Prolongation of lung xenograft survival in rats with a short course of deoxyspergualin and cyclosporin A

The efficacy of 15-deoxyspergualin (DSG), cyclosporin A (CyA), and splenectomy-alone or in combination-in prologing the survival of concordant lung xenotransplants was studied in the hamster-to-rat model. In the untreated group, rejection occurred within 3 days, with an elevation of lymphocytotoxic antibody titers. The rejected lung revealed that ED1+cells were more prevalent than MRC OX8+cells in the perivascular infiltrates. In the DSG group, the antibody response was suppressed and median survival increased to 7.5 days. The rejected lungs demonstrated a highly significant depression in ED1+cellular infiltration and a moderate MRC OX8+cellular infiltration. When maintenance CyA was combined with a short course of DSG, survival dramatically increased to beyond 100 days. There were no deposits of IgM, IgG, or C3 or of any cell infiltrate in the grafts of two animals sacrificed 107 and 119 days post-transplantation. We conclude that initial treatment with DSG combined with continuous CyA can suppress acute rejection in the hamster-to-rat lung xenograft model, resulting in longterm graft survival.     

The superior effect of the combination of FK 506 and deoxyspergualin on rat cardiac allograft survival

In this present study, the effects of FK 506 and 15-deoxyspergualin (DSG), with respect to dose, timing, and combination, were investigated in an ACI-to-LEW rat cardiac allograft model. FK 506 was adminstered intramuscularly for 14 days starting on day 0 after grafting, while DSG was given intraperitoneally for 7 days starting on day 0,4, or 7 after transplantation. FK 506 or DSG monotherapy prolonged cardiac allograft survival in dose-dependent manners, and the minimum effective dose for overcoming rejection was 0.1 mg/kg per day in the case of FK 506 and 1.0 mg/kg per day for DSG. The graft survival rate was higher with administration of DSG starting on day 4 on day 0 after transplantation. A low dosage of FK 506 strating on day 0, in combination with DSG starting on day 0 or day 4 (but not on day 7), had a synergistic effect in prolonging allograft survival for 14.0±3.3 days and 25.4±8.2 days, respectively. The most effective combination treatment schedule for prolongation of allograft survival was FK 506 starting on day 0 and DSG starting on day 4 after transplantation.     

Role of MLC serum inhibitory factors in high MLC-reactive kidney transplant recipients pretreated with donor-specific blood transfusion (DST)

In order to clarify the beneficial effect of donor-specific blood transfusions (DST) on kidney allograft survival, sera from 16 patients treated with DST were studied using the mixed lymphocyte culture (MLC) serum inhibition test. The results demonstrate that MLC inhibitory factors could be induced in the serum of the recipients after the completion of DST, and that these factors are directed against cells of the recipient but not against cell from the donor. Regarding the correlation with rejection episodes and clinical outcome, a significant improvement in renal transplant survival and reduction in rejection episodes was observed when MLC inhibitory factors were present in post-DST sera. These data suggest that such factors may contain antibodies directed against recognition sites on T lymphocytes, e.g., antiidiotypic antibodies, and the associated with prolonged graft survival of living-related, high MLC-reactive one-haplotype-mismatched kidney.     

Infiltration patterns of macrophages and lymphocytes in chronically rejecting rat kidney allografts

The migration of circulating leukocytes to sites of inflammation or antigen is based, at least in part, on the activities of adhesion molecules. In the context of organ transplantation, some of these have been shown to be upregulated during acute allograft rejection. As their role during chronic rejection has not been examined, we have used an established rat model to compare sequentially the presence of host cells within the grafts, as defined immunohistologically, with patterns of in vitro leukocyte binding and their dependence upon particular adhesion molecules. Various donor populations of peripheral blood lymphocytes (PBL), lymph node lymphocytes (LNL), and splenic monocytes were interacted with snap-frozen sections of allografted, isografted, and native kidneys at serial intervals up to 24 weeks after transplantation. Monocyte binding in the allografts rose at 8 weeks and peaked at 12 weeks, a period preceding the maximum numbers of macrophages noted immunohistologically in the chronically rejecting grafts at 16 weeks. Lymphocyte binding and infiltration patterns were similar, remaining stable throughout the follow-up period and consistently greater than those noted in isografts. In vitro binding of the monocytes was inhibited by mAbs against ICAM-1, LFA-1, CD18, and MAC-1; MAC-1 did not influence lymphocyte binding, although the other mAbs were effective. We conclude that adhesion molecules are responsible, at least in part, for patterns of cell populations infiltrating chronically rejecting renal allografts.     

