients (3.8%) had histologically proven localized cancer (six unilateral, two bilateral), seven in association with ACKD and one in association with autosomal dominant polycystic kidney disease. With a mean follow-up of 14 months (range, 3-33 mo), there has been no recurrence. The positive predictive value of a solid lesion on ultrasound was 100% (8 of 8 patients).

CONCLUSION

With the high prevalence (3.4%) of renal cell carcinoma in association with ACKD and the concern that immunosuppression accelerates the growth of preexisting cancers, we continue to recommend ultrasound screening of the native kidneys before renal transplantation.

Recurrent nocardiosis in a renal transplant recipient

As the case presented here illustrates, nocardiosis, like other infections in which cell-mediated immunity plays a large defensive role, can relapse after apparent cure and occasionally at times remote from the original infection. Although relapse in patients with transplants has been cited as a reason for continued prophylaxis, only a few of these cases are adequately documented. This case supports the advice of those authors who give suppressive antibiotic therapy for the duration of immunosuppression in transplant recipients recovering from infections due to Nocardia sp. Alternatively, many transplant centers are routinely using TMP/SMX chemoprophylaxis in all solid organ transplantations to prevent opportunistic infections with Pneumocystis and Listeria sp. Primary prophylaxis has also been associated with a decreased incidence of nocardial infections.

Fatal disseminated Conidiobolus coronatus infection in a renal transplant patient

A case of fatal disseminated fungal infection due to Conidiobolus coronatus in a patient with a renal transplant is described. This organism, known to cause localized infections in otherwise healthy individuals in the tropics, is now recognized as a cause of fatal infection in immunosuppressed hosts. Histologically, localized infections are characterized by lack of vessel invasion and the presence of an eosinophilic sleeve around fungal elements, called the Splendore-Hoeppli phenomenon. The histologic findings in the present case were more typical of mucormycosis, and the correct diagnosis was established only after the organism was isolated and identified in culture.

Racial differences in the survival of cadaveric renal allografts. Overriding effects of HLA matching and socioeconomic factors

BACKGROUND

The long-term survival of cadaveric renal allografts is lower in black recipients than in white recipients, although the one-year graft survival is similar in these racial groups. We sought to determine what factors account for this disparity.

METHODS

We studied 100 consecutive recipients of primary cadaveric renal allografts (57 were black and 43 white) at least 1 year after transplantation (mean, 40 months); all had received identical immunosuppressive therapy. We evaluated differences in the cause and duration of end-stage renal disease, the number of pretransplantation transfusions, age, matching for HLA-A, B, and DR antigens, race of the donor, insurance coverage, and compliance to assess their effect on graft survival in both groups.

RESULTS

Allograft survival after one year was significantly lower in black than in white patients (P = 0.025). According to univariate analysis, only the recipient's age at transplantation, the number of mismatches for HLA antigens, the type of insurance coverage, the source of referral for transplantation, and the degree of compliance correlated significantly with the rate of graft survival. The frequency of all variables that reduced graft survival was higher among the blacks. According to proportional-hazards analysis, the only factors contributing to a lower rate of graft survival were age of less than 30 years at transplantation (relative risk, 2.3; 95 percent confidence interval, 1.3 to 4.6), mismatches for all six HLA antigens as compared with three or fewer mismatches (relative risk, 5.6; 95 percent confidence interval, 3.3 to 9.6), and coverage by Medicaid or Medicare (relative risk, 2.2; 95 percent confidence interval, 1.5 to 3.2). Race had no additional effect. Noncompliance was more frequent among blacks (16 percent vs. 2 percent) and could substitute for insurance status in the model.

CONCLUSIONS

When immunosuppression is equivalent in black and white transplant recipients, apparently race-related differences in the long-term survival of renal cadaveric allografts appear to be related to other factors that affect graft survival unfavorably, notably poor HLA matching and unfavorable socioeconomic factors.

