A novel approach for intestinal elongation using acellular dermal matrix: an experimental study in rats

We tested the hypothesis that an anatomic scaffold placed in continuity with viable bowel might allow intestinal growth. Male ACI rats were used for the study. Acellular human dermis in the form of tubular scaffolds with an intraluminal diameter of approximately 0.3 cm was oriented with the luminal basement membrane and serosal dermal surface. The small bowel was transected approximately 2 cm distal to the ligament of Treitz. The graft was then anastomosed in continuity in group A (n = 5) or as a blind-ended pouch to a defunctionalized jejunal limb in group B (n = 8). The animals were sacrificed at various time points. Histology and immunohistochemistry were used to evaluate structural changes. Animals in group A developed peritonitis and were all sacrificed within the first week postoperatively. However, all animals in group B survived, increasing their body weight similarly to age-matched rats. Tissue samples obtained at sacrifice showed a progressively increasing amount of cellular infiltrate over time in the matrix. Epithelial regeneration, angioneogenesis, and myofibroblast infiltrate were seen at 2 weeks, while well-formed branching crypts were seen at 4 weeks. Intact mucosa extended across the anastomosis to the grafts at 6 months. This study demonstrated an anatomic scaffold of acellular matrix allowed mucosal regeneration from viable bowel placed in continuity. These findings set the basis for new intestinal elongation techniques.

Cytokeratin 7 and 20 and thyroid transcription factor 1 can help distinguish pulmonary from gastrointestinal carcinoid and pancreatic endocrine tumors

Expression of cytokeratin (CK) 7 and 20 is commonly used to help distinguish adenocarcinomas from different sites. Thyroid transcription factor 1 (TTF-1) is a 38-kd protein, located primarily in the nucleus of type 2 pneumocytes and clara cells. TTF-1 has been shown to be present in a variety of lung and thyroid tumors and in pulmonary small-cell carcinomas. Carcinoid tumors from the lung and the gastrointestinal (GI) tract are histologically similar and thus are difficult to differentiate from each other based on histologic criteria. Pancreatic endocrine tumors (PET) have a similar histologic appearance to these other tumors. The purpose of this study was to determine the efficacy of differentiating these 3 groups of tumors by their expression of CK7, CK20, and TTF-1. Routinely processed paraffin-embedded tissue sections from 62 carcinoid tumors (lung, 16; gastrointestinal [GI] tract, 46) and 12 PETs were immunohistochemically stained for CK7, CK20, and TTF-1. The degree of expression in each tumor was graded as 1+ (1% to 10% of cells positive), 2+ (11% to 25%), 3+ (26% to 50%), and 4+ (>50%). The data were compared between tumor types and between carcinoid tumors from the various locations in the GI tract (stomach, 8; small intestine, 19; large intestine, 17; appendix, 2). CK7 was expressed in 10 (63%) of 16 pulmonary carcinoid tumors and only 5 (11%) of 46 GI carcinoid tumors (P <.001). Pancreatic endocrine tumors showed CK7 positivity in 6 (50%) of 12 cases, which was similar to the findings in lung carcinoids and significantly higher than in GI carcinoids (P <.01). CK20 was expressed in 0 (0%) of 16 pulmonary carcinoid tumors, in contrast to 24% and 33% of GI carcinoid tumors (P <.05) and PETs (P <.05), respectively. TTF-1 expression was highly specific for pulmonary carcinoid tumors. This peptide was present in 11 (69%) of 16 pulmonary carcinoid tumors and in only 1 (2%) of 46 and 0 (0%) of 12 GI carcinoid tumors (P <.001) and PETs (P <.001), respectively. A CK7(+)/CK20(-)/TTF-1(+) immunopanel result was moderately sensitive (sensitivity, 50%), and highly specific (specificity, 100%), for a diagnosis of pulmonary carcinoid tumor. CK7, CK20, and TTF-1 did not differ significantly between carcinoid tumors located in different sites of the GI tract. However, a trend was observed toward a lower prevalence of CK20 positivity in gastric tumors (P =.06) than in GI carcinoid tumors from the small intestine, colon, or appendix. Expression of CK7 and CK20, and particularly TTF-1, may be useful in distinguishing pulmonary from GI carcinoid tumors and PETs, especially when evaluated as a panel of markers. TTF-1 is highly specific for pulmonary carcinoid tumors.

Activated neutrophils induce nitric oxide production in Kupffer cells

Neutrophils (PMN) are proposed to contribute to hepatic dysfunction during sepsis. Transmigrating PMN have been demonstrated to adhere to and injure parenchymal cells (hepatocytes); however, the effect of sepsis-activated PMN on hepatic macrophages or Kupffer cells (KC) is poorly characterized. We hypothesize that PMN influence KC inflammatory mediator production, including nitric oxide. Rodent KC were co-cultured with PMN obtained from controls (Norm-PMN) or endotoxemic rats [lipopolysaccharide (LPS)-PMN] for 18 h. After an 18-h incubation, supernatants and cell lysates of the KC were analyzed for nitric oxide (NO) production. Co-cultures with LPS-PMN/KC demonstrated significantly increased production of nitrite and up-regulation of inducible nitric oxide synthase (iNOS) protein compared to KC alone or Norm-PMN/KC co-cultures. Immunohistochemistry revealed preferential iNOS protein staining in the cytoplasm of KC cultured with LPS-PMN compared to controls. Nitrite production in co-cultures of KC and LPS-PMN where cell contact was inhibited by a cell impermeable but diffusable membrane was significantly reduced. These data provide evidence that KC can be stimulated directly by activated PMN for production of NO. Further, they suggest another mechanism by which PMN modulate hepatic function during sepsis.

