Plasmapheresis with intravenous immunoglobulin G is effective in patients with elevated panel reactive antibody prior to cardiac transplantation

BACKGROUND

Patients with a PRA >10% are considered to be at greater risk for the development of not only acute cellular and humoral rejection but also increased mortality when compared to nonsensitized patients following transplantation. All patients with a PRA >10% at our institution are treated with plasmapheresis and intravenous immunoglobulin G immediately prior to cardiac transplantation.

METHODS

Sixteen (Group 1) of 118 patients awaiting cardiac transplantation were found to be sensitized. These patients underwent plasmapheresis followed by 20 gm of intravenous immunoglobulin G (IVIG) immediately prior to cardiac transplantation. Group 1 was compared to the remaining 102 patients with a PRA <10% (Group 2).

RESULTS

Despite more patients in Group 1 having a positive crossmatch, pulmonary hypertension, and requiring mechanical circulatory support, there was no statistically significant difference in length of stay or mortality at a mean follow-up of 21.6+/-15.0 months. There was no difference in the occurrence of mild, moderate or severe cellular rejection or humoral rejection in these sensitized patients when compared to Group 2.

CONCLUSIONS

Pretransplant plasmapheresis followed by intravenous immunoglobulin G may be an effective therapy that obviates the need for a prospective crossmatch and allows sensitized patients to undergo cardiac transplantation. There is no increase in the post transplant length of stay, occurrence of rejection or short term mortality. Long term follow up is necessary to evaluate whether there is a difference in the development of late rejection, transplant vasculopathy and survival.

Analysis of risk factors for the development of bronchiolitis obliterans syndrome

Chronic rejection after lung transplantation, manifesting as bronchiolitis obliterans syndrome (BOS), has become the dominant challenge to long-term patient and graft survival. In order to elucidate risk factors for development of BOS we utilized the 1995 revision of the working formulation for the classification of lung allograft rejection (), and devised a quantitative method to retrospectively study lung transplant biopsies from all patients who survived at least 90 d. All transbronchial biopsies were regraded 0 to 4 for acute perivascular rejection and lymphocytic bronchitis/bronchiolitis (LBB), and the grades were totaled over a period of time to give two scores, respectively, for each patient. Also examined were timing of acute rejection and LBB episodes and decreased immunosuppression defined as two or more cyclosporine A levels < 200 ng/ml. Sixty-six patients with BOS and 68 with no BOS (NBOS) satisfied our criteria for inclusion in the study. Demographics including age, sex, and primary diagnoses were similar. The mean perivascular score for BOS was 6.2 over a mean follow-up of 822 d (range, 113 to 2,146) compared with 3.2 for NBOS over 550 d (range, 97 to 1,734) mean follow-up. Airway scores were 5.3 and 1.7, respectively, for the same follow-up periods. There was no correlation between length of follow-up and rejection or LBB scores, although mean length of follow-up for the two groups was significantly different. Late acute rejection and LBB were significantly associated with BOS as was decreased immunosuppression. In addition to perivascular rejection, LBB, late acute rejection, and decreased immunosuppression are significant risk factors for the development of BOS. Analysis of the current data leads us to believe that LBB, in the absence of infection, is in fact a manifestation of acute rejection, with similar implications for graft function as acute perivascular rejection.

A phase II trial of interleukin-2 in myelodysplastic syndromes

Patients with myelodysplastic syndromes (MDS) show a decrease in the number and function of natural killer (NK) cells, including lymphokine activated killer (LAK) cell activity. Interleukin-2 (IL-2) stimulates the proliferation and activity of these lymphocytes. Anecdotal clinical experience has shown haematological and cytogenetic improvement in myelodysplasia by low-dose IL-2 treatment. A total of 10 patients with MDS were treated with 1 million units of IL-2 subcutaneously daily for 12 weeks. Even though improvement in CD16+/CD56+ cell numbers was seen in a majority of the patients, the haematological status and transfusion requirements remained unchanged. There was minimal toxicity from this therapy.

