Factor XII, Plasma Prekallikrein, α2-Macroglobulin and C1-Inhibitor Levels in Renal Allograft Recipients During Immunosuppression with Cyclosporin A – Sequential Measurements over Four Months in 17 Patients

Factor XII clotting activity (F XII), plasma prekallikrein amidolytic activity (PK), α2-Macroglobulin (α2-M) and C1-Inhibitor (C1-Inh) antigens have been measured in 17 patients immediately before and sequentially for up to four months after kidney transplantation. Before transplantation mean F XII and PK levels were normal (99 ± 27% and 102 ± 21%, respectively, mean ± S. D.) and α2-M and C1-Inh levels were slightly elevated (115 ± 55% and 129 ± 32%, respectively, mean ± S. D.). In the first two weeks after transplantation a significant decrease of F XII to 65 ± 27%, of PK to 67 ± 20% and of α2-M to 88 ± 42%, and a rise of C1-Inh to 201 ± 44% (mean ± S. D.) were observed (2 p <0.005). F XII levels four month after operation remained significantly (2 p <0.05) lower than preoperatively. PK and α2-M values, however, were significantly higher (2 p <0.05) at four months as compared to the pretransplant period. Mean F XII levels in the 17 patients at various time points after transplantation correlated positively with PK, α2-M and serum albumin and negatively with CyA level and dose and serum bilirubin. PK and α2-M correlated positively with each other and albumin and negatively with creatinine, bilirubin and CyA (2 p <0.01). Whether CyA has a direct influence on production or consumption of F XII, PK, α2-M and C1-Inh, or whether the changes merely reflect altered protein metabolism awaits further study.

Measuring radioactive methane with the liquid scintillation counter

Although a gas proportional counter is the most convenient method of measuring the radioactivity of fixed gases such as methane, it cannot be used when high nonradioactive concentrations of methane are present in the gas phase, due to quenching. If only methane and carbon dioxide are present in radioactive form in the gas phase, a liquid scintillation method for measuring these substances can be used. The procedure is described in detail, and the solubility of methane in liquid scintillation cocktails is determined.

Atrial natriuretic peptide release and volume regulation following kidney transplantation

The major stimulus for atrial natriuretic peptide (ANP) release is atrial stretch and increased values are observed in volume overload states such as chronic renal failure. Since successful kidney transplantation restores volume homeostasis, we compared the effects of human cadaveric kidney transplantation on time course and changes of plasma ANP in the early postoperative period in 4 patients with successful and 4 patients with failed transplantation. ANP concentrations were elevated before transplantation in both groups (91 +/- 16 and 70 +/- 32 pmol/l) and decreased after successful (50 +/- 27 pmol/l, day 16) but increased after failed transplantation (146 +/- 45 pmol/l, day 16). Moreover, there was a close correlation between changes of body weight and ANP concentrations. Plasma renin activity decreased and plasma noradrenaline increased non-significantly in both groups, the latter more so after failed transplantation (116 +/- 42 to 194 +/- 156 vs 156 +/- 157 to 425 +/- 287 ng/l). No correlation was found between changes of renin activity or plasma catecholamines and ANP concentrations. The results indicate that the mechanisms governing release of atrial natriuretic peptide are operative in patients with chronic end-stage renal failure and after successful kidney transplantation with a return of atrial natriuretic peptide concentrations towards normal in the latter.

Risks and benefits of graft biopsy in renal transplantation under cyclosporin-A

261 patients who received a kidney transplant under cyclosporin-A immunosuppression were reviewed in order evaluate the benefits and the risks of renal graft biopsies. 240 graft biopsies were performed in 124 of the 261 patients. The biopsy diagnoses were 103x rejection, 90x cyclosporin-A toxicity, 8x acute tubular necrosis, 8x glomerulonephritis, 9x different biopsy results, and 12 cases of normal renal tissue. In 214 cases the clinical course was well explained by the biopsy result. The histological results led to therapeutical changes in 199 cases. 221 of the 240 biopsies were performed without any complications. There was only one biopsy with irreversible and there were 19 biopsies with reversible complications.