The effect of donor-specific transfusion and cyclosporin A on small bowel transplantation in the rat

Pre-transplant blood transfusions are given as a means of desensitization to reduce the required dose of cyclosporin A (CsA). In this study, the effect of pretransplant blood transfusion on host survival and T-cell function against alloantigen were investigated. Male Lewis rats (RT1¹) were used as the recipients in all experiments, and male DA rats (RT1^a) were used as the blood and small bowel donors, and as a source of allogeneic stimulator cells. Male BUF rats (RT1^b) were used as donors of third party blood, and of allo-stimulator cells in a delayed-type hypersensitivity (DTH) response. In our experimental design, Lewis rats were divided into the following groups according to the type of administration: (1) a donor-specific blood transfusion (DST) 8 days preoperatively and a concurrent 5-day course of CsA at 10 mg/kg per day; (2) a nonspecific third party blood transfusion (NST) and CsA at 10 mg/kg per day from day 8 to day 4 preoperatively; (3) CsA alone from day 8 to day 4 preoperatively; (4) DST alone 8 days preoperatively; or (5) no treatment, being the control group. Postoperative treatment consisted of CsA at 2.5 mg/kg per day for 30 days. Rats conditioned with NST plus CsA, CsA alone, DST alone, and the untreated control rats survived for 7.2 ±1.2, 9.0 ± 2.2, 6.8 ± 0.4, and 7.4 ± 1.6 days, respectively. In contrast, the five rats conditioned with DST plus CsA survived for 100 days or more. This study demonstrates that long-term survival of a small bowel allograft can be achieved by host-conditioning with a combined treatment of DST and low-dose CsA.This paper was presented at the 10th Congress of the Asian Association of Pediatric Surgeons held in Seoul, Korea from March 26–29, 1990, and at the 90th Annual Meeting of the Japanese Surgical Society held in Sapporo, Japan in 1990.     

Intestinal graft versus native liver cytokine expression in a rat model of intestinal transplantation with and without donor-specific cell augmentation

BACKGROUND: Immunomodulatory strategies such as donor-specific bone marrow or blood transfusions have been used to promote engraftment after intestinal transplants. We previously showed that delivery of donor antigen via the portal vein can effectively reduce the rate of intestinal graft rejection. The purpose of our current study was to investigate the impact of donor-specific cell augmentation (blood versus bone marrow) via the portal vein on cytokine expression in intestinal grafts versus native livers. MATERIAL AND METHODS: We performed heterotopic small intestinal transplants between male Brown-Norway (donor) and female Lewis (recipient) rats. We studied 10 groups according to the type of donor-specific cell augmentation and the use and dose of immunosuppressive therapy. For cell augmentation, donor-specific blood or bone marrow was transfused via the donor portal vein immediately before graft implantation. For immunosuppression, tacrolimus was used post-transplant at a high or low dose. Control rats received neither immunosuppression nor cell augmentation. Tissue samples for histological assessment were obtained at designated time points. RNA was extracted from intestinal graft and native liver biopsies for cytokine measurements (IL-1 alpha, IL-1 beta, IL-2, IL-4, IL-5, IL-6, IFN-gamma, TNF-alpha, and TNF-beta). Chimerism levels were determined using Q-PCR analysis. RESULTS: Without concurrent immunosuppression, neither portal donor-specific blood nor bone marrow transfusion reduced the rate of rejection. With immunosuppression, outcome was significantly better after portal donor-specific blood (versus bone marrow) transfusion. Irrespective of the type of donor-specific cell augmentation, severe rejection caused strong cytokine expression in the grafts of IL-1 alpha, IL-1 beta, IFN-gamma, and TNF-alpha; in the native livers, mainly of TNF-alpha (with IFN-gamma showing hardly any increase). In general, rejection caused stronger cytokine expression in the grafts than in the native livers. Mild rejection correlated well with strong intragraft expression of IL-6, TNF-alpha, and TNF-beta (early rejection markers); severe rejection with IL-1 alpha, IL-1 beta, IFN-gamma, and TNF-alpha (late rejection markers).In addition to cell augmentation per se, the type of cell augmentation also had an impact on cytokine expression in both grafts and native livers. Cell-augmented (versus tacrolimus-treated) rats showed hardly any differences in intragraft cytokine expression, but the expression of almost all cytokines was significantly stronger in the native livers. With immunosuppression, bone marrow infusion increased intragraft cytokine expression of IL-1 alpha, IL-1 beta, IFN-gamma, and TNF alpha, as well as liver cytokine expression of IL-1 beta, compared to blood transfusion. This finding reflected the more advanced rejection stages in the bone marrow infused group; different types of donor-specific cell augmentation had similar effects on liver cytokine expression. In the absence of myoablative therapy, chimerism levels were low, in both cell-augmented and non-cell-augmented groups. CONCLUSIONS: Rejection and donor-specific cell augmentation independently causes differences in intragraft versus native liver cytokine expression after intestinal transplants. Portal donor-specific blood transfusion, as compared with donor-specific bone marrow infusion, lowered the incidence of rejection and diminished intragraft cytokine up-regulation.     

