Successful Reversal of Diabetes by Single Donor Isologous Islet Transplantation in a Mouse Model

A method for isolating mouse islets which consistently gives a high yield with good purity is described. Using a bovine serum albumin gradient, the mean yield of islets per pancreas is 425 (SEM ± 15) with a consistent purity of over 90%. Single donor to single recipient of islets transplanted under the renal capsule restores normoglycemia in the diabetic recipients within 2 to 5 days of transplantation.

Transplantation of mouse pancreatic islets into primates--in vivo and in vitro evaluation

BACKGROUND

Islets transplanted from other species to man has the potential to cure diabetes but whether islets are subject to hyperacute rejection after xenotransplantation is contentious. We transplanted mouse pancreatic islets of mouse beneath the primate renal capsule and assessed natural xenoantibody binding, complement activation and cell lysis in vitro.

METHODS

Freshly isolated mouse islets were transplanted in a blood clot under the renal capsule of cynolmogus monkeys. The graft was removed after 24 hr for histological and ultrastructural analysis. Freshly isolated mouse pancreatic islets were analyzed in vitro by immunohistochemistry for Gal(alpha1,3)Gal and Von Willebrand factor expression and for IgG, IgM, C3, C4, and C5b-9 binding after incubation in 100% human serum. Complement mediated cell lysis was evaluated by 51Cr release assays after incubation of islets for 4 hr in human serum, plasma, and lymph with and without added neutrophils.

RESULTS

Mouse islets transplanted under the renal capsule of cynomolgus monkeys were destroyed within 24 hr by a process involving necrosis with neutrophil and mononuclear cell infiltration. Gal(alpha1,3)Gal was strongly positive on only 10% of islet cells. After islet incubation in 100% human serum before frozen section, human IgG and IgM, C3, C4, and C5b-9 was deposited on islets with increased intensity in the periphery. Measurement of 51Cr release from labeled fresh islets after four hours incubation in 100% human serum showed 17% lysis and was not changed by addition of neutrophils.

CONCLUSION

These results indicate that mouse islets in a primate recipient undergo rapid destruction by a process that has features similar to hyperacute rejection in vascularized organs and we propose the same term be used.

An overview of the immune system with specific reference to membrane encapsulation and islet transplantation

The concept of immunoisolation by use of a bioartificial membrane is discussed, concentrating on the immunological mechanisms that are likely to be operative in the light of recent information on the workings of the immune system. Special attention is given to the use of encapsulation for the purpose of treating autoimmune diabetes by implantation of xenogeneic islet tissue. It is argued that the term immunoisolation is misleading because the immune system is always activated by the indirect pathway of antigen presentation and that the term immunomodulation would be more appropriate.

Rising incidence of post-transplant lymphoproliferative disease in kidney transplant recipients

BACKGROUND

The purpose of this study was to determine whether the incidence of post-transplant lymphoproliferative disease (PTLD) has been increasing in renal transplant recipients in this centre.

METHODS

Prospectively gathered data were analysed to establish trends in the epidemiology of PTLD in 1537 patients.

RESULTS

Overall, PTLD occurred in 2.3 per cent of renal transplant recipients. An increase in its incidence coincided with the introduction of cyclosporin in the 1980s. However, there was a further increase in the incidence of PTLD in the 1990s when the only change in immunosuppressive policy was the abandonment of pretransplantation blood transfusion. The latter increase was particularly pronounced in patients with early-onset PTLD in whom it presented within 600 days after transplantation.

CONCLUSION

The incidence of PTLD has been increasing in renal transplant recipients. The recent increase appears to be independent of cyclosporin and may reflect the reduction in pretransplant blood transfusion. Changes in the incidence of PTLD may also mirror changes in the epidemiology of non-Hodgkin lymphoma in the general population.

Islet transplantation and glucose regulation

Transplantation of isolated islets of Langerhans for treatment of diabetes has been developed through experimental research in several species and is now being applied to humans with some success albeit limited. A significant problem for human islet allotransplantation or autotransplantation (following pancreatectomy) is the relatively poor yield of islets available for transplantation. The metabolic function of islet transplant recipients that have achieved insulin independence reflects the relatively small mass of insulin-secreting tissue implanted and the fact that only the intraportal site of transplantation appears to allow sufficient graft function to achieve insulin independence. The long-term function of such grafts has been poor, with most grafts showing deterioration in function within 5 years. Studies of islet transplantation in other species showed a similar result, although other sites for islet graft implantation, such as the spleen or kidney capsule, may be associated with a better outcome. These studies, however, also suffer from problems of relatively limited islet mass. Only in the rodent model where isogeneic strains are available is it possible to transplant sufficient numbers of islets to obtain an equivalent functional islet mass similar to that found in the normal pancreas; and in this case near-normal glucose metabolism is obtained and is maintained for the life-span of the animal.

Low dose aspirin as prophylaxis against renal-vein thrombosis in renal-transplant recipients

BACKGROUND

Renal-vein thrombosis (RVT) is an infrequent event that accounts for a high proportion of early renal allograft losses, since graft failure secondary to acute irreversible rejection is now relatively rare. The cause of RVT may be related to technical problems, clotting disorders, diabetes, or cyclosporin, but is often difficult to define.