The efficacy and tolerability of cyclosporine G in human kidney transplant recipients

Twelve consecutive first cadaveric kidney transplant recipients received cyclosporine G (CsG)(initial dose 12 mg/kg per day) as basic immunosuppressive treatment along with prednisone (initial dose 0.5 mg/kg per day) for the first three months after transplantation. Thereafter CsG was replaced by Sandimmun (cyclosporine, CsA). Evaluation of the immunosuppressive efficacy and assessment of possible side effects of CsG was made and compared with the results in 38 historical control patients starting with the same dose of CsA as part of the same immunosuppressive dosage schedule. Statistically, there was no difference in patient survival at three (91% in CsG group versus 95% in CsA group) and twelve months (91% in CsG group versus 92% in CsA group), or in graft survival at three (75% in CsG group versus 89% in CsA group) and twelve months (75% in CsG group versus 84% in the CsA group). At equivalent oral doses of CsG and CsA significantly higher blood levels of CsG were observed (2P less than 0.05). Nephrotoxicity assessed by graft biopsy could be demonstrated to a similar extent in both groups, whereas hepatotoxicity was more pronounced during CsG treatment. Sequential measurements of bilirubin revealed a significant increase in all patients but median values were significantly higher in the CsG patients. A pronounced and concordant elevation of liver enzymes occurred during CsG treatment in three out of 12 patients. Liver biopsies performed in these patients revealed histological alterations consistent with toxic liver injury. Thus, in human kidney transplant recipients CsG and CsA appeared to be equally immunosuppressive and nephrotoxic but more hepatotoxic. On the basis of this limited experience we conclude that in human kidney transplant recipients CsG has no advantage over CsA.

Giant mitochondria in "zero-hour" transplant biopsies

Giant mitochondria in kidneys have increasingly been observed since the introduction of Cyclosporin A (CSA) as immunosuppressant in kidney transplants and in patients with autoimmune disorders. In animals treated with CSA, giant mitochondria were also described. In a study of "zero-hour" biopsies taken immediately before or after reperfusion of the renal transplant, giant mitochondria were often unexpectedly found. Retrospective analysis revealed that a significant increase in the number of giant mitochondria is more often associated with CSA therapy than ischemia. Giant mitochondria with sparse cristae seem to prevail in ischemia, whereas those with dense matrix and crystalloid structures predominate in CSA therapy.

Renal graft rejection or cyclosporin toxicity? Early diagnosis by a combination of Papanicolaou and immunocytochemical staining of urinary cytology specimens

A method is described for distinguishing between graft rejection and cyclosporin nephrotoxicity in renal allograft recipients by analyzing fresh morning urine samples. The technique combines classic Papanicolaou with immunocytochemical staining and was performed in urine specimens from a series of 42 patients. Early-stage cyclosporin toxicity was usually associated with increased numbers of proximal tubular cells only, whereas in rejection and late-stage toxicity there were increases in both tubular cells and in lymphocytes and monocytes (greater than 2000 cells/ml urine). Differentiation between these two clinical conditions was achieved by immunostaining, which revealed that increased numbers of CD25+ and CD8+ cells, as well as an increase in the HLA-DR/Lu5 ratio, were typical of rejection. CD25 positivity proved to be the best indicator of rejection, with a sensitivity and specificity of more than 90%. A cytodiagnostic algorithm is presented that is based on cell numbers and types, including immunophenotypes. The proposed method has the advantage of being noninvasive and appears to represent a reliable and rapid adjunct for the monitoring of graft function, especially in high-risk patients on cyclosporin immunosuppression.

Early diagnosis of kidney transplant rejection and cyclosporin nephrotoxicity by urine cytology

A total of 2000 urine samples from 53 kidney transplant recipients were studied to develop a routine method for the early diagnosis of rejection and cyclosporin (CSA) nephrotoxicity in urine. New-Sternheimer staining and an immunocytochemical technique were used together with classical Papanicolaou staining to differentiate cells in the urine. After cell count and differentiation of second morning urine samples with New-Sternheimer and Papanicolaou stains, immunocytochemistry was performed using antibodies against the following antigens: CD2, CD4, CD8, CD25, CD71 (transferrin receptor), HLA-DR and cytokeratin (Lu-5). Cell counts were obtained for the positively-reacting cells per millilitre of urine. By New-Sternheimer and Papanicolaou staining, CSA nephrotoxicity was characterized by the predominance of proximal tubular cells. During rejection episodes, increased numbers of mononuclear cells and renal epithelial cells were found. Immunocytochemical analysis showed a significant increase in CD2-, CD4-, CD8-, CD25-, CD71-, and HLA-DR-positive epithelial cells and in the ratio HLA-DR/cytokeratin-positive epithelial cells in rejection. CD25-positive cells had the highest sensitivity and specificity for the diagnosis of rejection. Our urine cytology technique proved to be a useful and non-invasive method for the early diagnosis of rejection and CSA nephrotoxicity.