Effect of the number of pregraft blood transfusions in kidney graft recipients treated with bioreagents and cyclosporin A

The impact of a systematic, nondonor-specific, pregraft blood transfusion (BT) protocol was evaluated retrospectively in 446 consecutive, first renal transplant recipients with regard to graft survival rate, rejection, and incidence of infectious episodes. Cyclosporin A was the maintenance immunosuppressive treatment in all patients after a 2-week course of antithymocyte globulin or anti-IL-2 monoclonal antibody. Recipients were assigned to three groups according to the number of pregraft BT (one or two, three or four, or more than four). When nonimmunological failures were excluded from the study, patients receiving three or four BT had statistically better graft survival (P<0.02) and a lower incidence of rejection episodes (P<0.05) than those in the other groups. There were no significant differences between the three groups in the distribution of HLA mismatching (A, B and DR), time interval between the last BT and transplantation, DR6 recipient phenotype, or nonimmunological failures. Our results show that the number of pregraft BT is an important factor in transplantation.     

输血与心脏移植术后急性肾损伤相关性研究

目的研究围术期输血和心脏移植术后急性肾损伤(acute kidney injury,AKI)的相关性。方法选取2016年1月至2018年12月在广东省人民医院心外科行心脏移植术的67例患者作为研究对象。根据排除标准最后纳入63例患者,其中男53例、女10例,平均年龄(44.3±12.9)岁。将20例心脏移植术后使用连续性肾脏替代治疗(continuous renal replacement therapy,CRRT)的患者作为RT组,另外将没有使用CRRT的43例患者作为非RT组。比较两组患者基线资料、围术期输血资料及临床预后等指标。结果两组术前基线特征基本一致。两组在围术期输注红细胞量和血浆量、术后24 h出血量、是否再次手术探查等方面差异均有统计学意义(P<0.05)。多因素分析发现围术期输注红细胞量是AKI的独立危险因素(OR=1.115)。相关性分析显示肾损伤程度与围术期输注红细胞量呈正相关(r=0.686,P<0.05)。受试者工作特征(ROC)曲线下面积为0.923(95%CI 0.852~0.995,P<0.001)。经ROC曲线计算发现围术期输注红细胞超过18 mL/kg将增加心脏移植术后AKI发生率。结论围术期输血和心脏移植术后AKI密切相关,临床中输血越多肾损伤发生率越高、预后越差,建议可开展多种节约用血措施。     

Combined liver and kidney transplantation

Patients with end-stage renal and hepatic failure may be treated with combined liver and kidney transplantation (CLKTx). We reviewed the indications and outcomes of 16 CLKTx performed at the University of Minnesota between 1980 and 1994. The majority of the recipients (87.5%) were young patients affected by congenital hepatic anomalies and concomitant end-stage renal failure. Fourteen were treated with cyclosporin-based immunosuppression and had an excellent outcome: with an average of 6 years of follow-up, patient survival was 85.7%, liver graft survival 85.7%, and kidney graft survival 72%. The incidence of rejection episodes was similar to the rate of rejection in our solitary kidney and liver transplants. In conclusion, our experience supports the value of CLKTx in treating patients with simultaneous failure of both organs or with congenital enzymatic hepatic deficits leading to renal failure.     

Partial kidney transplantation: a successful kidney transplantation in a child with severe cardiac failure by surgical mass reduction of an adult donor kidney

We report on a trial of partial kidney transplantation performed on a low body weight child with impaired cardiac function due to mitral valve stenosis and uremic cardiomyopathy. The weight of the donated kidney was successfully reduced by one-third using bench surgery in order to obtain sufficient graft perfusion and function. Our procedure is justified when a graft is too large to be adequately perfused in a recipient suffering from cardiac failure.     