Acceptance of an ABO-incompatible mismatched (AB(+) to O(+)) liver allograft with the use of daclizumab and mycophenolate mofetil

Liver allograft survival rates of 50% to 60% are reported in blood group A, group B, group O (ABO)-incompatible mismatched grafts even when aggressive immunosuppressive protocols, including plasmapheresis, OKT(3), cyclophosphamide, cyclosporine, prostaglandin E(1), and steroids, are used. A 59-year-old woman, blood type O(+), required emergency retransplantation posttransplantation day 2 because of primary nonfunction of the liver allograft. A blood type AB(+) allograft was used. Induction immunosuppressive therapy included tacrolimus, mycophenolate mofetil, OKT(3) (muromonab-CD(3)), steroids, and prostaglandin E(1). In addition, plasmapheresis was performed daily for 9 days. OKT(3) and prostaglandin E(1) were also discontinued postoperative day 9. Biopsy-proven acute cellular rejection was diagnosed postoperative day 12 and was treated with double-dose OKT(3) (10 mg) for another 6 days. On the day OKT(3) was discontinued, daclizumab, 60 mg, was administered intravenously. This dose was repeated every 2 weeks for a total of 5 doses. At 1-year follow-up, the patient is doing very well with normal liver function. We are unaware of previous reports of the use of daclizumab and mycophenolate mofetil as part of an immunosuppressive protocol aimed to induce acceptance of ABO-incompatible mismatched liver allografts. Based on our experience with this case, it seems that mycophenolate mofetil is an adequate replacement for cyclophosphamide. We also believe daclizumab provided adequate protection at a critical time. Further experience with both these drugs is required to establish their role in ABO-incompatible mismatched liver allografts.

Iron reduction as an adjuvant to interferon therapy in patients with chronic hepatitis C who have previously not responded to interferon: a multicenter, prospective, randomized, controlled trial

Hepatic iron concentration has consistently been observed as being directly correlated with the response to interferon therapy in chronic hepatitis C virus (HCV). We therefore conducted a randomized, controlled trial comparing iron reduction by phlebotomy with iron reduction followed by retreatment with interferon in 96 patients with chronic hepatitis C who had previously not responded to a course of interferon. During the initial phase when all patients were undergoing phlebotomy, we found that serum alanine transaminase (ALT) activities decreased but by less than 50% from baseline in 67 patients (89%), decreased by more than 50% in 12 patients (13%) and became normal in 9 patients (9%) with no overall change in HCV-RNA levels. Subsequently no patient in either treatment group achieved a sustained virologic response. Improvements in necroinflammatory changes were noted in liver biopsy specimens in those patients receiving phlebotomy plus interferon (mean index 8.59 vs. 7.37, P <. 05). A slight but not statistically significant decrease in histologic activity index was noted in those subjects treated by phlebotomy alone (mean index 8.4 vs. 7.75, P not significant). We conclude that, although prior phlebotomy therapy does not improve the rate of sustained response to interferon retreatment, it does result in less liver injury manifested by a decrease in serum transaminase activity and a slight improvement in liver histopathology.

Expression of transforming growth factor-alpha and epidermal growth factor receptor in gastrointestinal stromal tumours

Activation of epidermal growth factor receptor (EGFR) is associated with cell growth and transformation. Both transforming growth factor-alpha (TGF-alpha) and epidermal growth factor bind to and activate EGFR. We studied the expression of TGF-alpha and two EGFRs (HER-1 and HER-2) in gastrointestinal stromal tumours (GISTs) of the stomach (n = 9) and small intestine (n = 6) using standard immunostaining techniques in paraffin-embedded sections. Most GISTs expressed TGF-alpha, and a few expressed HER-1. All HER-1-positive tumours expressed TGF-alpha. These results suggest that a TGF-alpha/EGFR autocrine loop is present in GIST and that TGF-alpha promotes proliferation of GIST tumour cells through its interaction with HER-1 in at least some GISTs. This is the first description of an autocrine loop in GIST. In contrast, HER-2 is not expressed in any GIST.

Inflammatory cell infiltrate in a responding metastatic nodule after vaccine-based immunotherapy

A patient with von Hippel Lindau disease, bilateral symmetric renal cell carcinoma and pulmonary metastases treated with immunotherapy is the subject of this study. A left kidney and tumour mass were removed and the tumour cells used to make an autologous tumour/bacille Calmette-Guérin (BCG) vaccine as part of the treatment protocol. The patient's pulmonary nodules responded, but the remaining renal nodule subsequently grew. Samples of both tumours were obtained allowing for an internally controlled evaluation of the histological and immunohistologic differences between a responding and non-responding tumour nodule after therapy. The immunotherapy protocol is designed to promote a T cell response to autologous tumour. Cellular infiltrates were demonstrated in both responding and non-responding nodules compared with the pretreatment tumour specimen, but the responding nodule contained proportionately more T cells as well as markedly increased numbers of plasma cells and granulocytes. This suggested that several arms of the immune system may have been operative in the responding nodule.

Florid angiogenesis in mucosa surrounding an ileal carcinoid tumor expressing transforming growth factor-alpha

Carcinoid tumors of the gastrointestinal tract are known to be associated with fibrosis and vascular elastosis, either within the tumor or at distant sites. The current report describes prominent vascular proliferation in the villi extending 38 cm proximal and 15 cm distal to an ileal carcinoid tumor. These villi were expanded by vessels, producing a segmental carpet of multiple small polypoid protrusions around the tumor. Immunohistochemical analysis suggested that the major stromal components were of endothelial and myofibroblastic cell origin. The stroma of the tumor itself had minimal fibrosis and vascularity. To our knowledge, this is the first description of vascular proliferation in the vicinity but distinct from a carcinoid tumor. The demonstration of transforming growth factor-alpha (TGF-alpha) synthesis by tumor cells supports the possibility of a field effect by angiogenic factor(s) secreted by the tumor.

