Soluble HLA class i antigens in pediatric patients with renal transplants from related living donors without acute rejection and treated with triple therapy

All HLA class I Ag—expressing cells may be the source of serum Ag sHLA I. T and B lymphocytes secrete considerable amounts of Ag sHLA I in a variety of in vitro and in vivo activation systems. The purpose of this study was to evaluate the level of Ag sHLA I in serum of children with kidney transplants from related living donors without acute rejection and with triple therapy. We studied 25 patients (2–21 years) with first kidney transplant, 19 individuals (10–20 years) undergoing hemodialysis without transplant, and 25 normal children (4–21 years). The levels of Ag sHLA in transplant patients was 0.2–3.2 μg/ml ( ). The hemodialyzed patients was 0.48-4.5 μg/ml ( ), and the normal control was 0.30-4.38 μg/ml ( ). A statistically significant reduction was observed in transplant patients compared to normal control and hemodialyzed patients (p < 0.05 in both cases), whereas between normal and hemodialyzed patients no significant difference was seen ( ). The reduced levels of Ag sHLA I in blood could be an expression of adequate immunosuppressive treatment. Human Immunology 50, 135–139 (1996)     

An experimental model of acute humoral rejection of renal allografts associated with concomitant cellular rejection

Acute humoral rejection (AHR), which occurs in up to 8% of kidney transplant recipients, is a significant cause of renal allograft dysfunction and loss. More efficacious treatment modalities are needed to eliminate or curtail alloantibody production and its deleterious effects on the kidney. The availability of animal models mimicking human AHR is essential to understand its pathophysiology and develop new treatment strategies. Using a mouse kidney transplant model, we demonstrate that presensitization of recipients with donor skin grafts results in rejection of subsequent renal allografts. All presensitized mice developed renal failure 8.6 +/- 4.3 days after engraftment, with serum creatinine values near 100 micromol/dl. Graft histology revealed mild, diffuse, interstitial, mononuclear cell infiltrates; prominent peritubular capillary inflammatory cell margination; patchy interstitial hemorrhage; interstitial edema; and focal glomerular fibrin deposition. Complement (C3d) deposition was diffuse and prominent in peritubular capillaries. Serum analysis demonstrated high levels of circulating alloantibodies with broad cross-reactivity to many MHC haplotypes. The clinical setting and histological findings of our model strongly resemble AHR, which is frequently associated with cellular rejection, a situation commonly encountered in human renal allograft recipients. This animal model provides a valuable tool to study the pathogenesis of AHR, its relationship to cellular alloimmunity, its contribution to graft injury, and the effects of various potential therapeutic interventions.     

Sialyl Lewisx- and L-selectin-dependent site-specific lymphocyte extravasation into renal transplants during acute rejection

Kidney allograft rejection is an inflammatory process dominated by lymphocytes. During rejection lymphocytes preferentially adhere to the peritubular capillary endothelium (PTCE), which acquires morphological features common to high endothelium. These observations indicate that PTCE is the site of lymphocyte entry into the rejecting renal allograft. Of the identified endothelial adhesion molecules, ICAM-1 was already expressed on the endothelium of normal kidneys, and its expression was strongly enhanced during rejection without site-specific restriction. VCAM-1 was not expressed on the endothelium of normal or syngeneic kidneys, but its expression was induced during allograft rejection not only in PTCE, but occasionally also on the endothelium of larger vessels. Sialyl Lewis^x (sLe^x) showed a very restricted pattern of expression; endothelium was sLe^x-negative both in control and syngeneic kidneys. On the other hand, PTCE reacted strongly with anti-sLe^x antibody in allografts. When kidney frozen sections were treated with sialidase the binding of lymphocytes decreased by 70%. Low-dose chymotrypsin treatment of lymphocytes, known to remove L-selectin from the lymphocyte surface, decreased their binding to PTCE by 60%. Likewise lymphocyte adhesion to PTCE was inhibited by 70% by anti-sLe^x- and anti-L-selectin-antibodies and by sLe^x tetrasaccharide. Finally PTCE in the allografts, but not in syngeneic grafts or normal kidneys, bound an L-selectin-IgG fusion protein, indicating that ligands for L-selectin were induced during rejection.     