[Glomerular hyperfiltration following unilateral nephrectomy in healthy subjects]

23 living related kidney transplant donors were prospectively studied to determine the degree of hyperfiltration which occurs after uninephrectomy and to monitor potential consequences of this procedure such as hypertension, microalbuminuria or renal functional impairment. Standard inulin and PAH clearance studies were performed immediately before (n = 23), one week after (n = 22) and one year after nephrectomy (n = 12). Hyperfiltration was defined as the ratio of (post-nephrectomy inulin clearance)/(0.5 x pre-nephrectomy inulin clearance), hyperperfusion was defined in an analogous way for PAH clearance. One week after uninephrectomy, hyperfiltration averaged 134 +/- 6% (SEM) and hyperperfusion was 138 +/- 6%. The degree of hyperfiltration did not correlate with donor age. One year after nephrectomy, hyperfiltration was nearly unchanged (130 +/- 7%) whereas hyperperfusion had significantly decreased to 119 +/- 8% (p less than 0.05). Blood pressure did not increase after nephrectomy and no new cases of hypertension were observed during follow-up. In contrast, there were two new cases of microalbuminuria at one week and one year after nephrectomy. Further follow-up of these kidney donors is warranted.

Morphologic findings in "zero-hour" biopsies of renal transplants

The extreme lack of renal grafts for transplantation stimulated us to analyze how strict the selection criteria of kidney donors must be. We investigated therefore if preexisting lesions in renal grafts influence initial and late renal function. 147 zero-hour biopsies of 101 donors (mean age 33, from 6-64 years) were examined. By ligh microscopy 38% of biopsies showed no, 44% showed nonspecific and 18% specific lesions. Nonspecific lesions comprised intimal fibrosis of small arteries in 44%, interstitial fibrosis in 8% and an arteriolar hyalinosis in 29%. Out of 102 immunohistologically examined biopsies 74.5% showed nonspecific IgM/C3 deposits in glomeruli and/or arterioles. An age dependent decrease of normal renal biopsies was found which was most evident in donors older than 40 years. Specific findings consisted of glomerulosclerosis (n = 4), glomerulonephritis (n = 11), intravascular coagulation (n = 10) and eclamptic kidney (n = 1). In case of nonspecific immunohistologic findings and in glomerulonephritis rebiopsies showed that antigen deposits usually disappeared within 4 months. Independent of morphologic findings 82% of transplant recipients had a good initial and late renal function. Since donor age, glomerulosclerosis, glomerulonephritis, intravascular coagulation or eclamptic changes seem not to compromise renal function after transplantation a more liberal choice of donors should be considered.

[Oral hairy leukoplakia in patients with kidney transplantation]

Oral hairy leukoplakia was initially reported only in HIV-infected patients and was considered pathognomonic for HIV infection. The presence of Epstein-Barr virus and the decrease in Langerhans cells seem to be necessary for the development of oral hairy leukoplakia. HIV antigen is not present in oral hairy leukoplakia. We report on seven renal transplant recipients with oral hairy leukoplakia. In six of these patients no HIV infection was present. All patients showed marked immunosuppression following a vigorous immunosuppressive regimen. Five patients each had several rejection episodes, which were treated with further immunosuppressive therapy in addition to the basic immunosuppressive regimen. One patient was infected with HIV from the renal graft and another suffered from liver cirrhosis with portal hypertension caused by chronic hepatitis B infection. We believe that oral hairy leukoplakia is a marker for severe immunosuppression that is not necessarily associated with HIV infection. Organ transplant recipients undergoing dermatological check-up should be examined for oral hairy leukoplakia.