METHODS

This retrospective study was performed to examine the influence of aspirin on the incidence of RVT in cadaveric and living-related renal transplant recipients receiving cyclosporin-based triple immunosuppression. The Oxford Transplant Centre database was used to identify all early (<30 day) non-immunological graft failures and case histories were examined for clinical and pathological evidence of RVT. In July 1991, aspirin (75 mg o.d. starting immediately before and continuing for 1 month post-transplant) was introduced as routine prophylaxis against RVT. Prior to this, aspirin prophylaxis was not used.

RESULTS

In the 6-year period from July 1985 to June 1991, there were 27 cases of RVT in 475 transplants (5.6%). In the subsequent 6-year period, there were six cases of RVT in 480 transplants (1.2%) (P:<0.01).

CONCLUSION

Although not abolished, this indicates a significant reduction in the incidence of RVT with the addition of low-dose aspirin.

Islet cell transplantation for insulin-dependant diabetes mellitus: perspectives from the present and prospects for the future

The long-term complications of insulin-dependant diabetes mellitus have become a major health care problem, and it is now clear that they arise from inadequate homeostatic control of blood glucose by injected replacement insulin. Transplantation of pancreatic islets is arguably the most logical approach to restoring metabolic homeostasis in people with diabetes. This review looks at the current status of human islet transplantation and the problems that remain. These include: (1) the limited supply of human islet tissue available for transplantation; (2) the adverse effects of current immunosuppressive protocols on diabetic patients; (3) the problems of primary nonfunction of the transplanted islets; (4) the rejection of islets; and (5) the recurrence of autoimmune diabetic disease. Some of the approaches that might solve these problems are then examined: (1) immune modulation to reduce or prevent immune attack by the recipient's immune system; (2) immunoisolation to prevent recognition of the islet graft; (3) induction of tolerance; (4) xenotransplantation using islets derived from animals; and (5) gene therapy.

Chronic allograft failure in human renal transplantation: a multivariate risk factor analysis

OBJECTIVE

To identify potential risk factors for the development of chronic renal allograft failure.

SUMMARY BACKGROUND DATA

Chronic allograft failure (CAF) is the leading cause of late graft loss in renal transplantation. The authors studied the risk factors for the development of CAF in a single center during a period in which a consistent baseline immunosuppression regimen (cyclosporine, azathioprine, and prednisolone) was used.

METHODS

Data from the Oxford Transplant Center Database were assessed on 862 renal allografts during a 10-year period. Risk factors were identified using multivariate logistic regression analysis.

RESULTS

Biopsy-proven CAF occurred in 77 patients (9.2%) in the entire group. Multivariate risk factor analysis revealed that early and late acute rejection episodes, proteinuria, and serum triglycerides were significant factors. Acute rejection after 3 months was more important than early acute rejection. Serum triglyceride level and proteinuria at 1 year were both elevated in the CAF group. Male sex provided a protective effect. Serum creatinine levels at 6 months after the transplant were not predictive of the risk of developing CAF.

CONCLUSIONS

These results from the largest single-center review to date suggest that both antigen-dependent and -independent factors are involved in the pathogenesis of CAF. Acute rejection at all time points has a significant impact on the development of CAF.

An evaluation of the Banff classification of early renal allograft biopsies and correlation with outcome

BACKGROUND

The Banff classification for assessment of renal allograft biopsies was introduced as a standardized international classification of renal allograft pathology and acute rejection. Subsequent debate and evaluation studies have attempted to develop and refine the classification. A recent alternative classification, known as the National Institutes of Health Collaborative Clinical Trials in Transplantation (NIH-CCTT) classification, proposed three distinct types of acute rejection. The 1997 Fourth Banff meeting appeared to move towards a consensus for describing transplant biopsies, which incorporated both approaches. Patients who received a renal allograft at the Oxford Transplant Centre were managed by a combination of protocol and clinically indicated biopsies. We have undertaken a retrospective analysis of the biopsies correlated with the clinical outcome to test the prognostic value of the original Banff (Banff 93-95) and NIH-CCTT classifications.

METHODS

Three hundred and eighty-two patients received renal allografts between May 1985 and December 1989, and were immunosuppressed using a standard protocol of cyclosporine, azathioprine and steroid. Adequate 5-year follow-up data were available on 351 patients, and of these, 293 had at least one satisfactory biopsy taken between days 2 and 35 after transplantation, the latter patients forming the study group. The D2-35 biopsies taken from these patients, which were not originally reported according to the Banff classification, were re-examined and classified according to the Banff 93-95 protocols. For each patient the biopsy found to be the most severely abnormal was selected, and the Banff and NIH-CCTT grading compared with the clinical outcome.

RESULTS

Seven hundred and forty-three biopsies taken from 293 patients between days 2 and 35 after transplantation were examined and the patients categorized on the basis of the 'worst' Banff grading as follows. Normal or non-rejection, 20%; borderline, 34%; acute rejection grade I (AR I), 18%; AR IIA, 6%; AR IIB, 14%; AR III, 1%; AR IIIC, 3%; widespread necrosis 3%. The clinical outcome for the last two groups combined was very poor with 18% of grafts functioning at 3 months and 6% at 5 years. The other groups with vascular rejection (AR IIB and AR III) had an intermediate outcome, graft survival being 78% at 3 months and 61% at 5 years. The remaining four groups (normal, borderline, cellular AR I and AR IIA) had the best outcome: graft survival 95% at 3 months and 78% at 5 years with virtually no difference between the four groups. Three forms of acute rejection, namely tubulo-interstitial, vascular and transmural vascular, were identified, but only the latter two categories were associated with a poor outcome.