Immunomodulatory effect of beta-carotene on T lymphocyte subsets in patients with resected colonic polyps and cancer

Results from a number of studies suggest that beta-carotene-containing foods prevent the initiation or progression of various cancers. One possible mechanism for this effect could be enhancement of the immune response. The aim of this study was to determine whether beta-carotene modulates T lymphocyte subsets in patients affected with colonic polyps or cancerous lesions. Patients with previous adenomatous colonic polyps (n = 18) or colon cancers (n = 19) were randomized to receive placebo or beta-carotene (30 mg/day) for three months. Percentages of T lymphocyte subsets were determined using flow cytometry in blood samples collected before randomization and at three months. T lymphocyte subsets of 14 normal control subjects were also determined for comparison. Initially, there was no difference in total leukocyte counts, percentage of lymphocytes, and various subsets of lymphocytes among the three groups, although in cancer patients there was a lower percentage of CD4 and interleukin-2 (IL-2) receptor-positive (IL-2R+) cells than in patients with polyps and in controls. After supplementation with beta-carotene, a significant increase in IL-2R+ T lymphocytes (from 12.7 +/- 3.0% to 26.0 +/- 1.9%) and CD4+ lymphocytes (from 40.9 +/- 3.1% to 45.6 +/- 3.2%) was seen only in the cancer patients. These percentages remained unchanged in patients with adenomatous polyps receiving placebo or beta-carotene. We concluded that beta-carotene increased the number of IL-2R+ T lymphocytes and CD4+ lymphocytes, which in turn may produce IL-2 only in patients with cancer who may already have some deficiency in their immune system. This increase in activated T lymphocytes may mediate cytotoxic reactions to cancer cells via cytokine production.

Polyclonal lymphoid tumor of the choroid plexus presenting as an intraventricular mass in a young gorilla

An unusual lymphoid lesion with reactive germinal centers, occurring in the choroid plexus of a young gorilla, is reported. It presented as a large mass in the lateral ventricle with hydrocephalus and neurological symptoms. A work-up did not reveal any underlying cause for this lesion. No similar lesion of the choroid plexus has been reported in either human or veterinary literature. Histological work-up, including flow cytometry, gene rearrangement studies and T and B cell markers, favored the lesion being a non-neoplastic lymphoid proliferation of unknown etiology. The prognosis is unknown, although, following complete removal, the animal is well and free of tumor at the time of this report.

Characterization of postcardiac transplant lymphomas. Histology, immunophenotyping, immunohistochemistry, and gene rearrangement

OBJECTIVE

Between 2% and 9% of cardiac transplant recipients develop posttransplant lymphoproliferative disease, which includes lymphomas. These are usually aggressive Epstein-Barr virus-associated B-cell proliferations similar to those seen in other immunodeficiency states. A retrospective pathologic study of the tumor tissue from 21 cardiac transplant recipients with posttransplant lymphoproliferative disease was undertaken.

DESIGN

Tumor histology, immunohistochemistry, immunophenotyping, and DNA analysis for clonal gene rearrangement and the presence of Epstein-Barr virus DNA were performed.

PATIENTS

The mean patient age was 53.4 +/- 10.2 years (range 33-67 years); 33% of the patients were alive at the time of study.

RESULTS

Histologically, the samples comprised one Burkitt's lymphoma, three diffuse mixed lymphomas, eight diffuse large-cell lymphomas, and nine immunoblastic lymphomas. Thirteen (93%) of 14 samples were infiltrated by small reactive T cells; five of the lymphomas qualified as T-cell rich. Of 14 cases studied, 12 had clonal immunoglobulin gene rearrangements, 1 had oligoclonal bands, and 1 exhibited only a germline pattern. The B cells were CD10+, CD19+, and CD20+, and the reactive T cells were CD2+, CD3+, CD5+, CD7+, CD8+, and CD57+ by immunophenotyping.

CONCLUSIONS

In this patient series, morphologically aggressive lymphomas and disseminated disease occurred early as well as late after transplantation. Most of the tumors showed a reactive T-cell component, which may represent a host attempt at controlling the B-cell proliferation.

Prepregnancy weight and antepartum insulin secretion predict glucose tolerance five years after gestational diabetes mellitus

OBJECTIVE

To identify phenotypic, genotypic, and metabolic parameters measured at the time of antepartum diagnosis of gestational diabetes mellitus that can indicate the risk of diabetes mellitus at early postpartum (< or = 6 mo after delivery) and at a 5-yr follow-up.

RESEARCH DESIGN AND METHODS

The recommendations from the National Diabetes Data Group and International Workshop Conferences on Gestational Diabetes Mellitus were used for screening, diagnosing, and subclassifying gestational diabetes mellitus. National Diabetes Data Group criteria were also used for classification of glucose tolerance postpartum. Plasma glucose, insulin, and free fatty acids were measured after an overnight fast. Plasma glucose and insulin were measured 15, 30, 60, 120, and 180 min after the 100-g oral glucose load. Postpartum glucose tolerance was evaluated at 3-6 mo (early), 1 yr, and annually thereafter.