Frequency and distribution of DNA fragmentation as a marker of cell death in chronic liver diseases

To study the early stages of cell death in various types of chronic liver injury, liver biopsies from a total of 26 patients, including 7 with chronic hepatitis C(CHC), 4 with chronic hepatitis B(CHB), 7 with alcoholic liver disease (ALD), 4 with autoimmune or drug hepatitis (AI/DH), and 4 with primary biliary cirrhosis(PBC), were examined by an in situ nucleotidyl transferase assay (ISNTA), which detects DNA fragmentation. Positive nuclei in hepatocytes and sinusoidal lining cells were counted in all parenchymal areas, excluding triads and areas of fibrosis, using a computer with Sigmascan software. The number of positive hepatocytes/mm2 was similar in the biopsies of patients with CHC, CHB, ALD and AI/DH, but significantly lower in PBC. The number of positive sinusoidal lining cells/mm2 was significantly greater in biopsies with CHC compared to CHB, ALD, AI/DH and PBC. Double staining revealed that the ISNTA-positive sinusoidal lining cells were also CD68 positive, indicating that they were Kupffer cells. The frequency of ISNTA positivity did not correlate with serum AST or ALT levels, steatosis, cell swelling or cirrhosis. ISNTA-positive hepatocytes were more frequent than acidophilic bodies in every disease category. We conclude that apoptosis may be a common pathway of cell death in different liver diseases, that the high frequency of DNA fragmentation in Kupffer cells in CHC suggests that during chronic hepatitis C infection activated Kupffer cells may be subject to regulatory control by apoptosis and that ISNTA is more sensitive than acidophilic bodies in assessing the degree of cell injury in the liver.

Interdigitating reticulum-cell sarcoma of the intestine: a case report and review of the literature

Dendritic cells are immune accessory cells which are widely distributed in many tissues. Those which are present within lymphoid follicle centers are classified as follicular dendritic cells. Those which are found outside germinal centers may be referred to as interdigitating reticulum cells, or Langerhans cells when they occur in the skin. Abnormal proliferations of dendritic cells are best known as the group of disorders comprising Langerhans-cell histiocytosis, which occurs primarily in children and teenagers. There are increasing reports of malignant proliferations of both types of dendritic cells in adults. However, there is only one previous description of the cytologic features of a dendritic cell sarcoma based on imprint cytology of a resected jejunal mass. The current report provides a detailed description of the cytologic features of a fine-needle aspirate of a recurrence of an interdigitating reticulum-cell sarcoma of the cecum.

Experimental autoimmune cystitis in the Lewis rat: a potential animal model for interstitial cystitis

To develop an autoimmune animal model for interstitial cystitis (IC), we injected rats with Freund's adjuvant (CFA) containing bladder homogenate (experimentals) or CFA alone (shams). We observed a doubling of urinary frequency in the experimental animals over the shams (P = 0.004) and histopathologic changes (venular congestion) consistent with IC. Statistically significant bladder capacity changes were not found. Mast cell (MC) number was not statistically different between experimentals and controls but the number of MCs from section to adjacent section within the same animal's bladder did vary markedly, indicating the MC counts are not a reliable measure of disease in the rat bladder. Splenocytes cultured from the experimental animals and transferred to naive syngeneic recipients were capable of transferring the urinary frequency changes and vascular congestion while splenocytes from animals which did not develop the condition were without effect. In summary, we have developed and autoimmune model for IC consistent with the clinical features of IC. The features of this model can be transferred to naive syngeneic recipients via adoptive splenocyte transfer. The model will permit us to ask and answer important questions about the pathogenesis and treatment of the human disease.

High-dose interferon-alpha 2b for re-treatment of nonresponders or relapsing patients with chronic hepatitis C. A controlled randomized trial

Relatively few patients with chronic hepatitis C treated with standard doses of interferon-alpha 2b (3 million units per week for 24 weeks) have a sustained response. Our aim was to evaluate whether higher doses of interferon would improve this rate of response. Twenty-four patients with chronic hepatitis C who had failed to respond to (N = 21) or had relapsed after (N = 3) an initial course of standard interferon therapy were randomized to 15 million units (N = 13) or 22.5-30 million units per week (N = 11) for 24 weeks. Five of 13 subjects given 15 million units per week and 3/11 of subjects given 22.5-30 million units per week had complete normalization of serum alanine aminotransferase levels during therapy. Five patients (24% who had not responded to standard interferon had a complete response to high-dose interferon during therapy. Only one patient had a sustained response, with normal serum alanine aminotransferase 24 weeks after stopping interferon. Six patients were withdrawn before completing treatment, five in the 22.5-30 million unit per week group. We conclude that higher doses of interferon ameliorate the severity of hepatitis in patients who failed to respond to or relapsed after standard interferon therapy, but are unlikely to produce a sustained response. High-dose therapy is associated with an increase in side effects.

Expression of p53 antigen in inflamed and regenerated mucosa in ulcerative colitis and Crohn's disease

Physiologic overexpression of p53 protein may occur in the G1 stage of the cell cycle to slow down the cell cycle and allow DNA repair in stressed or injured cells. We questioned whether there is increased expression of p53 protein in acutely inflamed mucosa (AI) and regenerated mucosa (RM) in ulcerative colitis (UC) and Crohn's disease (CD). Formalin-fixed paraffin-embedded sections of resected bowels from eight patients with UC and 20 with CD were reviewed, and blocks were selected having areas defined as follows: AI = two high-power fields (HPFs) at the edge of an ulcer, or one HPF with an inflamed crypt in the center; RM = branched or irregular glands with only mild chronic inflammation. Blocks with normal mucosa were available in 20 cases. One case of CD also had dysplasia, adenoma, and invasive carcinoma. p53 was identified with PAb1801 antibody using a labeled avidin-biotin immunoperoxidase technique. In each defined area, the positive nuclei were counted and expressed as the number of positive nuclei per 10 HPFs. Data were analyzed statistically for comparisons within and between the diseases. In normal mucosa, only rare cells expressed p53 in two cases of CD. The mean frequency of positive nuclei was 2.24/10 HPFs in AI and 0.30/10 HPFs in RM in CD, and 7.63/10 HPFs in AI and 1.14/10 HPFs in RM in UC. Differences between the means for AI and RM were statistically significant in both UC and CD. Although not significant, the frequency of positive staining in both AI and RM was greater in UC as compared with CD.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic leukocytoclastic vasculitis complicating HBV infection. Possible role of mutant forms of HBV in pathogenesis and persistence of disease