CONCLUSIONS

The eight sub-categories of the Banff classification of renal allograft biopsies are associated with three different prognoses with respect to graft survival in the medium term. These three prognostic groups correspond to the three NIH-CCTT types. The data provide support for the consensus developed at Banff 97 separating tubulo-interstitial, vascular and transmural vascular rejection (types I, II and III acute rejection).

Receptors mediating CGRP-induced relaxation in the rat isolated thoracic aorta and porcine isolated coronary artery differentiated by h(alpha) CGRP(8-37)

1 Receptors mediating CGRP-induced vasorelaxation were investigated in rat thoracic aorta and porcine left anterior descending (LAD) coronary artery and anterior interventricular artery (AIA), using CGRP agonists, homologues and the antagonist h(alpha) CGRP(8-37). 2 In the endothelium-intact rat aorta, h(alpha) CGRP, h(beta) CGRP, rat beta CGRP and human adrenomedullin caused relaxation with similar potencies. Compared with h(alpha) CGRP, rat amylin was about 25 fold less potent, while [Cys(ACM2,7)] h(alpha) CGRP and salmon calcitonin were at least 1000 fold weaker. 3 H(alpha) CGRP(8-37) (up to 10(-5) M) did not antagonize responses to h(alpha) CGRP, h(beta) CGRP or rat beta CGRP (apparent pKB <5). Peptidase inhibitors did not increase either the effect of h(alpha) CGRP or [Cys(ACM,2,7)] h(alpha) CGRP, while h(alpha) CGRP(8-37) remained inactive. Endothelium-dependent relaxation produced by h(alpha) CGRP was accompanied by increases in cyclic AMP and cyclic GMP, that were not inhibited by h(alpha) CGRP(8-37) (10(-5) M). 4 In porcine LAD and AIA, h(alpha) CGRP produced relaxation in an endothelium-independent manner. H(alpha) CGRP(8-37) competitively antagonized h(alpha) CGRP responses (pA2 6.3 and 6.7 (Schild slope 0.9+/-0.1, each), in LAD and AIA, respectively). In LAD artery, h(alpha) CGRP-induced relaxation was accompanied by increases in cyclic AMP that were inhibited by h(alpha) CGRP(8-37) (10(-7)-10(5 )). 5 In conclusion, the antagonist affinity for h(alpha) CGRP(8-37) in porcine coronary artery is consistent with a CGRP1 receptor, while the lack of h(alpha) CGRP(8-37) antagonism in rat aorta could suggest either a CGRP receptor different from CGRP1 and CGRP2 type, or a non-CGRP receptor.

Delayed graft function: risk factors and the relative effects of early function and acute rejection on long-term survival in cadaveric renal transplantation

Delayed graft function (DGF) and acute rejection have both been associated with reduced renal allograft survival. In some studies, they have been shown to have an interactive effect. We studied the risk factors for DGF and the relative impact of DGF and rejection on both short- and long-term survival in recipients of cadaveric renal transplants. Data from the Oxford Transplant Centre Database were assessed on 710 cadaver allografts over a 10-yr period, during which time all recipients received cyclosporin-based immunosuppressive protocols. The interaction between DGF and acute rejection was examined using logistic and Cox multivariate regression. Long cold ischaemia time (CIT), sensitisation and older donor age were found to be independent predictors of DGF. The occurrence of DGF resulted in a reduced 5-yr survival (56 vs. 75%). However, the effect of DGF was confined to the first year post-transplant, as there was no significant difference in survival, as measured by half-life (t1/2) of grafts functioning at 1 yr, with DGF alone and a group with good early function (t1/2 = 21.3 vs. 20.0 yr). There was no increase in acute rejection in grafts with DGF. However, the combination of DGF and acute rejection resulted in the worst short-term graft survival (68% at 1 yr, compared to 92.3% in those grafts with no DGF or acute rejection) and this continued over the long term (t1/2 = 10.5 yr). These data suggest that early function is critical to the success of renal transplantation. The effects of DGF are limited to the first year post-transplant. Long-term graft survival may be improved by efforts to limit CITs, particularly for grafts from older donors and sensitised recipients.

Preoperative prediction of graft patency for infrapopliteal arterial bypass using pulse-generated runoff

OBJECTIVE

to assess: (i) pulse-generated runoff (PGR) as a tool for preoperative prediction of graft patency; (ii) the effect of PGR use on graft patency.

DESIGN

retrospective analysis of continuous patient data.

MATERIALS

all patients undergoing bypass to the infrapopliteal vessels in the Oxford Regional Vascular Unit between 1989 and 1993.

METHODS

preoperative assessment using ankle-brachial indices, intra-arterial digital subtraction angiography and PGR. Six-monthly and then yearly clinical and duplex sonography follow-up to assess graft patency. Univariate analysis of graft patency to assess discriminatory ability of PGR for graft patency.

RESULTS

a biphasic signal in the artery of insertion was associated with significantly better graft patency rate at 1 month and at maximum follow-up than was a monophasic signal. A monophasic signal was associated with a 12-month patency of 25% and a mortality of 37.7%. Use of PGR did not affect graft patency significantly.

CONCLUSION

PGR is a useful, non-invasive, means of preoperative patient assessment to determine the potential for maintained graft patency.