RESULTS

The 5-yr cumulative incidence of diabetes during follow-up after gestational diabetes mellitus was nearly 50%. Among those who had diabetes within 5 yr, a history of diabetes in only the mother was nearly threefold more common than a history of diabetes in only the father (30 vs. 11%, P < 0.01). Those who displayed diabetes at early postpartum (< or = 6 mo) testing had significantly higher antepartum glucose levels at 60, 120, and 180 min compared with those whose early postpartum results were normal. They were also relatively insulinopenic at antepartum testing. Their fasting, acutely stimulated (15 and 30 min), and integrated 3-h response to oral glucose were all significantly lower relative to women who remained normal or had impaired glucose tolerance at early postpartum testing. Women who developed diabetes between 6 mo and 5 yr postpartum were more obese before the index pregnancy, and they had lower fasting, acutely stimulated (15 and 30 min), and integrated (1-3 h) insulin levels compared with women who remained normal or displayed impaired glucose tolerance at 5 yr postpartum. A multiple logistic regression model showed that diabetes present at early postpartum testing was independently associated with higher 2-h glucose and lower basal and total integrated insulin level. Later (> or = 6 mo-5 yr postpartum) development of diabetes was independently associated with prepregnancy weight and impaired insulin secretion at diagnosis of gestational diabetes mellitus.

CONCLUSIONS

Impaired beta-cell function and obesity at diagnosis of GDM were associated with the development of diabetes during a 5-yr, follow-up period. Studies designed to prevent diabetes in this high-risk group should examine strategies to maintain both optimal beta-cell function and maximum insulin sensitivity.

HLA-DR incompatibility predicts heart transplant rejection independent of immunosuppressive prophylaxis

To determine whether immunosuppressive prophylaxis reduces the effect of HLA-DR incompatibility on rejection, we compared clinical and immunologic variables of patients given horse antithymocyte globulin, OKT3, or no immunosuppressive prophylaxis. Median follow-up was 27 months. Groups were similar in race; preoperative HLA reactivity; ABO matching; number of HLA-A, -B, -C, and -DR mismatches; and rejection severity. Patients given immunosuppressive prophylaxis were younger (p = 0.04), had a greater frequency of preoperative ischemic disease (p = 0.03), and had a higher 6-month rejection rate (p = 0.02). A highly significant association was found between the number of mismatches at the HLA-DR locus and rejection severity (p = 0.005). Within the OKT3-based immunosuppressive prophylaxis group and the no immunosuppressive prophylaxis group a significant association was found between the number of HLA-DR mismatches and rejection severity (p = 0.01 and p = 0.009, respectively). A similar trend was identified in the group given horse antithymocyte globulin-based immunosuppressive prophylaxis. Logistic regression, used to identify independent predictors of rejection, showed that the number of HLA-DR mismatches and not the use or type of immunosuppressive prophylaxis is significantly associated with rejection (p = 0.0009). One-year patient survival was 83% in the group with two HLA-DR mismatches and 85% in the group with one or no HLA-DR mismatch. Thus the lower rejection rates in patients with one or no HLA-DR mismatch were not associated with a 1-year survival, which was better than that of patients with two HLA-DR mismatches. The potential benefit of HLA-DR matching on rejection and patient survival must be confirmed by larger prospective studies.

Role of humoral immunity in acute cardiac allograft dysfunction

To elucidate the pathogenic mechanisms of acute allograft dysfunction that is not caused by acute cellular rejection, we have studied the clinical and immunopathologic characteristics of 11 heart transplant recipients who had acute allograft dysfunction in the absence of interstitial mononuclear cell infiltrates on endomyocardial biopsy samples. Six of eleven patients (54%) had a striking increase in levels of anti-HLA antibodies in close temporal proximity with the episode of acute allograft dysfunction. Cardiac allograft function improved in all patients with intensification of immunosuppression.