A young woman developed arthritis and leukocytoclastic vasculitis, followed by hepatitis due to a precore mutant strain of hepatitis B virus (HBV) incapable of synthesizing HBe antigen. Tests for antibodies to HCV were persistently negative. Treatment of the patient with alpha interferon initially led to a severe exacerbation of hepatitis. Later, higher doses of interferon were tolerated and were associated with reduction of HBV replication and improvement in liver histopathology and serum aminotransferases. After interferon therapy, sequencing of HBV DNA from a repeat liver biopsy showed a cluster of new mutations, which may have led to alterations in immunodominant epitopes of viral proteins. The findings suggest that a "naturally occurring" mutant form of HBV was associated with chronic hepatitis and vasculitis in the patient, and that the immunological pressure on HBV produced by therapy with interferon may have led to other mutations in the viral genome with persistence of low-level HBV infection.

Induction of chronic graft-versus-host disease in a rat model after transplantation of sensitized small bowel allografts

The recent success in controlling acute rejection in clinical small bowel transplantation has resulted in a number of patients with functioning grafts and an occasional occurrence of graft-versus-host disease (GVHD). To better understand this complication following small bowel transplantation, a model of chronic GVHD was developed, using the Brown Norway-->Lewis rat strain combination. When the Lewis recipients were immunocompromised at the time of transplantation and received a graft specifically sensitized against Lewis, fatal GVHD developed in 3 of 5 animals. Serial histologic evaluation and determination of donor major histocompatibility complex (MHC) class I antigens were used to delineate the course of GVHD. Although the histologic results were inconsistent, with the exception of the animals developing fatal GVHD, the detection of donor MHC antigens correlated well with the development of GVHD. Determination of donor MHC class I antigens may serve as useful indicators for the development of GVHD.

Acute hepatic and renal toxicity from low doses of acetaminophen in the absence of alcohol abuse or malnutrition: evidence for increased susceptibility to drug toxicity due to cardiopulmonary and renal insufficiency

A 67-yr-old man with chronic cardiopulmonary disease exhibited severe hepatic and moderately severe renal injury after short-term ingestion of therapeutic doses of acetaminophen (1 to 3 gm/day for 3 days). Drug metabolism and other studies, performed 5 mo after recovery from the acute insult, indicated that the patient had decreased rates of hepatic metabolism of acetaminophen to its primary, nontoxic metabolites and decreased kidney function that was compromised further by acetaminophen ingestion. He also had abnormally low concentrations of hepatic and plasma reduced glutathione. Alcohol abuse and malnutrition could not be implicated in the pathogenesis of injury; rather it appeared that advancing age with chronic renal, cardiac and pulmonary insufficiency contributed to acetaminophen toxicity in this patient.

Mucosal recipient-type mononuclear repopulation and low-grade chronic rejection occur simultaneously in indefinitely surviving recipients of small bowel allografts

Lewis rat recipients of long-term, surviving, orthotopic Brown-Norway rat intestinal allografts, initially treated with cyclosporin A (CyA) or FK 506, were evaluated for their functional capacity and morphology over 1 year after the immunosuppressive therapy had been discontinued. Functional parameters such as nitrogen and fat balances, maltose absorption, blood chemistry, hematologic studies, and the weight gained by the allografted animals did not differ from those of syngeneically grafted or age-matched normal animals. Immunohistochemical studies showed that the lamina propria of the allografts was repopulated with recipient MHC class II+ mononuclear cells and that a normal distribution of T helper, T suppressor/killer, and IgA+ plasma cells had occurred. However, fibrous replacement of the mesenteric lymph nodes and Peyer's patches were detected in all, and an inflammatory obliterative arteriolopathy developed in the mesenteric vasculature of half of the allografted animals. No such findings were observed in recipients of syngeneic grafts. These results demonstrate that the limited use of potent immunosuppressive agents immediately after transplantation averts rejection and is followed by recipient-type mucosal lymphocytic repopulation. Simultaneously, a clinically not recognizable chronic rejection evolves. This suggests that the timely diagnosis of chronic rejection may not be possible with the use of standard tests of gut function and random mucosal biopsies alone.

Mixed cryoglobulinemia in chronic hepatitis C infection. A clinicopathologic analysis of 10 cases and review of recent literature

We present 10 cases of mixed cryoglobulinemia in patients infected with hepatitis C, including pertinent clinical, serologic, and pathological data. The findings attributable to MC appear to be similar in patients who are HCV-infected as in those with unknown HCV status. The prevalence of MC in HCV-infected patients appears to be lower in our region (13%) than in southern Europe (50-90%) although some of this difference is due to our requirement that patients included in our study have a cryocrit of at least 5%. In our patients, cryoglobulins were shown to be deposited in skin and kidney, but not in liver. The mechanisms by which HCV and MC are related remain uncertain. Although we and others have evidence for enrichment of HCV RNA in the cryoprecipitates of some patients, this was not always the case, and it is not yet clear that this finding is of fundamental pathogenic importance. Finally, it appears that some patients with HCV and MC may have a beneficial clinical response of vasculitic symptoms to therapy with alpha-interferon, as well as to glucocorticoids or other immunosuppressants. In our group, no predictors were apparent to distinguish responders from nonresponders before treatment. Similarly, the duration of response remains to be determined.