Type 1 diabetes: the facts fit a deficient inhibitory signal given by MHC class II

This paper presents a hypothesis regarding the aetiology of Type 1 (autoimmune) diabetes, which suggests that autoimmunity is normally prevented by an inhibitory or negative signal delivered by MHC molecules, and that in Type 1 diabetes it is the inability of beta cells to deliver sufficient negative signal from MHC Class II that drives the underlying autoimmune process. Based on a broad survey of the diabetes literature, a list of clinical, pathological, experimental and epidemiological 'facts' about Type 1 diabetes is presented which are considered to be widely accepted as proven. The new theory is then compared to other recent theories on the aetiology of diabetes with regard to its ability to explain these accepted 'facts'.

Formation and fate of tyrosine. Intracellular partitioning of newly synthesized tyrosine in mammalian liver

Tyrosine in an hepatocyte is transported from the plasma, synthesized from phenylalanine, or released during protein turnover. Effects of phenylalanine and tyrosine on the formation and fate (partitioning) of tyrosine from the different sources were examined in primary rat hepatocyte cultures. Rates of tyrosine degradation, transport, incorporation into and release from protein, and synthesis from phenylalanine were measured as well as the intracellular dilution of labeled tyrosine and phenylalanine incorporated into protein. We found tyrosine had little effect on phenylalanine hydroxylation over a wide range of conditions, that transported tyrosine and tyrosine from phenylalanine are in different metabolic pools, and that there appears to be channeling of newly synthesized tyrosine during degradation. In addition, under some conditions, intracellular partitioning of tyrosine is determined by tyrosine concentration. Specifically, if extracellular tyrosine is low and phenylalanine is at a normal plasma level, tyrosine use in protein synthesis takes precedence over tyrosine degradation or export. It is proposed that the mechanism controlling this is kinetic, based on relative rates of tyrosyl-tRNA formation and tyrosine degradation and export. A quantitative model of tyrosine and phenylalanine in-flow and out-flow in hepatocytes is given, incorporating tyrosine synthesis, degradation, plasma membrane transport, and tyrosine and phenylalanine use and release during protein turnover.

Major histocompatibility complex-based suppression: a mechanism for T-cell control

The crucial cell for immune system control is the T-cell. Current theories for T-cell control lack a credible mechanism for active down-regulation, because any mechanism that actively switches off T-cells must be secure from duplication by invading organisms. This hypothesis presents a system for T-cell control which is secure because it requires recognition of the highly polymorphic molecules of the MHC by the T-cell receptor as the down-regulatory mechanism, thus using the MHC as a form of individual security code.

Cytokine gene expression in pancreatic islet grafts in the rat

We examined the production of cytokine message in allogeneic and syngeneic rat pancreatic islet grafts using specific primers and polymerase chain reaction. Freshly isolated islet preparations contained transcripts for interleukin (IL)-1alpha, IL-6, IL-10, and interferon-gamma (IFN-gamma) but not for IL-2. IL-1alpha in allogeneic grafts showed increased and consistently high expression from 1 to 7 days after transplantation, but the level in syngeneic grafts fell quickly to pretransplant levels. IL-2 and IFN-gamma transcripts were found in allogeneic grafts at 1, 3, 5, and 7 days after transplantation with a peak at day 5, but these cytokines were almost absent from syngeneic grafts. The peak of IL-6 expression was 1 day after transplantation in both syngeneic and allogeneic grafts, and then the level fell quickly. IL-10 was produced at approximately the same high level at all time points in both syngeneic and allogeneic grafts. The results show that freshly isolated islet preparations contain IL-1alpha, IL-6, IL-10, and IFN-gamma transcripts at the time of transplantation. The initial production of cytokines in islet grafts, especially IL-1, may explain phenomena such as graft nonfunction, rapid rejection, and lack of response to immunosuppression.

The factor V Leiden (R506Q) mutation and risk of thrombosis in renal transplant recipients

BACKGROUND

Renal transplantation and chronic renal failure are associated with an increased risk of venous thrombosis and myocardial infarction (MI). We investigated whether resistance to activated protein C due to a mutation in the factor V gene (FV Leiden/FV506Q) may predispose patients to thrombosis.

METHODS

Three hundred patients who had undergone renal transplantation were genotyped for the FV mutation. Seventy-seven patients who had suffered thrombotic complications (42 venous, 28 arterial, and 7 both) were compared with 223 patients free of thrombosis.

RESULTS

Thirty-two patients had suffered early renal allograft thrombosis (30 venous), and 33 patients had suffered MI. A higher proportion of the patients with thrombosis, compared to those without, had a family history of arterial cardiovascular disease (42% vs. 26%, P=0.04). Eighteen (6%) patients were heterozygous for FV506Q and seven (39%) of these had suffered venous thrombosis (including four primary allograft thromboses), compared with 15% of the patients without the mutation (P<0.05). The odds ratio for risk of venous thrombosis for FV506Q carriers was 3.6 (95% confidence interval: 1.3-9.9) or 4.0 (1.2-13.8) for primary allograft thrombosis. Only one of the FV506Q carriers had suffered an MI.

CONCLUSIONS

Carriers of the factor V 506Q mutation with chronic renal failure who have undergone transplantation are at an increased risk of venous but not arterial thrombosis. This mutation explained 14% of all venous and 20% of primary allograft thrombosis, suggesting that other unidentified genetic and environmental factors contribute to the risk of thrombosis in renal transplant recipients.