Long-term results of donor-specific blood transfusion with cyclosporine in living related kidney transplantation

Donor-specific blood transfusion (DST) was introduced to achieve better graft survival. However, its benefits are controversial considering the immunosuppression of cyclosporine (CYA) or tacrolimus (Tac), and its long-term effects have not been well discussed. Of the 40 patients who received DST with CYA, 3 (7.5%) became cross-match positive. Of the 37 patients with negative cross-match, 34 patients received a one-haplotype-matched kidney and were compared to patients with one-haplotype-matched kidney transplant without preoperative DST (n = 13). Acute rejection within 3 months after transplant was 29.4% in the DST group, and 15.4% in the non-DST group. All rejection episodes were steroid resistant in the non-DST group. If the graft survival rates were calculated excluding non-immunological graft loss, graft survival rate was 91.0 and 72.8% at 5 and 10 years in the DST group, and 83.3% at 5 and 10 years in the non-DST group, respectively. The two graft survival lines converged 7 years and 7 months after transplantation. No beneficial effect of DST was statistically evident under CYA immunosuppression. In terms of the severity of acute rejection or the onset of chronic rejection, DST induced a small benefit, however, which seemed to disappear within 8 years after transplantation.     

Effect of the number of pregraft blood transfusions in kidney graft recipients treated with bioreagents and cyclosporin A

Abstract. The impact of a systematic, nondonor-specific, pregraft blood transfusion (BT) protocol was evaluated retrospectively in 446 consecutive, first renal transplant recipients with regard to graft survival rate, rejection, and incidence of infectious episodes. Cyclosporin A was the maintenance immunosuppressive treatment in all patients after a 2-week course of antithymocyte globulin or anti-IL-2 monoclonal antibody. Recipients were assigned to three groups according to the number of pregraft BT (one or two, three or four, or more than four). When nonimmunological failures were excluded from the study, patients receiving three or four BT had statistically better graft survival ( P < 0.02) and a lower incidence of rejection episodes ( P < 0.05) than those in the other groups. There were no significant differences between the three groups in the distribution of HLA mismatching (A, B and DR), time interval between the last BT and transplantation, DR6 recipient phenotype, or nonimmunological failures. Our results show that the number of pregraft BT is an important factor in transplantation.     

The effect of deoxyspergualin (DSG) on rejection and graft-versus-host disease (GVHD) after small bowel transplantation

Abstract Both rejection and graft-versus-host-disease may occur after fully allogeneic small bowel transplantation. In this study, we established unidirectional models of rejection and GVHD in rats and evaluated the efficacy of 15-deoxyspergualin (DSG). When F1 small bowel was transplanted into LEW rats (rejection model) the graft was acutely rejected. The administration of DSG (5 mg/kg per day for 10 days) significantly prolonged the survival, but was efficacious only when used prophy-lactically. When a unidirectional GVHD model (F1 ± LEW SBTx) was examined, the administration of DSG from day O after grafting greatly suppressed GVHD, resulting in more than 300 days survival. However, only cutaneous GVHD, but not fatal GVHD, was suppressed when the start of administration was postponed until day 4 after grafting. From in vitro studies, DSG inhibited natural killer cell activities to K-562 and skin epidermal cells. The response was well correlated with in vivo GVHD course. These results suggest that DSG is an effective immunosuppressant for both rejection and GVHD when used prophylactically. DSG exerted the effect more stongly against cutaneous GVHD than fatal GVHD by inhibiting natural killer systems.     

Minimal sensitization and excellent renal allograft outcome following donor-specific blood transfusion with a short course of cyclosporine

A new protocol of donor-specific blood transfusion under cyclosporine coverage was developed and examined for immunologic consequences and clinical efficacy in recipients of one- or zero-HLA-haplotype-matched renal allografts. Between 1985 and 1989, 75 recipients were transfused with 100 ml of stored whole blood at 1, 8, and 15 days of its storage from either one-HLA-haplotype-matched related donors (n = 65, 33 from their parents, 30 from siblings, and 2 from offspring) or from zero-HLA-haplotype-matched donors (n = 10, 7 from spouses and 3 from siblings). During DST, all recipients received cyclosporine, 6 mg/kg/day, starting a day before and finishing a week after DST (23 days). Recipients were monitored by donor-specific mixed lymphocyte culture responses before and after DST, and serially for antibodies by fluorescence activated cell sorter analysis and by standard complement-dependent lymphocytotoxicity assay. Following DST with CsA, only 3 of 75 patients (4%) were sensitized against the blood donor. This rate is considerably lower, albeit statistically not significantly, compared with the 10% rate found in 30 recipients who had received DST without CsA in our previous study. Repeat MLC studied one to two months after DST (the day before transplant) were significantly increased compared with pre-DST (stimulation index: mean +/- SEM; 10.3 +/- 1.4 to 15.8 +/- 2.8, P = 0.004, and relative response: 40.9 +/- 5.1% to 49.8 +/- 5.5%, P = 0.003). Since the stimulation index with controls did not change after DST (23.4 +/- 2.9 to 26.2 +/- 3.3), enhanced MLC responses appear to be donor-specific. The changes in MLC responses did not correlate with the number of blood transfusion received prior to DST, the number of rejection episodes, or graft outcome. Fifty-seven recipients underwent a kidney transplant from their one-HLA-haplotype-matched blood donors within two to three months after DST. All 10 recipients of zero-haplotype-matched donors were also successfully transplanted from their respective blood donors. The graft survival rates were at least 90% at two years in both groups. In conclusion: (1) 100 ml of stored whole-blood DST, three times at weekly intervals with a short course of CsA is minimally sensitizing but effective in enhancing graft survival; (2) this protocol could be used in donor-recipient pairs who do not share a haplotype; and (3) DST with CsA elicits augmentation of donor-specific MLC responses.     