Hand mirror variant of adult acute lymphoblastic leukemia. Evidence for a mixed leukemia

Blast cells from a female patient with acute lymphoblastic leukemia-hand mirror variant were examined using various techniques, including light and ultrastructural morphologic examination, cytochemical analysis, surface antigen characterization, cytogenetic analysis, and gene rearrangement studies. The blast cells were found to be pre-B cells (CD19+ and Tdt+) that also expressed the myeloid antigens CD13 and CD33 and demonstrated a heavy chain immunoglobulin gene rearrangement. Cytogenetic studies revealed a t(11;19) translocation previously described in biphenotypic leukemias. A subset of acute lymphoblastic leukemia-hand mirror cells has been previously defined and includes predominately female patients with an indolent course. The authors' findings place this case, a mixed leukemia, within that subgroup. The possibility of mixed lineage should be considered in future cases of hand mirror variants of adult acute lymphoblastic leukemia. Furthermore, hand mirror morphologic features in any case of acute leukemia should alert the hematopathologist/hematologist to the possibility of mixed lineage.

Lymphoblastic crisis of chronic myelogenous leukemia. Hand mirror variant

We present, to our knowledge, the first extensively studied case of lymphoid L2 blast crisis of chronic myelogenous leukemia with a hand mirror cell (HMC) variant. Special stains revealed the leukemic cells to be terminal deoxynucleotidyl transferase positive by immunofluorescence and cytochemically positive for alpha-naphthyl acetate esterase and acid phosphatase (diffuse granular). Immunophenotyping identified the major leukemic cell population as B-cells that expressed CD10+, CD19+, and HLA-DR+. It was not possible to separate the HMC and the non-HMC leukemic population by gating various cell populations, dual staining, cytochemistry, or by terminal deoxynucleotidyl transferase. Gene rearrangements were observed in both Ig heavy-chain alleles and one T-cell antigen receptor gamma-subunit allele. The rearrangements occupied all of the cells, indicating that the HMC and non-HMC were of a common clonal origin. The patient had a mosaic karyotype, with 90% of the cells having t(9;22), t(8;14), and t(9;15) translocations, an additional chromosome 8, and deleted chromosomes 9 and 15. Antibodies to simian sarcoma-associated virus and baboon endogenous virus were isolated in the patient's peripheral blood plasma.

Prospective randomized trial of OKT3- versus horse antithymocyte globulin-based immunosuppressive prophylaxis in heart transplantation

To compare monoclonal anti-T3-receptor antibody (OKT3) and horse antithymocyte globulin (HATG) immunoprophylaxis, 23 heart transplant recipients were randomized to OKT3 (N = 12) 5 mg IV x 14 days of HATG (N = 11) 5 mg/kg IV x 10 days and followed up for 216 +/- 137 days receiving triple immunosuppression. Recipient groups were demographically and clinically similar. First rejection occurred later in OKT3 recipients vs HATG recipients (31.7 +/- 18.3 vs 15.1 +/- 2.3 days; p less than 0.01), but the first rejection necessitating intensified immunosuppression occurred at similar times (30.9 +/- 14.6 vs 21.9 +/- 10.2 days; NS). Phenotypic characterization of peripheral blood lymphocytes by flow cytometry revealed that OKT3 and HATG recipients had similar decreases in total T lymphocytes and lymphocyte subpopulations. During the follow-up period rejection rates in the OKT3- and in the HATG-treated patients were 3.4 +/- 2.7 and 5.9 +/- 4.7, respectively (NS). The number of rejection episodes per recipient treated with intensified immunosuppression was 1.4 +/- 1.2 in the OKT3- and 2.0 +/- 3.1 in the HATG-treated patients (NS). Infection rates were 4.9 +/- 5.2 in the OKT3- and 2.7 +/- 1.7 in the HATG-treated patients (NS). The number of infection episodes that necessitated intravenous antimicrobial therapy was 2.7 +/- 2.3 in the OKT3- and 1.6 +/- 1.3 in the HATG-treated recipients (NS). The number and length of hospitalizations were similar in patients given OKT3-based or HATG-based immunoprophylaxis. We conclude that immunosuppressive prophylaxis with OKT3 vs HATG in heart transplant recipients is associated with a slightly lower incidence and severity of rejection and slightly higher infection rates.

Gestational diabetes mellitus: a syndrome with phenotypic and genotypic heterogeneity