Successful reversal of diabetes by single donor isologous islet transplantation in a mouse model

A method for isolating mouse islets which consistently gives a high yield with good purity is described. Using a bovine serum albumin gradient, the mean yield of islets per pancreas is 425 (SEM +/- 15) with a consistent purity of over 90%. Single donor to single recipient of islets transplanted under the renal capsule restores normoglycemia in the diabetic recipients within 2 to 5 days of transplantation.

Shortening in femoral shaft fractures in children treated with spica cast

Early spica cast treatment is one method used for children's femoral shaft fractures; it is increasingly advocated as treatment that allows early hospital discharge. The outcome of early spica cast treatment in 100 children, ages 2 to 10 years, with uncomplicated and isolated closed femoral shaft fractures treated at Johns Hopkins Hospital between October 1987 and March 1994 were analyzed. The objective was to identify those children who can be treated safely and dependably with early spica casting without excessive shortening of the fracture fragments. Eighty-one (81%) children had an acceptable outcome and 19 (19%) had an unacceptable outcome by the definition of more than 25 mm of fracture fragment overlap after clinical healing. A new clinical test, the telescope test, was statistically significant for correlation with spica cast outcome. Age, gender, fracture, location, mechanism of injury, fracture type, and resting radiograph of fracture fragment overlap were not statistically significant. The telescope test had a sensitivity of 80% and a specificity of 85% for predicting outcome. The relative risk for failure of spica cast treatment with a positive telescope test was 20.4 (95% confidence limits = 2.7-225.1). Children 2 to 10 years of age with uncomplicated femoral shaft fractures and a negative telescope test can be treated appropriately in most cases with early application of a spica cast.

Effect of one-HLA-haplotype-matched and HLA-mismatched blood transfusions on recipient T lymphocyte allorepertoires

BACKGROUND

Pretransplant blood transfusion has a well-known beneficial effect on posttransplant graft survival. Recently, it has been proposed that the clinical benefit of transfusion is due to HLA-DR antigen sharing between the blood donor(s) and the recipient. Immunological studies have suggested that this might result from a functional deletion of donor-reactive cytotoxic T lymphocytes.

METHODS

We investigated frequencies of alloreactive lymphocyte precursors with cytotoxic or interleukin-2-producing helper function by limiting dilution analysis in 10 renal dialysis patients before and after transfusion with fresh, allogeneic whole blood. Five patients received blood transfusions from donors matched for one HLA haplotype (or one HLA-B-DR antigen) and the other five patients received blood from fully HLA-mismatched donors.

RESULTS

Contrary to some previous reports, frequency analysis of cytotoxic T lymphocyte precursors revealed no significant differences between the two treatment groups in terms of development of blood donor-specific hyporesponsiveness after transfusion. Split-well analysis of cytotoxic T lymphocyte precursors reactive with single-mismatched HLA antigens demonstrated that the effects of transfusion on alloreactive specificity are complex and may vary depending on the particular antigens mismatched between the recipient and blood donor. Analysis of donor-specific helper T lymphocyte precursor frequencies revealed a significant decrease of interleukin-2-producing cells 3 months after transfusion in the total patient population. This effect was most prominent in the recipients of HLA-mismatched blood, but it also exhibited some degree of nonspecificity, as frequencies of third-party reactive helper T lymphocyte precursors were also significantly reduced.

CONCLUSIONS

Our overall results suggest that the degree of HLA matching between blood donor and recipient does not greatly influence the effect of blood transfusion on the T lymphocyte allorepertoire. The apparent induced down-regulation of helper T lymphocyte activity may play a role in the reported immunosuppressive effects of allogeneic blood transfusion.

Prospective evaluation of pretransplant blood transfusions in cadaver kidney recipients

BACKGROUND

A beneficial effect of pretransplant transfusions on graft survival was demonstrated in the early 1970s. In the mid-1980s, however, retrospective studies showed that transfusions had lost their graft-protective effect in the cyclosporine era. During the last 10 years, deliberate transfusion pretreatment of transplant patients has been discontinued.

METHODS

Within a collaborative project of 14 transplant centers, prospective recipients of cadaver kidney grafts were randomized to receive either three pretransplant transfusions or transplants without transfusions. RESULTS; The graft survival rate was significantly higher in the 205 transfusion recipients than in the 218 patients who did not receive transfusions (at 1 year: 90+/-2% vs. 82+/-3%, P=0.020; at 5 years: 79+/-3% vs. 70+/-4%, P=0.025). Cox regression analysis showed that this effect was independent of age, gender, underlying disease, prophylaxis with antilymphocyte antibodies, and preformed lymphocytotoxins. CONCLUSIONS; Transfusion pretreatment improves the outcome of cadaver kidney transplants even with the use of modern immunosuppressive regimens.