Retrieval of renal function by revascularization of renovascular disease

Renal dysfunction due to renal artery occlusive disease is potentially reversible and this diagnosis should be considered in all patients with renal failure, especially in patients with other manifestations of occlusive peripheral vascular disease, those with severe hypertension, and those over 45 or under 20 years of age at the onset of hypertension (i.e., older or younger than the usual age for onset of "essential" hypertension). Renovascular disease should also be suspected in hypertensive patients with mild to modest impairment of renal function who demonstrate a sudden worsening of renal function following administration of an angiotensin-converting enzyme inhibitor. Effective and safe techniques for renal revascularization are available in almost all cases to achieve greater longevity and improved quality of life, as well as to reduce the economic impact of chronic renal failure and renovascular hypertension.

Renal transplantation in Mississippi

The present article reviews the results of cadaveric renal transplantation and organ donation in Mississippi during the years 1984-88. Patient and graft survival in cadaveric renal transplantation have continued to improve since the introduction of cyclosporine as an immunosuppressive agent. In the Mississippi Transplant Program recipients of primary cadaveric renal transplants currently demonstrate 93% patient and 82.3% graft survival rates. Despite this improvement in outcome slightly more than 1% of ESRD patients in the state undergo transplantation annually compared to 7.5% nationally.

Captopril-associated acute interstitial nephritis

A 57-year-old male with mild impairment of renal function secondary to diabetic glomerulosclerosis developed acute renal failure (creatinine 32.4 mg/dl) associated with a generalized desquamative skin rash and peripheral eosinophilia shortly after initiation of antihypertensive therapy with captopril. An acute interstitial nephritis was demonstrated on renal biopsy, and improvement was temporally related to initiation of therapy with prednisone. A review of the literature revealed 5 similar cases in whom acute deterioration of renal function occurred following initiation of captopril and in whom there were features of a hypersensitivity reaction, including skin rash, fever, eosinophilia, azotemia, eosinophiluria, and a Coombs-positive hemolytic anemia. Renal biopsy, where available, revealed an acute interstitial nephritis. Observations from these cases suggest that, of the angiotensin-converting enzyme inhibitors, this syndrome appears to be specific for captopril, begins within the 1st month of therapy, is not dose-dependent, and generally resolves on cessation of therapy. Steroids may hasten recovery, but sufficient data are not available to confirm their efficacy.

Plasma kinin levels in acute renovascular hypertension in dogs

The role of kinins in the hypertensive response to acute renal artery constriction (RAC) was examined in the dog. RAC resulted in an increase in systemic arterial pressure (SAP) from 144 +/- 6 to 155 +/- 4 mm HG (p less than 0.05). Simultaneously, arterial plasma bradykinin decreased from 2.3 +/- 0.2 to 1.4 +/- 0.1 ng/ml (p greater than 0.01), while renal venous bradykinin remained unchanged (2.3 +/- 0.2 to 2.0 +/- 0.4 ng/ml, p greater than 0.05). At the same time urinary kallikrein decreased from 55 +/- 6 to 33 +/- 4 milliesterase units (mEU)/min (p less than 0.05), while urinary kinin decreased from 3.2 +/- 0.4 to 1.9 +/- 0.3 ng/min (p less than 0.05). There was a significant correlation between the decrease in arterial bradykinin and the rise in SAP induced by RAC (p less than 0.01). Administration of the dipeptidyl hydrolase inhibitor SQ20881 during RAC reduced angiotensin-converting enzyme levels from 578 +/- 86 to 10 +/- 0.0 mU/ml (p less than 0.005). There was an associated increase in arterial bradykinin (1.4 +/- 0.1 to 5.8 +/- 0.8 ng/ml, p less than 0.001), renal venous bradykinin (2.0 +/- 0.4 to 5.7 +/- 0.5 ng/ml, p less than 0.005), and urinary kinin (1.9 +/- 0.3 to 5.0 +/- 0.7 ng/min, p less than 0.01) in conjunction with return of SAP to control levels. Urinary kallikrein, however, remained depressed following SQ20881 (33 +/- 4 to 30 +/- 5 mEU/min, p greater than 0.05). These results suggest that (1) decreases in circulating BK may potentiate the vasoconstrictor effect of angiotensin II and contribute to the hypertension induced by RAC, and (2) urinary kallikrein is an unreliable marker of changes in plasma bradykinin in this model of hypertension.