一种改进的大鼠肾移植模型

目的建立一种改进的大鼠异体肾移植模型。方法应用120只Wistar大鼠分别作为供体和受体，采用原位灌注、将供肾的血管与受体的同名血管作端-端吻合以及输尿管直接植入膀胱的方法建立大鼠原位肾移植模型。结果建立并改进了大鼠同种异体肾移植模型，成功率达到90％。热缺血时间小于3s，冷缺血（低温灌洗、供肾修整和冷保存）时间（40±5）min，血管吻合时间约35min，总手术时间为（160±10）min。结论该模型稳定性强，重复性好，适合于移植免疫的基础研究。     

Long-term effects of steroid withdrawal in kidney transplantation

The long-term graft function after withdrawal of steroids from maintenance immunosuppression was analyzed in 98 kidney recipients (59 on cyclosporin monotherapy, 39 on cycloporin plus azathioprine) who had not developed an early rejection episode when prednisolone was discontinued. Seven years after steroid withdrawal the probability of an increase in serum creatinine (>20% of baseline levels) was 51%. The increase in creatinine was associated with sclerosing arteriopathy as a marker of chronic rejection in 29 of 43 graft biopsies. The addition of azathioprine had no, effect on the stability of long-term graft function and did not influence the 7-year graft survival rate in this highly selected group of patients.     

Effect of enalapril on proteinuria after kidney transplantation

We studied the effect of enalapril, an inhibitor of angiotensin-converting enzyme (iACE), on proteinuria and renal function in recipients of renal allografts. Twenty-two patients with post-transplant nephrotic syndrome were treated with incremental doses of enalapril for 1 year. Urinary protein excretion decreased after 2 months of treatment from a mean of 8.9 g/day (range 4.0–18.9 g/day) to 4.5 g/day (range 0.4–10.0 g/day; P<0.01) and remained significantly low for the rest of the study. However, in the same period, creatinine clearance did not change significantly; it went from 47.8 ml/min (range 17.1–110.3 ml/min) before treatment to 44.2 ml/min (range 16.5–88.5 ml/min) after 2 months of iACE therapy. Analysis of individual data showed that there was a significant reduction in proteinuria in 14 of the 22 patients and that the rate of deterioration of renal function did not increase in 17 of the 22 patients. We did not observe any serious side effects of enalapril administration. The results of our study prove that iACE can be used safely and effectively to reduce post-transplant proteinuria.     

Prevalence and significance of anti-HLA and donor-specific antibodies long-term after renal transplantation

Post-transplant circulating anti-human leukocyte antigens (HLA)-antibodies and C4d in allograft biopsies may be important in chronic rejection in renal transplant recipients (RTR). We determined the prevalence and significance of anti-HLA-antibodies and donor-specific antibodies (DSA). Sera were collected from 251 RTR >6 months post-transplant. Sera were tested using enzyme-linked immunosorbent assay (ELISA) screening for anti-HLA antibodies. Positive sera were retested with ELISA-specific panel for antibody specificity. A 11.2% of patients had anti-HLA antibodies and 4.4% had DSA. Anti-HLA antibodies were significantly associated with pretransplant sensitization, acute rejection and in multivariate analysis, higher serum creatinine (2.15 +/- 0.98 vs. 1.57 +/- 0.69 mg/dl in negative anti-HLA antibodies group). Allograft biopsies performed in a subset of patients with anti-HLA antibodies revealed that 66% had C4d in peritubular capillaries (0% in patients without antibodies). Anti-HLA antibodies were associated with a worse allograft function and in situ evidence of anti-donor humoral alloreactivity. Long-term RTR with an increase in creatinine could be screened for anti-HLA antibodies and C4d in biopsy.