Histopathological findings in oesophageal carcinoma with and without preoperative chemotherapy.

AIMS: To investigate the pathological effects of preoperative chemotherapy on oesophageal carcinoma. METHODS: Qualitative and quantitative changes in oesophageal carcinoma after preoperative chemotherapy were assessed by examination of biopsy specimens before treatment and resected specimens. RESULTS: Of 13 patients with adenocarcinoma treated with 5-fluorouracil, adriamycin, and mitomycin (FAM), nine showed minor histological changes compared with 14 control cases. All 12 patients with squamous carcinoma treated with preoperative mitomycin, ifosfamide, and cisplatin (MIC) showed noticeable histological changes when compared with the 13 control cases. Changes included complete ablation (n = 1) and partial regression (n = 5) of the tumour. A quantitative estimate of the proportion of tumour to stroma showed no difference between control adenocarcinomas and those treated with chemotherapy. There was, however, a significant reduction (p < 0.01) in the proportion of tumour to stroma in the treated squamous group compared with the controls. There was no relation between the degree of response in squamous carcinomas and the degree of differentiation of the tumour. Patients in which squamous carcinomas responded well, as assessed quantitatively, showed a tendency to better survival at one year. CONCLUSIONS: Histopathological changes attributable to chemotherapy can be observed in oesophageal carcinoma. The response of squamous carcinoma to MIC is histologically more evident than that of adenocarcinoma to FAM. A quantitative technique may be useful in assessing the effect of chemotherapy in oesophageal squamous carcinoma.     

Acute cellular rejection and cyclosporine nephrotoxicity monitored by biopsy in a renal allograft recipient. The differentiation of drug nephrotoxicity from rejection by phenotyping of cellular infiltrates

Serial allograft biopsies were performed on a renal transplant patient who experienced recurrent episodes of acute cellular rejection as well as cyclosporine nephrotoxicity. Five biopsies were performed after acute elevations of the serum creatinine level (15, 46, 155, 244, and 324 days after transplant). Each specimen was evaluated by routine histologic techniques as well as by immunofluorescence analysis and by monoclonal antibody labeling for determination of the cell phenotype of the mononuclear cell infiltrates within each specimen. The first and third specimens disclosed significant T-cell infiltrates with an equal number of T-cytotoxic-suppressor (Leu 2a) and T-helper-inducer (Leu 3a) cells in a diffuse cortical pattern, while the second biopsy showed a slightly milder infiltrate with a marked elevation (7:1) in the Leu 3a:Leu 2a ratio in the cortical-diffuse pattern. Clinically, the patient responded dramatically to cyclosporine dosage reduction following the second biopsy, and bolus steroid antirejection therapy following the first and third biopsies. These findings suggest that phenotypic cell marker analysis within the context of histologic pattern is a useful adjunct to the routine histologic evaluation of renal allograft biopsy specimens and may provide a means of differentiating rejection from cyclosporine nephrotoxicity.     

T-cell/periodic acid-Schiff stain: a useful tool in the evaluation of tubulointerstitial infiltrates as a component of renal allograft rejection

Distinguishing between tubulitis and tubulointerstitial mononuclear cell infiltrates and determining the severity of tubulitis are critical components of diagnosing and grading renal allograft rejection using the 1993 Banff schema, the revised 1997 Banff schema, or the Cooperative Clinical Trials in Transplantation grading system. We describe a novel staining method, the T-PAS stain (CD3 and periodic acid-Schiff), which removes some of the subjectivity in the evaluation of tubulointerstitial infiltrates in renal allograft biopsies. The method simply combines two routine stains, immunoperoxidase staining for T cells (CD3) and periodic acid-Schiff (PAS) staining for tubular basement membrane, on the same section.     