[Familial adult cystic kidneys and malignant teratomas after kidney transplantation with cyclosporin therapy]

We report on two brothers with adult polycystic kidney disease, malignant teratomas and other genital malformations. Because of the unusual accumulation of malformations of embryologically related organs, we postulate a connection between malformations of the kidneys and the genital tract, on the one hand, and teratomas on the other. No genetic coherence is known so far. It is unlikely that immunosuppression with cyclosporin after transplantation had caused these tumours.

[Tendency to thrombosis following bone marrow transplantation?]

Various thrombosis related parameters of the hemostatic system were evaluated in 11 patients who had had bone marrow transplantation (BMT). At 0, 1, 3 and 6 months after BMT, antithrombin III, heparin cofactor II, protein S (PS), factor VIII:C, von Willebrand factor (vWF:Ag, vWF:RiCof), tissue plasminogen activator (tPA), plasminogen activator inhibitor, thrombin antithrombin III complexes (TAT), d-dimers (DD) and antiphospholipid antibodies (APA) were determined. A statistically significant rise in the levels of vWF was observed after BMT, with a similar trend for tPA. High TAT and/or DD were detected in 10/11 patients and positive APA only in 5/11. Of the other parameters only free PS was permanently low, with normal total PS and C4bBP. These findings suggest persistent thrombin generation peri- and post-BMT. The significantly high vWF and the low free PS could foster a procoagulant state.

von Willebrand factor and factor VIII in renal transplant recipients under immunosuppression with cyclosporine and steroids. Sequential measurements over 4 months in 17 patients

In 17 consecutive cadaver kidney transplant recipients treated with cyclosporine (CsA) and steroids, the median of antigenic and functional levels of von Willebrand factor (vWF) and factor VIII (FVIII) before transplantation were elevated (vWF:Ag: 206%, vWF:RCof: 202%; FVIII:Ag: 248%, FVIII:C: 224%; normal values 50-150%). Sequential measurements after transplantation and during CsA treatment revealed a transient significant increase of median values with highest amounts of vWF:Ag of 362% (2 p less than 0.0001), FVIII:Ag of 398% (2 p less than 0.001) and FVIII:C of 360% (2 p less than 0.0001) (Friedman test). vWF:RCof did not show statistically significant changes. After 4 months, levels of vWF and FVIII comparable to those obtained before transplantation were observed. In univariate statistical analysis no correlation was found between vWF of FVIII on the one hand and plasma creatinine levels, CsA dose or CsA whole blood through levels on the other hand. However, multivariate statistics revealed to some extent a positive influence of CsA blood levels on vWF:Ag levels. Patients with vascular rejection or chronic CsA nephrotoxicity showed significantly lower levels of vWF:Ag as compared with patients without endothelial cell damage in the kidney (2 p less than 0.05). However, the difference in vWF:Ag levels already existed before transplantation. In contrast to recent reports, plasma vWF levels were not indicative of vascular injury in kidney graft recipients nor was the marked elevation of vWF and FVIII associated with thromboembolic complications ascribed to CsA treatment.

[Asymptomatic microhematuria: follow-up in 39 patients]

We have studied 39 patients with asymptomatic microhematuria (AM) over a mean period of 3.7 years (2.6 to 5.3). In 28 patients, the etiology of the AM had remained unknown despite extensive work-up at the time of AM diagnosis. During follow-up, the urine was examined by the dipstick method and a urine sediment was prepared by standard techniques. Erythrocyturia was judged as grade I or grade II (3-9 or less than 9 erythrocytes/hpf) and classified by phase-contrast microscopy as glomerular or non-glomerular (greater than 30% or less than 30% of erythrocytes with glomerular characteristics). The results were as follows. All patients were in good health during the whole follow-up. None developed significant proteinuria or gross hematuria. AM persisted in 28 of the 39 patients (72%) and in 22 of the 28 with AM of unknown etiology (79%). Persistence of AM was independent of grade and morphology of AM. Among the patients with AM of unknown cause, the fifteen who initially showed grade I AM had grade I AM in 92% and grade II AM in 8% of follow-up urinalyses, and the seven with grade II AM at the first examination had grade II AM in 65% and grade I AM in 35% of follow-up urinalyses (p = 0.007). The last morphologic classification of AM corresponded to the first in all patients with grade II AM, but only in 74% of patients with grade I AM. The following conclusions were drawn. (1) Most AM of unknown etiology persists over several years irrespective of grade and morphology of erythrocyturia.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic cyclosporine-associated nephrotoxicity in bone marrow transplant patients

