Muromonab-CD3 therapy for refractory rejections after liver transplantation: a single-center experience during two decades in Japan

Background/purpose

Refractory rejections still occur in the liver transplantation (LT) field. The aim of this study was to investigate significant factors for the introduction of therapy with muromonab-CD3 (MCD3) after LT.

Methods

A total of 1415 LT patients were retrospectively evaluated, and 11 of the recipients received MCD3 therapy because of steroid-resistant rejections. The clinical factors before LT and before MCD3 therapy were investigated.

Results

The recipients were retrospectively divided into two groups based on responses to MCD3 therapy, including their clinical courses after MCD3 therapy and their outcomes. The MCD3 therapy had positive effects in LT recipients with the following four factors: low score of model for end-stage liver disease or pediatric end-stage liver disease; earlier time point of the first incidence of rejection; more frequent steroid pulse therapy (SPT) within 2 weeks after LT; and the expression of CD3 in the peripheral blood before MCD3 introduction.

Conclusion

Optimal induction of MCD3 triggered recovery from refractory rejections, especially in LT recipients in a stable condition, but not in those in a critical or compromised condition.     

High or low dose steroid therapy for acute renal transplant rejection after prophylactic OKT3 treatment: a prospective randomized study

In this prospective randomized study, acute renal transplant rejections occurring in patients who received prophylactic OKT3 therapy were treated with either 3 pulses of 8 mg/kg methylprednisolone (MPS) in an alternate-day regimen (total dose 25 mg/kg in 1 week, H group, n = 24) or 5 daily pulses of 3 mg/kg MPS (total dose 17 mg/kg, L group, n = 22). Acute rejection was proven by biopsy in more than 85% of cases in both groups. No difference was observed in rejection reversal (H 88%, L 91%), graft losses in the following 3 months (H 11%, L 4%) or the time evolution of the serum creatinine levels. The number (H 14, L 21) as well as the nature and severity of infections were similar in both groups. Only one death occurred in a patient who received OKT3 rescue therapy for corticoresistant rejections and developed Epstein-Barr virus (EBV)-related lymphoma. In conclusion, low dose MPS pulses appear as effective and safe as a higher dose to reverse acute rejection occurring after OKT3 prophylaxis. Thus, we favour the use of the low dose regimen in these patients.     

Morbidity and mortality of recurrent hepatitis C infection after orthotopic liver transplantation

Summary. Through molecular virological testing it is now clear that HCV reinfection of the allograft is virtually universal in liver transplant recipients. Although histopathological recurrence of hepatitis C occurs in the majority of patients, it is absent in a substantial minority. To date, no prognostic factors, other than genotype lb, have been identified that accurately predict these dissimilar outcomes. The natural history of recurrent hepatitis C varies. Historically, it has been regarded as generally benign. However, with increasing numbers of patients transplanted for hepatitis C it is now clear that a subgroup of patients develops severe progressive cholestatic hepatitis associated with allograft failure and death without retransplantation. Within 5 years following OLT, approximately 15–20% of patients progress to chronic active hepatitis and another 15–20% become cirrhotic. A minority of patients develop glomerulopathy or vasculitis, which are often associated with cryoglobulinaemia. The impact of immunosuppressive medications and rejection episodes on histopathological recurrence of progressive hepatitis C remains controversial and requires further studies. Although actuarial survival rates of patients transplanted for hepatitis C differ among transplantation centres, it appears that histopathological recurrence of hepatitis C does have an adverse impact on actuarial survival compared to the survival of patients transplanted for autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis and metabolic liver diseases. When allograft failure develops in patients with recurrent hepatitis C, retransplantation is indicated, even though recent reports indicate that mortality may be increased, especially with concurrent renal insufficiency.     

Primary Sjögren's Syndrome and Psoriasis Vulgaris in a Case of OKT4 Epitope Deficiency

We report a 29-year-old female OKT4 epitope deficiency patient with primary Sjögren's syndrome and psoriasis vulgaris. Immunological investigations during the prolonged clinical course of her herpes zoster revealed that she has OKT4 epitope deficiency and primary Sjögren's syndrome. She had been treated for psoriasis vulgaris for 17 years without systemic immunosuppressive therapy. Flow cytometric study revealed that her OKT4 deficiency is heterogeneous and excluded interference with the OKT4 epitope by anti OKT4 autoantibodies. The rare coexistence of primary Sjögren's syndrome and psoriasis implicates an immune disturbance due to an unusual phenotype of CD4.     