Differential distribution of tenascin and cellular fibronectins in acute and chronic renal allograft rejection.

BACKGROUND: Acute and chronic renal allograft rejection injuries involve, albeit variably, all compartments of the organ and are associated with significant structural changes. We hoped to gain new insights into these phenomena by determining distribution of certain extracellular matrix proteins known to be involved in architectural remodeling processes. EXPERIMENTAL DESIGN: Frozen tissue samples from biopsies of acute (n = 14) and chronic (n = 12) human renal allograft rejections were studied to compare distribution of tenascin, the extradomains A and B (EDA, EDB), and oncofetal (Onc) isoforms of cellular fibronectin (cFn). Normal kidneys (n = 4) served as controls. Cryosections were immunostained by the avidin-biotin-complex method with monoclonal antibodies specific for those molecules. RESULTS: In acute rejection, reactivity for tenascin and EDA-cFn was increased slightly to moderately in glomerular mesangia and in most vessels while it was intensely and diffusely increased in the interstitium. Rarely were focal EDB-cFn and Onc-cFn reactions seen in lesions deemed to reflect acute injury. In chronic rejection, tenascin and EDA-cFn were strongly increased in most glomerular mesangia and in vascular walls but unevenly in the interstitium. In rare glomerular synechiae and vessels, enhanced staining for tenascin and EDA-cFn as well as EDB-cFn and Onc-cFn was noted while in obsolete glomeruli only EDB-cFn and Onc-cFn were detected. The enhanced distribution of tenascin and EDA-cFn partly reflected that noted during nephrogenesis, whereas staining patterns for EDB-cFn and Onc-cFn differed from their fetal counterparts. CONCLUSIONS: Tenascin and EDA-cFn are strongly and preferentially expressed in the interstitial and vascular compartments of acute and chronic renal rejection injury suggesting that, in these sites, active repair and remodeling occur during both phases of the rejection process irrespective of the changes seen by conventional microscopy. Tenascin, EDA-cFn as well as EDB-cFn and Onc-cFn are all involved, albeit variably, in the glomerular and vascular alterations of chronic rejection. The finding of tenascin and of the three isoforms of cFn in glomerular synechiae with actively proliferating epithelium suggests that certain epithelial cells might partake in the synthesis of these molecules.     

Anti-adrenal cellular hypersensitivity in Addison's disease. II. Correlation with clinical and serological findings

Previous observations suggesting the existence in idiopathic Addison's disease of a state of anti-adrenal cellular hypersensitivity is extended to a larger material comprising thirty cases of idiopathic Addison's disease and seven cases of tuberculous Addison's disease. The specific anti-adrenal humoral and cellular hypersensitivity is evaluated by means of the indirect immunofluorescence technique and the leucocyte migration test, respectively.

Anti-adrenal cellular hypersensitivity was demonstrable in 46% of patients with idiopathic Addison's disease but in no case of Addison's disease of unquestionable tuberculous origin. Anti-adrenal cellular hypersensitivity could be demonstrated more frequently in males (eight out of eleven) than in females (six out of nineteen).

Anti-adrenal humoral hypersensitivity, i.e. occurrence of circulating anti-adrenal antibody, could be demonstrated in 73% of the patients with idiopathic Addison's disease. Humoral and/or cellular anti-adrenal hypersensitivity was found in 90% of the patients with idiopathic Addison's disease.

No correlation was observed between the occurrence of anti-adrenal cellular hypersensitivity, and the duration of clinical illness and the presence or absence of anti-adrenal antibody.

In two patients with diabetes mellitus humoral as well as cellular anti-adrenal hypersensitivity was demonstrated, although they had no clinical signs of Addison's disease.

     

Study of antibody dependent cellular cytotoxicity (ADCC). II. ADCC activity in renal graft recipients and acute accelerated graft rejection.