Patterns of graft infiltration and cytokine gene expression during the first 10 days of kidney transplantation

Understanding of the events preceding acute cellular rejection of kidney transplants would be useful in the development of immunosuppressive strategies to prevent rejection. Information about these events in humans has been scarce, because of the lack of early, serial, biopsy samples. We took daily fine needle aspirates from kidney allografts for the first 10 days after transplant. Samples were analyzed by morphological cytology of graft-infiltrating cells, and reverse transcriptase-polymerase chain reaction for detection of interleukin (IL)-2, IL-4, IL-6, IL-10, and gamma-interferon gene expression. During the first 4 days, all of the grafts developed a low-grade monocyte-rich mononuclear cell infiltrate, accompanied by IL-10 gene expression. Thereafter, the infiltrates either remained stable or intensified. Of the 13 grafts with dense infiltrates, seven developed graft dysfunction. The remaining six did not, despite significant interstitial infiltrates. Both rejecting and nonrejecting dense infiltrates were associated with a biphasic pattern of IL-2 and gamma-interferon gene expression, preceding and accompanying lymphocytic graft infiltration. Grafts that did not develop dense infiltrates had no detectable IL-2 or gamma-interferon gene expression and did not suffer cellular rejection during the study period. The development of both rejecting and nonrejecting infiltrates was strongly associated with DR mismatches between donor and recipient. IL-2 and gamma-interferon gene expression are necessary, but not sufficient, for the development of acute cellular rejection in the first 10 days of kidney transplantation, and are more closely associated with the period leading up to rejection than with the period of graft dysfunction.

Management of severe pancreatitis in renal transplant recipients

OBJECTIVE

The authors determine if any aspects of the treatment of renal transplant patients with pancreatitis were of particular benefit with regard to graft and patient survival.

BACKGROUND

The incidence of pancreatitis in renal transplant patients is low (1%-2%), but the mortality of the disease approaches 100%. Although several descriptive reports have been published, there is no consensus-regarding management.

METHODS

The authors conduct a retrospective chart review.

RESULTS

Twenty-one patients were identified with posttransplant pancreatitis (1.3% incidence). The cause of pancreatitis was presumed to be maintenance immunosuppression in all cases. Patients were classified by dynamic computed tomography (CT) scans having 1) mild/edematous disease (4 patients), 2) localized abscess or pseudocyst (6 patients), or 3) severe disease (11 patients). Patients with mild/edematous pancreatitis did well with medical management. The six patients with localized abscess or pseudocyst were successfully treated with standard operative intervention. Of the 11 patients with severe disease, 6 had several days of intensive medical management before operation, and all died. The other five patients underwent early operative intervention based principally on CT scan findings, and all survived. The latter group had multiple operations and four of five had functioning renal allografts at discharge.

CONCLUSION

The severity of pancreatitis in the posttranplant patients may be difficult to assess by clinical criteria. Dynamic CT scanning is, therefore, essential in defining the extent of disease. Early, and perhaps repeated, operations may be lifesaving in those patients having CT scan findings of severe pancreatitis.

Encapsulated islet cells: the role of direct and indirect presentation and the relevance to xenotransplantation and autoimmune recurrence

Immuno-isolation of islet tissue for the purpose of curing diabetes without immunosuppression is an attractive concept that has been extensively investigated over the last 20 years. Rather than give a detailed review of the past and present history of the immuno-isolation or encapsulation approach for islet transplantation, this paper will examine the concepts behind encapsulation, concentrating on the immune mechanisms involved.

Preemptive cadaveric renal transplantation--clinical outcome

Preemptive cadaveric renal transplantation (PCRT) maximizes the chance of maintaining high quality of life and may avoid the morbidity of dialysis and the associated financial costs. These benefits are offset by disadvantages, which include the possibility of transplantation many months before the need for dialysis, resulting in wasted organ function; an immediate risk of graft failure with conversion to a dialysis-dependent state; and uncertainty of the safety of PCRT. Patients who underwent PCRT between June 1976 and December 1994 at the Oxford Transplant Centre were compared with a matched cohort of first cadaveric transplant recipients who were dialysis-dependent when transplanted. The 116 patients in the PCRT cohort were well matched to the control group with respect to sex, age, blood group, HLA match, degree of sensitization, donor age, immunosuppression, and year of transplantation. Patient and graft survival were significantly better in the PCRT group. The difference in graft survival did not appear to be completely explained by better patient survival, as suggested by a trend toward better graft survival after excluding death with a functioning graft as a cause of failure. Among surviving grafts there were no significant differences in graft function as assessed by 1, 2, and 3 year plasma creatinine levels. In conclusion, PCRT appears to be safe and may even be associated with superior graft survival when compared with conventional transplantation. Early inclusion on a transplant waiting list with a view to PCRT can be justified with respect to the clinical outcome but the financial costs and implications for the utilization of cadaveric donor kidneys must also be considered.

A ten year audit of surgery for vascular trauma in a British teaching hospital

Vascular trauma is uncommon in the U.K. with the exception of Northern Ireland. In marked contrast to North America, gunshot wounds are rare and stabbings are infrequent. A 10 year audit was carried out in a regional vascular referral unit to determine the mechanisms, treatment and outcome of vascular injuries. Forty-seven patients were operated on during the period. The median age was 26 years (range 7-85 years); two-thirds were men. Road traffic accidents accounted for 21 (45%) of injuries, other accidents 15 (32%) and stabbings 11 (23%). There were no gunshot wounds. Most injuries were penetrating with no associated fracture. Commonly injured vessels were the brachial (30%) and superficial femoral (15%) arteries. Fifty-three primary operations were performed, 10 were vein interpositions and 21 were bypass grafts. There were three primary amputations (6%). Eleven patients suffered a complication including one death. One graft occluded requiring a further bypass. Two patients required fasciotomy as a secondary procedure. Median follow-up was 6 months. Eighty-one percent of patients were symptom free at last follow-up. There were no late vascular complications. Our experience is likely to represent that of other vascular units in countries with strict gun control legislation, little civil violence and modest levels of road traffic accidents.