Induction of renal adenocarcinoma by a nonmutated erbB oncogene

Oncogenicity tests have revealed that a nonmutated erbB oncogene induces renal adenocarcinoma in addition to erythroblastosis. The erbB oncogene is a truncated form of the chicken epidermal growth factor receptor that lacks the extracellular ligand-binding domain. Previously, the nonmutated erbB oncogene has been reported to cause only erythroblastosis. The expansion of the disease potential of erbB to additional neoplasms has been associated with mutations (truncations, deletions, and point mutations) within the erbB gene. Our results indicate that a nonmutated virally expressed erbB oncogene (REB-c) causes a 100% incidence of renal neoplasia.

Clinical course, morphology, and treatment of chronically rejecting small bowel allografts

As acute rejection episodes are most frequently prevented or controlled in clinical organ transplantation, chronic rejection processes have become the major reason for late dysfunction and eventual loss of the allograft. The recent reports on successful clinical intestinal transplantation prompted us to investigate chronic rejection processes that may arise after the initial control of acute rejection. Using the strongly histoincompatible ACI-->LEW rat strain combination and serial graft biopsies after limited initial immunosuppressive therapy with cyclosporine, we defined the clinical and pathomorphologic course of chronic rejection of orthotopic small bowel allografts. Differing from acute rejection, the bowel wall (especially the mucosa and submucosa) was not the primary target of chronic rejection. We observed progressive destruction of the Peyer's patches and the mesenteric lymph nodes of the graft--a process which began during the 4-week course of CsA--and infiltration and destruction of graft mesenteric vessels. Testing the immunosuppressive drugs FK506 and CsA for their efficacy to ameliorate ongoing chronic rejection, we found that a short course (5 days) of FK506 was more effective than a second 4-week course of CsA. However, while allograft function recovered sufficiently to allow a temporary improvement of the recipient's global nutritional state, pathomorphologic graft changes failed to reverse substantially. Eventually all grafts failed due to progressive chronic rejection.

Successful treatment of ongoing intestinal allograft rejection permits recovery of graft structure and function

Acute rejection episodes often complicate clinical small bowel transplantation, which prompted us to investigate whether such episodes can be reversed and the intestinal graft salvaged. Inbred Lewis rats that received fully allogeneic Brown-Norway small bowel allografts were treated with cyclosporin A (10 mg/kg) for 5 days, and the drug was then discontinued. Clinical and histologic signs of acute rejection developed, and the animals were subsequently treated with FK 506 (2 mg/kg) on days 14, 16, and 18. Survival was significantly prolonged (201.7 +/- 46.8 days) when compared with animals that were not administered FK 506 (16.5 +/- 0.8 days) or allograft recipients that received no immunosuppressive therapy (10.8 +/- 0.7 days). The histologic changes and functional impairment due to rejection that were observed prior to the start of the FK 506-therapy were reversed. However, biopsy specimens of all animals exhibited features of chronic rejection. This study provides evidence that acute rejection of intestinal allografts can be successfully treated with a short course of FK 506.

Potassium supplementation attenuates experimental hypertensive renal injury

The long-term roles of dietary sodium and potassium on the renal end-organ damage of hypertension were investigated in Wistar-Kyoto (WKY) and in spontaneously hypertensive (SHR) rats. Eight rats from each strain were maintained since 1 month of age on one of four dietary combinations of either low (0.4%) or high (6.0%) NaCl and low (0.51%) or high (7.6%) KCl providing sodium/potassium molar ratios of 1:1, 1:15, 15:1, and 15:15, respectively. Urinary sodium/potassium excretion ratios confirmed the proportion of salts consumed. Systolic blood pressures (SBP) were similar at 5 months of age and at the completion of the study at 9.5 months; SBP was significantly higher in SHR than in WKY rats and was not attenuated by dietary potassium supplementation of a magnitude that raised plasma potassium concentrations. Albumin excretion rate (AER) was also higher in SHR than in WKY rats (P less than 0.0001). In SHR, AER rose further with high sodium intake (P less than 0.035) but, contrary to SBP, was ameliorated by an equimolar addition of potassium (P less than 0.01). Morphologic lesions were generally absent in WKY rats and were more common in SHR as a group (P less than 0.001). In all four SHR groups, the graded histopathologic injury correlated well with measured AER but a major improvement in hypertensive renal lesions occurred largely in the KCl-supplemented, salt-loaded SHR group. These results show a disassociation between the effects of dietary monovalent cations on the level of SBP and their effect on renal injury. Sodium aggravates renal injury and potassium protects against this renal effect of sodium independent of SBP effect.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunological effects of treatment with sequential administration of recombinant interferon gamma and alpha in patients with metastatic renal cell carcinoma during a phase I trial

Many anticancer mechanisms of the interferons have been proposed but none have been associated with clinical response to date. The biological activities of the interferons in vivo have included effects upon the natural killer cell, T- and B-lymphocytes, and macrophages. This report details a prospective study of the immunological effects on peripheral blood mononuclear cells of sequentially administered recombinant (r) interferon (IFN) gamma and rIFN alpha in 28 patients with metastatic renal cell carcinoma. Natural killer cell activity, T-cell phenotype (CD4, CD8, CD56, CD16, CD4/HLA-DR, CD8/HLA-DR, CD56/HLA-DR) and 2',5'-oligoadenylate synthetase were measured prior to therapy, during therapy, and following completion of treatment. Statistical analysis of all parameters was performed for the entire group, by individual patient, by dosage, by time, and by clinical response. An overall significant depression in natural killer cell activity and in the percentage of circulating CD56, CD16, and CD8+ cells were noted. Significant increases in 2',5'-oligoadenylate synthetase and in the percentage of circulating CD4 cells were also noted. Although an association between the magnitude of change in percentage of CD16+ cells and 2',5'-oligoadenylate synthetase and dosage of rIFN gamma and rIFN alpha, respectively, was observed, optimal biological dose of this sequence of rIFNs could not be determined due to the limited number of patients. A decrease in the percentage of circulating CD8+ cells was observed among patients with objective clinical response (partial and complete). Sequentially administered rIFN gamma and rIFN alpha can modulate immunological parameters in vivo in patients with metastatic renal cell carcinoma. A fall in percentage of circulating CD8+ cell is associated with response and suggests that this sequence of rIFN alpha and rIFN gamma might influence T-cell mediated antitumor activity.