ADCC activity in 27 cadaver renal allograft recipients was studied. All the patients were given standard immunosuppressive treatment. Significant positive correlation between high ADCC activity during first 5 days after grafting and accelerated rjection crisis was found. The high positive ADCC test may signalize the possibility of acute accelerated rejection of renal allograft.     

3-Methylglutaconic aciduria type III in a non-Iraqi-Jewish kindred: clinical and molecular findings

Type III 3-methylglutaconic aciduria (MGA) (MIM 258501) consists of early bilateral optic atrophy, later development of spasticity, extrapyramidal dysfunction and occasionally cognitive deficits, and urinary excretion of 3-methylglutaconic acid and 3-methylglutaric acid. The presence of the disorder in an Iraqi-Jewish genetic isolate led to mapping of the OPA3 gene to chromosome 19q13.2-q13.3, followed by isolation of the gene itself. OPA3 consists of two exons and codes for a peptide of 179 amino acids. Iraqi-Jewish patients with type III MGA are homozygous for a splice site founder mutation in OPA3 (IVS1-1G>C) which abolishes mRNA expression in fibroblasts. Here we report a novel mutation in OPA3 (320-337del) in a Kurdish-Turkish patient with optic atrophy and 3-methylglutaconic and 3-methylglutaric aciduria, previously carrying the diagnosis of type IV MGA. We conclude that type III MGA occurs in patients of non-Iraqi-Jewish ancestry, and should be considered in patients with type IV MGA that have optic atrophy and ataxia.     

Histopathological findings in renal allografts at time of transplantation and correlation with onset of graft function.

Histopathological changes quantified using the chronic allograft damage index (CADI) have been shown to predict subsequent graft outcome and developing chronic rejection. The aim of the study reported here was to investigate the extent to which cadaveric renal allografts exhibit histopathological changes at time of transplantation, focusing on changes covered by the CADI. We also analysed whether any histopathological change predicts delayed graft function. One hundred and twenty-eight cadaveric kidney allografts with adequate protocol biopsy were studied. Tubular epithelial anisometric vacuolization was the commonest change, found in 62% of grafts and scored moderate or severe in 28% of these cases. Other prevalent changes were interstitial fibrosis, vascular hyalinosis, glomerular sclerosis and tubular basement-membrane thickening in 40%, 37%, 28% and 22% of biopsies, respectively. Intensities were, however, scored as mild in over 95% of specimens. The mean CADI for all grafts was 0.74. A significant difference in CADIs was seen between grafts from donors under and over 40 years of age. Grafts with early, delayed and no function had a similar incidence of histopathological changes. Histopathological changes in renal allografts were mostly uncommon and mild at time of transplantation, but some grafts exhibited changes which were quantified using the CADI. Though histopathological changes quantified with the CADI are predictive of subsequent graft function, they did not affect onset of graft function.     

The clinical and pathologic implications of plasmacytic infiltrates in percutaneous renal allograft biopsies

Plasmacytic infiltrates in renal allograft biopsies are uncommon and morphologically distinctive lesions that may represent variants of acute rejection. This study sought significant clinical and pathologic determinants that might have influenced development of these lesions and assessed their prognostic significance. Renal allograft biopsies (n = 19), from 19 patients, with tubulointerstitial inflammatory infiltrates containing abundant plasma cells, composing 32 +/- 8% of the infiltrating mononuclear cells, were classified using Banff '97 criteria. Clonality of the infiltrates was determined by immunoperoxidase staining for kappa and lambda light chains and polymerase chain reaction for immunoglobulin heavy-chain gene rearrangements, using V(H) gene framework 3 and JH consensus primers. In situ hybridization for Epstein-Barr virus encoded RNA (EBER) was performed in 17 cases. The clinical features, histology, and outcome of these cases were compared with kidney allograft biopsies (n = 17) matched for time posttransplantation and type of rejection by Banff '97 criteria, with few plasma cells (7 +/- 5%). Sixteen of 19 biopsies (84%) with plasmacytic infiltrates had EBER-negative (in 14 cases tested) polyclonal plasma cell infiltrates that were classifiable as acute rejection (types 1A [4], 1B [10], and 2A [2]). These biopsies were obtained between 10 and 112 months posttransplantation. Graft loss from acute and/or chronic rejection was 50% at 1 year and 63% at 3 years, and the median time to graft failure was 4.5 months after biopsy. There was no significant difference in overall survival or time to graft failure compared with the controls. Three of 19 biopsies (16%) had EBER-negative polyclonal plasmacytic hyperplasia, mixed monoclonal and polyclonal polymorphous B cell hyperplasia, and monoclonal plasmacytoma-like posttransplantation lymphoproliferative disease (PTLD) and were obtained at 17 months, 12 weeks, and 7 years after transplantation, respectively. Graft nephrectomies were performed at 1, 19, and 5 months after biopsy, respectively. Plasmacytic infiltrates in renal allografts comprise a spectrum of lesions from acute rejection to PTLD, with a generally poor prognosis for long-term graft survival.     