Epidemic hemorrhagic fever with renal syndrome. A broadening horizon

A virus identical to or closely related to the viruses of the epidemic hemorrhagic fevers and/or nephropathia epidemica has been demonstrated serologically in rats from geographically separate areas of this country by three groups of investigators. This information suggests a previously unrecognized health threat that should be considered in the differential diagnosis of patients initially seen with febrile illnesses and acute renal failure. The salient features of these viral diseases and the clues that should alert the clinician to seek serologic confirmation of Hantaan or an immunologically related virus are discussed herein.

The role of prostaglandins in gentamicin-induced nephrotoxicity in the dog

The effects of chronic gentamicin administration on renal function was studied in dogs receiving 4 mg/kg i.m. of gentamicin b.i.d. for 28 days. Administration of gentamicin resulted in a bimodal change in renal function. A decrease in urine osmolality was first noted on day 6 and declined progressively throughout the study. This decrease in urinary concentrating ability was preceded by a steady rise in urinary prostaglandin E2 (PGE) excretion and followed by a rise in plasma renin activity (PRA). Prior to an increase in azotemia, urinary PGE decreased precipitously while PRA continued to rise throughout the remainder of the study. The precipitous decrease in GFR was accompanied by a significant increase in FENa to seven times control. These studies suggest a dual effect of chronic gentamicin administration on renal function: (1) an early effect manifested by stimulation of urinary prostaglandin production with a concomitant loss of urinary concentrating ability and mild prerenal azotemia, and (2) a late effect, preceded by a decrease in urinary prostaglandin excretion while PRA continues to increase, and manifested by increase fractional excretion of sodium and progressive azotemia.

Influence of thiopental anesthesia on renal sodium and water excretion in the dog

The influence of thiopental anesthesia on renal tubular sodium reabsorption was investigated in the well-trained dog. After administration of the anesthetic, renal sodium reabsorption was depressed, leading to the enhanced excretion of sodium and water. Associated with this response was a decrease in the plasma levels of epinephrine and norepinephrine. Neither renal hemodynamic functions nor the humoral factors, prostaglandin E, plasma renin activity, or arginine vasopressin appeared to be the major determinants of the natriuresis. These observations suggest that the administration of thiopental depresses renal sympathetic nerve activity, thereby diminishing the renal tubular transport of sodium.

Modulation of vasopressin action by reducing agents in Bufo marinus

The effects of the reducing agent dithiothreitol (DTT) on vasopressin (AVP)-stimulated osmotic water flow and adenylate cyclase activity were studied in the urinary bladder of Bufo marinus. DTT produced concentration-dependent inhibition of the hydroosmotic water permeability response to 10 mU/ml AVP and 10 mM theophylline but did not inhibit the response to 10 mM adenosine 3',5'-cyclic monophosphate (cAMP). The inhibitory effects of DTT on AVP responsiveness were partially reversed by washing in DTT-free Ringer solution or by addition of oxidizing agents such as dehydroascorbic acid (DHA) or H2O2. The inhibitory effects of DTT were completely reversed by washing in DTT-free Ringer plus addition of DHA. In addition, the inhibitory effects of DTT on AVP-induced osmotic water flow were partially reversed by the GTP analogue 5'-guanylyl imidodiphosphate [Gpp(NH)p]. DTT also inhibited the adenylate cyclase response to AVP but did not alter the response to AVP plus Gpp(NH)p or the response to NaF. These observations suggest that the inhibitory effect of thiol compounds on AVP responsiveness may be modulated through alterations of a redox system distal to the hormone receptor but proximal to the catalytic subunit of adenylate cyclase. Inasmuch as Gpp(NH)p partially reversed the inhibitory effects of DTT on AVP-stimulated osmotic water permeability and prevented the inhibitory effect of DTT on AVP-stimulated adenylate cyclase, an effect on either GTPase or binding of GTP to the regulatory protein of adenylate cyclase is suggested by these observations.