Proliferative glomerulopathy following extracorporeal shock wave lithotripsy in the pig

Histopathologic changes after extracorporeal shock wave lithotripsy (ESWL) were studied in kidneys from four groups of nine pigs treated with an EDAP LT-01 (five pigs/group) or Dornier HM3 (four pigs/group) lithotripter, and sacrificed at time zero, 48 hours, one week and one month. Treatment dosages increased consistently within each group. Samples from primary treatment area and opposite control kidney were processed routinely for light, immunofluorescence, and electron microscopy. Tubulointerstitial changes included hemorrhages at zero and 48 hours and scars at one week and one month with both lithotripters. Glomerular mesangial cell proliferation started by 48 hours and increased over one month in treated and control samples. Electron microscopy showed mesangial deposits and phagolysosomes. Immunofluorescence showed trace IgG, zero IgM, and 1-2+ C3. The conclusions were: 1) Mesangial cell proliferation associated with deposits of C3 and phagocytosis of cellular debris starts by 48 hours post ESWL and increases thereafter, with both Dornier and EDAP lithotripters. 2) The pathogenesis appears to involve phagocytosis of circulating cellular debris and red blood cell fragments presumed to derive from breakdown of the hematoma caused by the lithotripsy.

Induction of graft-versus-host disease and rejection by sensitized small bowel allografts

This study was undertaken to investigate under which circumstances graft versus host disease occurs following fully allogenic small bowel transplantation in the rat. To facilitate the development of GVHD, Brown-Norway donors were specifically sensitized against the Lewis hosts prior to transplantation. Additionally, the Lewis recipients were immunocompromised before transplantation using splenectomy, cyclosporine, and antilymphocyte serum. No further immunosuppressive therapy was administered after transplantation. When all pretreatment regimens were used, acute lethal GVHD arose in two of nine animals (22%), whereas in two animals (22%) signs of acute GVHD and rejection were observed concurrently. When recipients of sensitized grafts were pretreated with CsA alone, one of eight animals (12.5%) showed signs of GVHD and rejection. All other animals died of acute rejection without clinical signs of acute GVHD. However, histological signs of GVHD were observed frequently in hosts grafted with a sensitized small bowel transplant. These data show that acute lethal GVHD can occur when an immunocompromised host is grafted with a sensitized intestinal transplant.

Hepatic steatosis due to total parenteral nutrition: the influence of short-gut syndrome, refeeding, and small bowel transplantation

This study was undertaken to determine whether refeeding through the native small intestine or through a small bowel transplant would reverse hepatic steatosis induced by total parenteral nutrition (TPN), and of what influence a coexisting short-gut syndrome is. Three short-gut syndromes of different severity were established in Lewis rats (short-gut I, mild; short-gut II, moderate; short-gut III, severe). TPN was administered for 10 days and the animals were refed for 20 days. A liver biopsy after the TPN period confirmed a mild to moderate fatty infiltration of the liver in all groups. After the refeeding period a second liver biopsy was obtained and no evidence of hepatic steatosis was observed in Groups 1, 2, 3, and 4 (normal Lewis rat, short-gut I, II, and III). The animals in group 5 (short-gut I) received a syngeneic small bowel transplant after discontinuation of TPN. After the refeeding period the liver biopsies showed no evidence of fatty infiltration. The intestinal graft also reversed the nutritional deficiencies which were observed in the animals with short-gut and showed normal body weight gain and nitrogen and fat uptake in comparison to the normal animals (Group 1). These data show that a small bowel graft is capable of reversing the deleterious sequelae of short-gut syndrome as well as the TPN-related hepatic steatosis.

Resolution of cirrhotic glomerulonephritis following successful liver transplantation

A 38-year-old man with liver failure due to Laennec's cirrhosis developed nephrotic range proteinuria and hematuria. Renal biopsy showed membranoproliferative glomerulonephritis with 2+ staining for IgA and complement consistent with cirrhotic glomerulonephritis. After orthotopic liver transplantation, proteinuria and hematuria rapidly resolved. This case indicates that glomerulonephritis associated with cirrhosis may be successfully treated with hepatic transplantation. Whether the improvement in glomerular abnormalities resulted from immunosuppression therapy or from restoration of normal hepatic function is unknown.