Telomere shortening and cellular senescence in a model of chronic renal allograft rejection

Cellular senescence has been suggested to play a role in the deterioration of renal graft function and has been linked to telomere shortening. We have investigated markers of cellular senescence in the F344 to LEW rat model of chronic renal transplant rejection. Syngeneic and LEW to F344 transplants were used as controls. Substantial telomere shortening was observed in all transplants, including allogeneic and syngeneic grafts from day 7 post-transplant onwards. Ischemia of native F344 kidneys was already sufficient to induce telomere shortening. It is known that shortened telomeres can activate cell cycle regulators, such as p21 and p16. Accordingly, all cases showed a transient p21 increase, with a maximum at day 7 and a sustained expression of p16. Importantly, senescence-associated beta-galactosidase staining, a cytological marker for senescence, was only observed in tubular epithelial cells of chronically rejecting F344 allografts from day 30 post-transplantation onwards. Long-term surviving LEW allografts or syngeneic F344 grafts were negative for senescence-associated beta-galactosidase. In conclusion, ischemia during transplantation results in telomere shortening and subsequent activation of p21 and p16, whereas senescence-associated beta-galactosidase staining is only present in chronically rejecting kidney grafts.     

Pulmonary involvement in type 1 Gaucher disease: functional and exercise findings in patients with and without clinical interstitial lung disease

Pulmonary disease is a well-known complication of Type 1 Gaucher disease (GD), although its incidence is not well established and its severity varies. The purpose of this study was to determine the frequency and extent of pulmonary involvement in patients with GD. Pulmonary involvement was assessed by history, physical examination and chest radiograph in 150 consecutive patients with Type 1 GD presenting at a specialized center for genetic diseases. Five patients were noted to have clinical evidence of pulmonary involvement. Full pulmonary function tests were performed in these five patients and in an additional 13 patients randomly selected from the remaining 145. Many of the 18 patients also underwent radionuclide body imaging with 67 Gallium citrate and 111Indium-tagged leucocyte scans, as well as incremental cardiorespiratory exercise tests. Lung biopsies were available in two patients with lung disease, and a second examination of lung tissue was performed in one of these two patients post-mortem. Clinical lung disease was detected in five patients. All five had dyspnea, diffuse infiltrates, restrictive impairment and low single breath CO diffusing capacity (DLCOSB). Two of these patients underwent exercise testing and showed abnormalities consistent with lung disease (ventilatory limitation, excessive ventilation and increased dead space) as well as decreased VO2 max. and anaerobic threshold (AT). In contrast, in the other 13 patients, physical examination, chest radiographs and pulmonary function were normal (except for a low DLCOSB in one patient). Responses on exercise testing (performed in six of the 13 patients) were consistent with a circulatory impairment (decreased VO2 max. and AT). Our study found that <5% of patients with Type 1 GD have clinical interstitial lung disease. In addition, we found that some patients, without evident lung involvement, may experience limitations in physical exertion and are easily fatigued; this is attributable to impaired circulation.