Cytomegalovirus infection and colonic perforation in renal transplant patients

Cytomegalovirus (CMV) infection in immunocompromised patients is a major cause of morbidity and mortality. A well-documented manifestation of gastrointestinal CMV infection is gastrointestinal haemorrhage. In contrast, CMV-associated intestinal perforation has rarely been reported after transplantation, although it is well documented in AIDS patients. Three patients are reported who received their first cadaveric renal transplant in 1994 and subsequently developed CMV disease. During the course of their CMV illness, which was treated with ganciclovir, each presented with clinical suspicion of peritonitis and proceeded to laparotomy. All three were found to have sigmoid colon perforations with histological evidence of CMV infection. Following bowel resection and defunctioning, two patients made an uneventful recovery and have had the continuity of their bowel restored, but one died of overwhelming sepsis within hours of surgery. The explanation for the apparent clustering of this rare condition in transplant patients is uncertain.

Late reflush in clinical renal transplantation. Protection against delayed graft function not observed

Mechanical flushing of cadaveric kidneys with organ preservation fluid immediately before transplantation has been reported to be associated with improved early graft function. We report here the results of a prospective randomized controlled study of cadaveric renal transplantation after late reflush with organ preservation fluid in which no benefit with respect to delayed graft function was observed and, indeed, the protocol may have been harmful. The study was terminated after recruitment of only 18 patients (9 to each arm) because postreperfusion biopsies of reflushed kidneys contained unusual features, including abnormal cellular debris within the tubules or eosinophilic proteinaceous material within Bowman's capsule. These features were not present in the control kidneys. Acute tubular necrosis and biopsy-proven acute rejection episodes were more frequently seen in the reflushed kidneys, but at 1 year there was no significant difference in the function of the surviving grafts.

Cytomegalovirus infection and colonic perforation in renal transplant patients

Cytomegalovirus (CMV) infection in immunocompromised patients is a major cause of morbidity and mortality. A well-documented manifestation of gastrointestinal CMV infection is gastrointestinal haemorrhage. In contrast, CMV-associated intestinal perforation has rarely been reported after transplantation, although it is well documented in AIDS patients. Three patients are reported who received their first cadaveric renal transplant in 1994 and subsequently developed CMV disease. During the course of their CMV illness, which was treated with ganciclovir, each presented with clinical suspicion of peritonitis and proceeded to laparotomy. All three were found to have sigmoid colon perforations with histological evidence of CMV infection. Following bowel resection and defunctioning, two patients made an uneventful recovery and have had the continuity of their bowel restored, but one died of overwhelming sepsis within hours of surgery. The explanation for the apparent clustering of this rare condition in transplant patients is uncertain.

The role of zinc in solutions used for cold preservation of pancreatic islets

Advances in the field of organ transplantation have been made possible by progress in cold preservation as well as advances in immunosuppression, postoperative surgical care, and refinement of surgical techniques. The optimal solution for cold storage of pancreatic islets has not been defined, although recent studies have suggested that University of Wisconsin (UW) solution or derivatives may be significant advances. Zinc has a central role in the storage, synthesis, and secretion of insulin and is taken up preferentially by isolated islets to levels 30-fold higher than those of extracellular zinc. Since the currently used cold storage solutions do not contain zinc, we have investigated the effect of adding zinc to Hanks and UW solution and assessed the viability status of the islets at 0 h and at 1, 3, and 6 days. Islets of standard diameter were suspended in four solutions: Hanks solution, Hanks +20 microM zinc, UW solution, and UW +20 microM zinc. Viability was assessed by supravital staining, and each islet was scored at 0 h and at 1, 3, and 6 days. The results showed that UW solution was superior to Hanks solution for the preservation of pancreatic islets up to 6 days, but the addition of zinc was not beneficial. Despite the integral role of zinc in islet metabolism, we were unable to find a beneficial role for zinc in cold storage solutions for the purposes of islet preservation.

Hepatic cystic disease in an adult polycystic kidney disease transplant population

BACKGROUND

A study of the incidence of polycystic liver in a transplant population and an assessment of the impact of this disease on the group was undertaken. Clinical presentation, investigation and treatment of hepatic polycystic disease are explored.

METHODS

The study examined the morbidity incurred by polycystic liver disease in patients, patient and graft survival, incidence of hepatic cysts and presentation, investigation and management of morbid hepatic cystic disease. One hundred and eleven patients were studied.

RESULTS

It was found that hepatic cysts occurred in the majority of patients that underwent transplants for renal failure because of polycystic kidney disease at this institution. Symptomatic hepatic cystic disease was found to be primarily responsible for three deaths and affected between 15 and 20% of the group. Gall bladder disease was found to be associated with highly symptomatic hepatic cystic disease.

CONCLUSION

Hepatic cystic disease is common in patients that have had kidney transplants because of polycystic kidney disease. Morbidity is likely to increase as patients survive for longer periods. Cholecystectomy should be considered in patients with significant hepatic cystic disease.