A phase IA trial of sequential administration recombinant DNA-produced interferons: combination recombinant interferon gamma and recombinant interferon alfa in patients with metastatic renal cell carcinoma

This study investigated the effects of sequentially administered recombinant interferon gamma (rIFN gamma) and recombinant interferon alfa (rIFN alpha) in 36 patients with metastatic renal cell carcinoma (RCC). rIFN alpha was subcutaneously administered daily for 70 days at dosages that varied (2.5, 5, 10, and 20 x 10(6) U/m2) across four cohorts of patients. Within each cohort of patients receiving a given dose of rIFN alpha, three subsets of patients received either 30, 300, or 1,000 micrograms/m2 rIFN gamma. rIFN gamma was administered intravenously for 5 days every third week, 6 hours prior to administration of rIFN alpha. Dose-limiting toxicity (DLT) included constitutional symptoms, leukopenia, nephrotic syndrome with acute renal failure, hypotension associated with death, and congestive heart failure. DLT was related more often to the rIFN alpha dose level than to rIFN gamma dose level. Maximum-tolerated dose (MTD) was 10 x 10(6) U/m2 rIFN alpha and 1,000 micrograms/m2 rIFN gamma. Six patients failed to complete a minimum of 21 days of therapy due to toxicity or rapid progression of disease. Clinical responses were seen in eight of 30 assessable patients. Two patients experienced complete remission and have remained in complete remission 20+ and 22+ months. An additional six patients have shown partial responses for 4 to 18+ months. One patient in partial remission continues to show slow regression of pulmonary and liver lesions off therapy with rIFNs. Clinical responses have remained durable for patients with complete remissions and patients with partial remissions. The results of this study suggest that toxicities associated with combination rIFN therapy can be reduced by administering these agents sequentially as opposed to simultaneously.

The use of FK-506 for small intestine allotransplantation. Inhibition of acute rejection and prevention of fatal graft-versus-host disease

Small intestine allotransplantation in humans is not yet feasible due to the failure of the current methods of immunosuppression. FK-506, a powerful new immunosuppressive agent that is synergistic with cyclosporine, allows long-term survival of recipients of cardiac, renal, and hepatic allografts. This study compares the effects of FK-506 and cyclosporine on host survival, graft rejection, and graft-versus-host-disease in a rat small intestine transplantation model. Transplants between strongly histoincompatible ACI and Lewis (LEW) strain rats, and their F1 progeny are performed so that graft rejection alone is genetically permitted (F1----LEW) or GVHD alone permitted (LEW----F1) or that both immunologic processes are allowed to occur simultaneously (ACI----LEW). Specific doses of FK-506 result in prolonged graft and host survival in all genetic combinations tested. Furthermore, graft rejection is prevented (ACI----LEW model) or inhibited (rejection only model) and lethal acute GVHD is eliminated. Even at very high doses, cyclosporine did not prevent graft rejection or lethal GVHD, nor did it allow long-term survival of the intestinal graft or the host. Animals receiving low doses of cyclosporine have outcomes similar to the untreated control groups. No toxicity specific to FK-506 is noted, but earlier studies by other investigators suggest otherwise.

Neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin for locally advanced transitional cell carcinoma of the bladder

Nine patients with locally advanced transitional cell carcinoma (TCC) of the bladder were treated with neoadjuvant methotrexate, vinblastine, Adriamycin (doxorubicin; Adria Laboratories, Columbus, OH), and cisplatin (M-VAC) followed by radical cystoprostatectomy and modified pelvic lymphadenectomy. Five patients, including three with pelvic sidewall fixation, had clinical stage T4N0M0 tumors whereas the remaining patients had T3N0M0 tumors. All patients were pathologically restaged by a referee pathologist after surgery. The complete response rate was 22% and an additional 44% experienced a partial response. Neutropenia preventing a second cycle of M-VAC occurred in one patient. Downstaging of locally advanced TCC of the bladder was achieved in the majority of patients treated with neoadjuvant M-VAC.

Normotensive renal failure in systemic sclerosis

Of 140 patients with "scleroderma renal crisis" encountered during a 33-year period, 15 of 131 (11%) whose blood pressures were recorded were normotensive during this complication. In comparison with 116 patients with hypertension, the normotensive patients significantly more often had microangiopathic hemolytic anemia (90% versus 38%) and thrombocytopenia (83% versus 21%). Pulmonary hemorrhage occurred in 6 normotensive patients. More normotensive patients had received high doses of corticosteroids (prednisone greater than or equal to 30 mg/day) during the 2 months immediately preceding renal crisis (64% versus 16%). A role for corticosteroids in precipitating renal crisis is suggested. The 12-month survival was significantly reduced in the normotensive patients (13% versus 35%).

Induction of stable chimerism and elimination of graft-versus-host disease by depletion of T lymphocytes from bone marrow using immunomagnetic beads

The goal of transplantation is the induction of immunologic tolerance. At present, nonspecific immunosuppression is used to prevent graft rejection and, commonly, graft-versus-host disease (GVHD). Nevertheless, nonspecific immunosuppressive therapy is frequently complicated by infection, malignant tumors, and drug toxicity. In order to examine whether hematopoietic chimerism can be used to induce specific allograft tolerance, we have reconstituted lethally irradiated Lewis rats with ACI bone marrow that has been depleted of T cells with use of immunomagnetic beads. This technique consists of binding OX-19, a mouse anti-rat pan-T lymphocyte monoclonal antibody, to magnetic polymer beads. Mixing of bone marrow or splenocytes with the bead/OX-19 complexes, followed by magnetic separation, results in significant depletion of T cells with minimal nonspecific cell loss. Immunomagnetic T-cell depletion of bone marrow, followed by reconstitution of a lethally irradiated host, allows for the development of stable, mixed hematopoietic chimerae without evidence of GVHD. These hosts are immunocompetent by clinical criteria. Recipients of untreated donor bone marrow that did or did not receive nonspecific immunosuppression demonstrated varying degrees of GVHD and reduced survival. The ability to rapidly and simply deplete T lymphocytes from bone marrow and produce stable, immunocompetent hematopoietic chimerae without GVHD may be an important method for tolerance induction to vascularized allografts.