This study describes the prevalence and degree of chronic cyclosporine-associated nephropathy and its risk factors. For this purpose we reviewed all available renal histology specimens in 169 bone marrow transplant recipients treated during an eight year period with cyclosporine for prevention of graft-versus-host-disease, and determined their pattern and degree of histomorphological changes. A total of 51 specimens obtained from 49 patients by biopsy (n = 12) or autopsy (n = 39) was evaluated. The pattern of histomorphological changes was compared with diagnosis, age, sex, and potential risk factors--such as cyclosporine dose, levels, duration of therapy, changes in serum creatinine and onset of hypertension. Morphological lesions of chronic cyclosporine-associated nephropathy were found in 67% of the specimens. They were more frequent and more severe with increasing duration of cyclosporine therapy, in patients with a higher increase in serum creatinine during the first 3 months and in patients given total-body irradiation for conditioning. These latter findings suggest that additional damage sensitizes the kidney to irreversible toxic effects of cyclosporine.

[Transplantation of kidneys of relatives]

In the last few decades kidney transplants have shown an increasing survival rate of about 85% after one year. The growing demand for transplants is limited by the insufficient availability of kidneys and the living donor represents a possible means of reducing the discrepancy between supply and demand. We report here results of 41 transplantations from related, living donors. The overall transplant survival rate at one year was 91% and at 5 years 71%. In the group treated with cyclosporine the survival rate was 92% at 5 years. The mean serum creatinine levels at the latest follow-up was 115 mumol/l, while the mean blood pressure was 139/82 mmHg. Donor nephrectomy resulted neither in morbidity nor mortality. An extensive follow-up study of 8 donors revealed normal values for both blood pressure and serum creatinine. Careful donor selection is crucial in order to guarantee the voluntary nature of donation and, thus, to avoid the risk of commercialism.

Oral hairy leukoplakia in a HIV-negative renal transplant patient: a marker for immunosuppression?

We report the case of a 58-year-old renal transplant patient who developed oral hairy leukoplakia. Examination for HIV-1 and HIV-2 infection was negative. Biopsy of the lateral tongue showed ballooned prickle cells and electron microscopy revealed herpes-type viruses. In situ hybridization and examinations with the Southern blot technique yielded Epstein-Barr virus. Serology for Epstein-Barr virus was reactive. Immunological investigation of the patient showed a marked decrease of T-helper and T-suppressor cells as the result of immunosuppressive regimen. Oral hairy leukoplakia may be a marker for severe immunosuppression but is not necessarily associated with HIV infection.

Factor XII, plasma prekallikrein, alpha 2-macroglobulin and C1-inhibitor levels in renal allograft recipients during immunosuppression with cyclosporin A--sequential measurements over four months in 17 patients

Factor XII clotting activity (F XII), plasma prekallikrein amidolytic activity (PK), alpha 2-Macroglobulin (alpha 2-M) and C1-Inhibitor (C1-Inh) antigens have been measured in 17 patients immediately before and sequentially for up to four months after kidney transplantation. Before transplantation mean F XII and PK levels were normal (99 +/- 27% and 102 +/- 21%, respectively, mean +/- S.D.) and alpha 2-M and C1-Inh levels were slightly elevated (115 +/- 55% and 129 +/- 32%, respectively, mean +/- S.D.). In the first two weeks after transplantation a significant decrease of F XII to 65 +/- 27%, of PK to 67 +/- 20% and of alpha 2-M to 88 +/- 42%, and a rise of C1-Inh to 201 +/- 44% (mean +/- S.D.) were observed (2 p less than 0.005). F XII levels four month after operation remained significantly (2 p less than 0.05) lower than preoperatively. PK and alpha 2-M values, however, were significantly higher (2 p less than 0.05) at four months as compared to the pretransplant period. Mean F XII levels in the 17 patients at various time points after transplantation correlated positively with PK, alpha 2-M and serum albumin and negatively with CyA level and dose and serum bilirubin. PK and alpha 2-M correlated positively with each other and albumin and negatively with creatinine, bilirubin and CyA (2 p less than 0.01). Whether CyA has a direct influence on production or consumption of F XII, PK, alpha 2-M and C1-Inh, or whether the changes merely reflect altered protein metabolism awaits further study.