The long-term metabolic function of intraportal and renal subcapsular islet isografts and the effect on glomerular basement membrane thickness in rats

Previous studies of intraportal islet autotransplantation in large animals have reported graft failure after months or years. In the rat it has been reported that intraportal islet isografts eventually failed whilst islets transplanted to the renal subcapsule functioned up to a year. We made Dark Agouti (DA) rats severely diabetic with streptozotocin, then 1000 or 3000 DA islets were transplanted beneath the renal capsule or into the liver. One set of transplanted rats and untreated diabetic and normal non-diabetic littermates were monitored lifelong by measurement of plasma glucose, others were killed at 6, 12 and 18 months for measurement of haemoglobin A1c, intravenous glucose tolerance test, pancreas insulin content and histology of the kidney. Renal glomerular basement membrane thickness was measured by the orthogonal intercept method. The results showed that intraportal isografts reversed hyperglycaemia significantly faster than renal subcapsular isografts. In the renal subcapsular site, consistent reversal of diabetes was achieved with 3000 islets but not with 1000 islets. Furthermore, intraportal islet grafts with 3000 islets led to lower, normal random glucose level than renal subcapsular grafts for the first 13 months. Normoglycaemia was maintained lifelong in all rats that achieved early normoglycaemia after transplantation of 3000 islets, irrespective of the site of islet transplantation. The fasting glucose, haemoglobin A1c levels, K value and glomerular basement membrane thickness of the recipients of 3000 islets to either the intraportal and subcapsular site were not significantly different from each other and the normal controls up to 18 months.(ABSTRACT TRUNCATED AT 250 WORDS)

A new cyclosporin derivative, SDZ-IMM-125, prolongs renal allograft survival in dogs

Previous studies in vitro and in rodent transplantation models have suggested that an analogue of cyclosporin, SDZ-IMM-125, has immunosuppressive properties at least equivalent to that of cyclosporin. As the bioavailability of the drug was considered to be greater than that of cyclosporin, it was hoped that lower doses could be used with the avoidance of nephrotoxicity. Renal allografts were undertaken between beagle dogs from two partially inbred breeding colonies. After transplantation, SDZ-IMM-125 was given orally at a dosage of 5, 7.5, 10 or 20 mg/kg/day, and graft survival compared to that in dogs given cyclosporin 10 mg/kg or in untreated animals. The results showed that SDZ-IMM-125 is immunosuppressive in dogs and prolongs graft survival up to 50 days at a dosage of 20 mg/kg/day. However, at this dose histological changes suggestive of liver toxicity were observed in one dog, and mild anaemia was produced,but there was no evidence of nephrotoxicity. Absorption profiles suggested that the drug is rapidly absorbed and metabolized, and that a more frequent daily dosage may be appropriate. Overall, there appeared to be no significant advantage for the analogue SDZ-IMM-125 over cyclosporin. The transplant model was associated with a high spontaneous renovascular thrombosis rate, particularly after cyclosporin administration, which was prevented by the daily administration of aspirin.

The quality of function of renal allografts is associated with donor age

The quality of renal allograft function was assessed by prospective measurement of creatinine clearance at 1 year (n = 197) and at 3 years (n = 115) after cadaveric renal transplantation in a cohort of 268 patients treated with triple therapy immunosuppression. Donor age (P < 0.0012) and recipient age (P < 0.01) were independently associated with creatinine clearance both at 1 and at 3 years. In patients with donor age above 50 years and recipient age above 45 years, the mean creatinine clearance was 32.7 (SD 10.4) ml/min (n = 27). When the donor age was below 30 years and recipient age below 45 years, the mean creatinine clearance was 55.6 (SD 14.4) ml/min (n = 47, P < 0.001). However, in these patients there was no significant association between graft function and many of the factors known to influence graft survival, such as HLA matching, sensitisation of the recipient, and the occurrence of rejection. In conclusion, the quality of renal allograft function declined with increasing donor and recipient age in our patients, whilst immunological factors were not significantly associated with function in surviving grafts.

Muscarinic cholinoceptor-stimulated synthesis and degradation of inositol 1,4,5-trisphosphate in the rat cerebellar granule cell

A detailed analysis of the generation and subsequent metabolism of inositol 1,4,5-trisphosphate [Ins(1,4,5)P3] following muscarinic cholinoceptor stimulation in primary cultures of rat cerebellar granule cells has been undertaken. Following incubation of cerebellar granule cell cultures with [3H]inositol for 48 h, labelling of the inositol phospholipid pool approached equilibrium. Significant basal labelling of inositol pentakisphosphate (InsP5) and inositol hexakisphosphate (InsP6), as well as inositol mono- to tetrakisphosphate, fractions was observed. Addition of carbachol (1 mM) caused an immediate increase in level of Ins(1,4,5)P3 (peak increase two-fold over basal by 60 s), which was well-maintained over the initial 300 s following agonist addition. In contrast, only a modest, more slowly developing, increase in inositol tetrakisphosphate accumulation was observed, whereas labelling of InsP5 and InsP6 was entirely unaffected by carbachol stimulation. Analysis of the products of Ins(1,4,5)P3 and inositol 1,3,4,5-tetrakisphosphate metabolism in broken cell preparations strongly suggested that Ins(1,4,5)P3 metabolism occurs predominantly via the inositol polyphosphate 5-phosphatase route, with metabolism via the Ins(1,4,5)P3 3-kinase being a relatively minor pathway. In view of the pattern of inositol (poly)phosphate metabolites observed on stimulation of the muscarinic receptor, it seems likely that, over the time course studied, the inositol polyphosphates are derived principally from phosphoinositide-specific phospholipase C hydrolysis of phosphatidylinositol 4,5-bisphosphate, although some hydrolysis of phosphatidyl-inositol 4-phosphate cannot be excluded.