A modified technique of orthotopic transplant of the kidney in rabbits

In this study kidneys were harvested from bred-for-research cats weighing 4 to 5 kg. General principles of donor bilateral nephrectomy en bloc with aorta, vena cava, renal vessels, and ureters were followed. After the harvest the grafts were placed in lactated Ringer slush. A cuff was prepared on the renal vein over a 10 French plastic tube. The aorta was divided and left in connection with the renal artery at each side. Twenty female checkered Flemish giant rabbits weighing 4.0-6.0 kg served as recipients. After premedication with 40 mg/kg of ketamine, anesthesia was maintained with repeated doses (every 10-15 min) of a 0.1-mL mixture of 5 parts ketamine and 1 part acepromazine diluted 50% in a normal saline. Arterial pressure, CVP, blood gases, and temperature were monitored. Through a limited midline incision a native left nephrectomy was performed. The venous anastomosis was performed with a cuff technique without clamping the vena cava (which causes severe hemodynamic instability); the anastomotic time was 2-3 min. The arterial anastomosis was performed with an end-to-side aorta-to-aorta anastomosis; the anastomotic time was 5 to 7 min. There were no episodes of venous or arterial thrombosis. The donor procedure took approximately 40 min, and the backtable preparation of the graft an additional 45 to 60 min. Preparation of the recipient for the anastomosis took 15 min and the anastomotic time (warm ischemia) was 13 +/- 5 min. In this model suitable for xenograft research the duration of the surgery in the recipient has been greatly reduced because of (1) the previous backtable preparation of the graft, and (2) the cuff technique used for venous anastomosis. The present anesthesia regimen and careful hemodynamic monitoring were also important in the success of this model.

Morphologic features of rejection in long-surviving canine small bowel transplants

We studied morphologic features of small bowel transplants in 25 dogs immunosuppressed by cyclosporine, and preoperative graft irradiation. Graft and host bowel were compared with respect to multiple histologic parameters in a blinded analysis. A lymphoplasmacytic infiltrate in nerves and vessels in submucosa and muscle was present in 18 graft bowels and only 3 host bowels, suggesting that these findings represent a cellular rejection reaction. The other histologic parameters were the same in graft and host bowel. Although the dogs did not exhibit clinical signs of rejection, end-stage scarring of the bowel and death occurred in 6 dogs. The animals did not develop systemic graft-verus-host reaction. These findings indicate that under cyclosporine therapy, a subclinical rejection reaction persists deep in the wall and may remain undetectable in mucosal biopsies, but may progress to destroy the graft.

Participation of dendritic cells in vascular lesions of chronic rejection of human allografts

Immunohistochemical techniques were used to investigate the pathogenesis of obliterative arteriopathy, a major obstacle to long-term solid organ allograft survival. T-lymphocytes, macrophages, and proliferating smooth muscle cells made up most of the thickened intima. More importantly, S100-protein-positive dendritic cells were also present in the intima, especially during active inflammation and smooth muscle cell proliferation. These are phenotypic characteristics of tissue "dendritic" cells, pivotal accessory cells in T-dependent immune reactions. Their localisation in the arterial wall signals the presence of an ongoing immunological reaction directed at native constituents of the artery or at exogenous antigens which permeate the damaged vessel wall.

Effect of pretransplant graft irradiation on canine intestinal transplantation

This study was done to define the tolerance of ex vivo administered irradiation to intestinal allograft and to assess the effect of irradiation on the incidence and severity of rejection and graft versus host disease after intestinal transplantation in dogs. Excessive intestinal damage was produced by 2,500 rads, but 750 and 1,500 rads produced no detectable acute or chronic damage in dogs observed from 100 days to two years. Using cyclosporine for postoperative immunosuppression, 1,500 rads reduced the incidence of acute (p = 0.05) and chronic rejection (p = 0.08), yet did not impair intestinal absorption of cyclosporine. The greatest improvement in survival occurred with 750 rads (p = 0.02). Histologic evidence of graft versus host disease appeared in the native small intestine in two of four long term surviving dogs receiving a nonirradiated graft but in none of the dogs receiving irradiated grafts. Irradiation of the graft may be a promising adjunct in the search for a clinically applicable method of intestinal transplantation.

The definition of ABO factors in transplantation: relation to other humoral antibody states

The first examples of hyperacute rejection of renal hemografts were seen almost 25 years ago when kidneys were transplanted to ABO incompatible recipients whose plasma contained antigraft isoagglutinins. Hyperacute rejection caused in sensitized recipients by lymphocytotoxic antibodies is similar in that the immune reaction triggers an acute inflammatory reaction that leads to widespread thrombotic occlusion and devascularization of the graft. The events after xenotransplantation between certain species are essentially the same. Potential strategies to avoid the precipitating antigen antibody reaction or to mitigate the resulting effector cascade are described.

Prolongation of pig-to-dog renal xenograft survival by modification of the inflammatory mediator response

The pathogenesis of hyperacute renal rejection consists of a nonspecific effector cascade that invokes most of the components of a typical acute inflammatory response. Platelet-activating factor (PAF) represents the most recent and perhaps the most significant mediator and promoting agent of this phenomenon. These studies evaluated SRI 63-441, a novel, synthetic, and the most potent PAF receptor antagonist available, alone and in combination with other prostanoids, for their ability to influence this response and to prolong renal xenograft survival and function in a model of pig-to-dog heterotransplantation. Inhibition of PAF by SRI 63-441 alone, at the dosage and schedule used in these experiments, did not significantly prolong xenograft survival or function. However, the combination of SRI 63-441 with either prostacyclin (PGI2) or prostaglandin E1 (PGE1) infusion demonstrated significant synergism, and resulted in a 6-9-fold increase in kidney survival and a 3-20-fold increase in urine output. Neither PGI2 nor PGE1 infusions alone significantly influenced this xenograft model. Electromagnetic flow studies demonstrated significantly delayed diminution in renal artery blood flow in the combination-treated animals. Serial and end-stage histologic examination of kidneys receiving combination therapy demonstrated a delayed onset of the pathologic deterioration and an overall amelioration of the entire process. These studies demonstrate that significant abrogation of a rapid and violent form of hyperacute rejection can be achieved solely by the pharmacologic manipulation of the inflammatory mediator response.