One hundred ninety-nine gravida with gestational diabetes mellitus (GDM) defined as "carbohydrate intolerance of varying severity with onset or first recognition during pregnancy" have been stratified into subgroups on the basis of fasting plasma glucose and evaluated for further phenotypic and genotypic heterogeneity. A significantly greater proportion of the women in all our groups were older and heavier than in a "control" population of 148 consecutive gravida with documented normal oral glucose tolerance. After correction for age and weight by covariate analysis, absolute insulinopenia in response to oral glucose could be demonstrated in all GDM groups, although exceptions were present in each. The incidence of diabetes in the mothers of our patients with GDM was 8-fold greater than in controls; the incidence in fathers did not deviate from control patterns. HLA-DR3 and DR4 antigens were more frequently present in GDM and the increase was statistically significant in blacks. At the time of diagnosis, cytoplasmic islet cell antibodies (ICA) were significantly more common in GDM associated with elevated fasting plasma glucose than in controls; the frequency of ICA was 18.4% (7/38) in women with fasting plasma glucose greater than or equal to 130 mg/dl. Our findings indicate that GDM entails genotypic as well as phenotypic diversity and may include patients with slowly-evolving Type I diabetes mellitus, as well as patients with Type II diabetes mellitus, and women with asymptomatic diabetes which antedated the pregnancy (i.e. pregestational diabetes mellitus). Appreciation of this heterogeneity should be incorporated into any evaluation of intervention strategies for women with GDM or into prognoses concerning their postpartum metabolic status.

Human leukocyte antigens in cutaneous T cell lymphoma

Mycosis fungoides (MF) and Sézary syndrome (SS) are malignant non-Hodgkin's lymphomas, characterized by the proliferation of helper type T lymphocytes with a predilection for the skin. Because of the similarities in cytologic, histologic, cytogenetic, immunologic, and functional aspects of the malignant cells, as well as overlapping clinical features, these disorders are currently classified as cutaneous T cell lymphoma (CTCL). Though the etiology of these disorders remains obscure, environmental factors as well as viral infection have been implicated. In this study, seventy-six white patients with CTCL were typed for human leukocyte antigen (HLA)-A, -B, and -C to assess genetic susceptibility as determined by the major histocompatibility complex. An increase in the frequency of B8 and Bw35 was seen in SS patients but not in MF patients.

Graft-versus-host disease in rhabdomyosarcoma following transfusion with nonirradiated blood products

Graft-versus-host disease is a complication of transfusion of nonirradiated blood products into an immunocompromised patient, and it has been reported in hematologic and lymphoid malignancies as well as in neuroblastoma in children. We report the first case of acute graft-versus-host disease in a child undergoing chemotherapy for a rhabdomyosarcoma, who received transfusions during an intercurrent illness. The graft-versus-host disease was accompanied by an allogeneic lymphoid graft and was diagnosed on the basis of HLA studies on the patient's and her family's circulating lymphocytes and confirmed by HLA typing of the patient's skin fibroblasts.

HLA linkage vs association in hypertrophic cardiomyopathy. Evidence for the absence of an association in a heterogeneous Caucasian population

Human leukocyte antigen (HLA) tissue-typing studies on patients with genetically transmitted hypertrophic cardiomyopathy have demonstrated an HLA linkage in a Caucasian and black patient group and an HLA-DR locus association in a Japanese population sample. To confirm whether a specific HLA antigen(s) might serve as a marker for hypertrophic cardiomyopathy, we performed tissue-typing studies on 50 unrelated, normotensive North American Caucasians with the disorder. Patients were subdivided into three hemodynamic subgroups: obstructive (35), provocable (ten), and nonobstructive (five). Although there was an increased frequency of the B12 and AW32 HLA antigens in the total group, after correction of P values for the number of antigens studied, the associations were not statistically significant. Analysis of the HLA antigen frequencies in the three hemodynamic subgroups yielded no statistically significant HLA-A, B, or C locus associations, and no unusual deviation in linkage disequilibrium between A and B locus antigens was observed. We conclude that although on the sixth chromosome there may be a susceptibility gene for hypertrophic cardiomyopathy, which segregates with a specific haplotype in a given family, no specific HLA-A, B, or C locus antigen was found useful as a marker. HLA-DR locus antigen typing might prove useful in this population.

Use of high dose X-irradiation to block back stimulation in the MLC reaction

Paradoxical stimulation, "back stimulation" was observed in MLR (mixed lymphocyte culture reaction) in both family and population studies. This is one of the major problems in obtaining clear cut-off points for stimulation and non-stimulation in MLR using LD (lymphocyte defined) homozygous typing cells. The ability to provoke back stimulation was found to be different among LD homozygous typing cells. The presence of nonspecific blastogenic factors in supernatant from mixed culture of LD homozygous cells and heterozygous cells, which might be responsible for back stimulation, was confirmed. It was clearly shown that irradiation of LD homozygous typing cells with 6,000 rads instead of the widely used 3,000 rads can greatly reduce or eliminate this back stimulation without introducing any false non-stimulation.