Reversal of copper-induced inhibition of vasopressin responsiveness by reducing agents

Copper inhibits the hydro-osmotic response to vasopressin in the urinary bladder of Bufo marinus at a site proximal to cyclic AMP production. This effect is not reversed by washing in Cu2+ -free Ringer's solution but is overcome by serosal addition of reducing agents, suggesting that vasopressin responsiveness in this tissue is modulated by either the redox potential or the sulfhydryl content of the serosal membrane.

Nephrostomy in patients with ureteral obstruction secondary to nonurologic malignancy. Obstructive uropathy in malignant disease

A retrospective study was undertaken to determine the effects of nephrostomy on renal function in 11 patients with either bilateral ureteral obstruction (nine) or obstruction of a solitary kidney (two) due to advanced metastatic malignancy of nonurologic cause. Nephrostomy resulted in substantial improvement in renal function and lowering of blood pressure. The BUN and serum creatinine levels decreased from 80 +/- 32 and 12.1 +/- 6.3 mg/dL to 34 +/- 24 and 2.4 +/- 2.0 mg/dL, respectively. Mean arterial blood pressure decreased from 112 +/- 22 to 88 +/- 6 mm Hg and correlated significantly with weight loss. Mean patient survival after nephrostomy was 6.7 months. The major complications of nephrostomy included hemorrhage and infection. Nephrostomy resulted in significant improvement in renal function and blood pressure in this group of patients and might add to length of patient survival.

Myeloid bodies in patients without clinical Fabry's disease

Electron microscopy of renal biopsy specimens obtained from three patients revealed typical laminated electron-dense bodies (myeloid bodies) previously believed to be diagnostic of Fabry's disease. None of the patients manifested clinical features characteristic of this disorder, and in one patient leukocyte alpha-galactosidase levels were normal. In comparison with patients with either the heterozygous or homozygous expression of Fabry's disease, in our patients the myeloid bodies were much fewer in number. These observations suggest that the findings of occasional myeloid bodies in renal biopsy specimens should be interpreted with caution.

Exertion-induced rhabdomyolysis with acute renal failure and disseminated intravascular coagulation in sickle cell trait

From 1970 to 1974, among thousands of trainees seen at two large military installations who were subjected to the same physical and environmental stresses, only four recruits were hospitalized because of acute exertional rhabdomyolysis, renal failure and coagulopathy. The illness followed the performance of vigorous exercise. These four patients had sickle cell trait. In an attempt to explain this association, the data in these four cases are summarized. The hypothesis is then developed that rhabdomyolysis and endothelial damage, terminating in severe coagulopathy, may more likely occur in patients with sickle cell trait who are subjected to virorous physical exertion.

Effect of subtotal parathyroidectomy on dialysis dementia

A case of dialysis dementia syndrome is reported which apparently responded to parathyroidectomy. Serial electroencephalograms reflected the changing clinical condition of the patient. Her brain calcium level was elevated which may inplicate secondary hyperparathyroidism as a cause of this neurologic syndrome. Further studies are indicated to elucidate the relationship of this disorder to parathormone excess.

Renal failure following gentamicin in combination with clindamycin

Acute renal failure (ARF) occurred concomitantly with the administration of gentamicin in combination with clindamycin in three patients in whom no other known predisposing cause of ARF could be demonstrated. The evidence for combined nephrotoxicity consisted of the temporal relationship between administration of the antibiotics and the development of ARF, and the prompt improvement in renal function upon cessation of therapy. Complete or partial recovery of renal function occured in all patients. Renal function should be carefully monitored in patients receiving this antibiotic combination.