[Diagnosis of glomerular and non-glomerular erythrocyturia using phase contrast microscopy of the urine sediment]

Recently the appearance of deformed polymorphous erythrocytes in the urinary sediment has been described as characteristic of glomerular bleeding. We studied 30 patients with histologically confirmed glomerular disorders and 25 patients with urological diseases and with hematuria. In the sediment of 10 ml urine 200 erythrocytes were counted under phase-contrast microscopy and evaluated relative to their morphology. The number of glomerular erythrocytes was expressed as a percentage. In all groups of glomerular disorders (mesangial-proliferative, membranous and membrano-proliferative glomerulonephritis, focal segmental glomerulosclerosis, glomerulonephritis of systemic disease, thinning of the glomerular basement membrane) the percentage of glomerular erythrocytes varied widely between 2 and 100%. In 7 cases less than 10% of glomerular erythrocytes were found. There was no correlation between the percentage of glomerular erythrocytes and the degree of renal insufficiency, hematuria or proteinuria. On the other hand, in patients with hematuria from the lower urinary tract, erythrocytes were uniformly non-glomerular in shape (95-100%). We conclude that 10-20% or more of glomerular erythrocytes in the urinary sediment are a good indicator of glomerular disease, whereas lower figures do not definitely rule out a glomerular origin for hematuria.

[Criteria for hemostasis in kidney transplant patients. Comparison of patients undergoing immunosuppression with cyclosporin and azathioprine steroids]

Studies on one-year function conducted by the European Multicenter Trial showed that, after renal allograft transplantation, bleeding complications were only found in patients treated with cyclosporin as compared with those treated with azathioprin/steroids. To investigate a possible relationship between the bleeding tendency and the cyclosporin treatment, 18 parameters of hemostasis were studied in 11 patients, 6 of whom received cyclosporin A and the other 5 conventional treatment with azathioprin/steroids. Bleeding tendency could not be related to any specific coagulation parameter. Of interest is that clot retraction was significantly lower in the cyclosporin group (88 +/- 9% vs. 125 +/- 10%). Considering the fact that the skin bleeding time according to Ivy was normal in all patients, the clinical significance of the lower levels of the clot retraction appears to be minor. Discriminant analysis showed that these significantly lower clot retraction values could not be related to the lower platelet count levels in platelet rich plasma (205 000 +/- 85 000/mm3 vs. 280 000 +/- 67 000/mm3) but were associated with cyclosporin A treatment. All factor-VIII related activities were elevated in both groups. The main difference between the cyclosporin group and the conventionally treated group was significantly elevated levels of factor VIII procoagulant antigen (VIII: CAg) (cyclosporin A treated group: VIII: CAg 435 +/- 145%, conventionally treated group: VIII: CAg 215 +/- 99%). These results suggest hypercoagulability rather than bleeding tendency under cyclosporin treatment.

[Reduced fibrinolytic activity in the marginal zones of decubital ulcers]

Healing of decubital ulcers is, in contrast to that in other skin wounds, protracted. The reason for this is still unknown. The microscopic findings show the typical picture of a chronic ulcer with prominent scar tissue. To investigate the fibrinolytic activity of the ulcer margin and the adjacent skin tissue, samples of 13 ulcers were obtained and incubated on fibrin plates using the technique of PERMIN, ASTRUP and MULLERTZ. Lytic activity is expressed as mm2 of the lysed fibrin spots. In the border zone (1.5 mm zone), fibrinolytic activity was significantly reduced (12.7 mm2) as compared with the activity of the 9 mm zone (38.1 mm2) of the adjacent skin. Skin samples at a distance of 12 mm from the ulcer border still exhibited significantly lower fibrinolytic activity (39.4 mm2) than normal skin (71.5 mm2). The significantly lower fibrinolytic activity of the ulcer border in decubital ulcers may contribute to the poor healing tendency and indicates a decreased microcirculation. The fibrinolytic activity test offers an objective test of therapeutic principles.