Increase of sTNF receptor levels in acute renal allograft rejection after treatment with OKT3

The use of OKT3 is associated with severe clinical side-effects.Adverse reactions are partly attributed to release of tumournecrosis factor (TNF). TNF binds to two receptors on the outermembranes of most human cell lines. Shedding of these proteins(sTNFR-p55 and sTNFR-p75) may block biological effects of TNF.Here we show a fair correlation between serum levels of sTNFRsand renal function as measured by glomerular filtration rate(GFR). In addition we assessed levels of sTNFR-p55 and sTNFRp75, corrected for reduced renal clearance, in renal allograftrejection and following treatment with OKT3. Corrected serumlevels (CSL) of sTNFR-p55 and sTNFR-p75 were determined in 12renal allograft patients treated for an acute rejection episodewith either OKT3 or methylprednisolone (MPNS). Serum levelsof CSLsTNFR-p55 and CSLsTNFR-p75 in both groups prior to anti-rejectiontreatment were not elevated. CSLsTNFRs peaked at 1 h after theadministration of OKT3, whereas in the MPNS group CSLsTNFRsremained unchanged. We conclude that in acute renal transplantrejection CSLsTNFRs increase after treatment with OKT3. In spiteof high circulating sTNFRs levels all OKT3-treated patientssuffered from clinical side-effects.     

Leukocyte surface antigens in patients with multiple sclerosis

Lymphocyte phenotypes have been measured in 20 normal females, 19 normal males, 3 females with acute exacerbations of MS and 21 females and 17 males with chronic progressive MS. Using a FACS IV, lymphocytes were gated by light scattering properties, and fluorescence was analyzed using a log amplifier. No abnormalities were found in the 3 females with acute exacerbations. In male patients the percentage of OKT8 was significantly reduced, the percentage of OKT4 was significantly increased, and the ratio of OKT4/T8 was increased. In females with chronic progressive disease the percentage of OKT8 was not statistically altered, but the percentage of OKT4 and the OKT4/T8 ratio were elevated. Interpretation of these findings requires more extensive study in control populations.     

Phenotypic heterogeneity of human T-cell malignancies: demonstration by monoclonal antibodies and cytochemical markers

The present study sought to delineate the phenotypic heterogeneity of the human T-cell malignancies. Twenty T-cell neoplasms were investigated for reactivity with the OKT hybridoma monoclonal antibodies and expression of acid alpha-naphthyl acetate esterase (ANAE), beta-glucuronidase (BG), and acid phosphatase (AP) activity. Twelve cases (Mycosis fungoides, Sezary syndrome, cutaneous T-cell lymphoma, chronic lymphocytic leukemia) were OKT3'T4', ie, expressed the phenotype commonly associated with mature T-helper cells. These cases were further divisible into ANAE+BG+ (6 cases), ANAE-BG+ (5 cases), and ANAE-BG- (1 case) phenotypes. In contrast to the 12 OKT3+T4+ cases, the remaining 8 cases showed considerable inter- and intratumor heterogeneity with respect to reactivity with the OKT antibodies. Six of these cases (acute lymphoblastic leukemia, lymphoblastic lymphoma) expressed phenotypes consistent with various intrathymic stages of T-cell differentiation. Five of the latter 6 cases were AP+BG+ANAE-, analogous to the majority of normal cortical thymocytes; an OKT3+T4-T8+T10+ neoplasm was ANAE+, analogous to normal medullary thymocytes. Two cases expressed the previously undescribed OKT3+T4-T8-T10+ phenotype. These studies demonstrate that the T-cell malignancies are divisible into phenotypes which correspond to normal maturational stages of T-cell differentiation and functionally distinct T-cell subsets. Phenotypic analysis of the human T-cell malignancies may provide a basis for understanding their biological heterogeneity and may aid in the identification of transitional stages of T-cell differentiation and minor T-cell subsets.     

Anti-lymphocyte antibodies late in the course of pediatric renal transplantation

 Beyond the immediate post-transplant period, physicians are often reluctant to use anti-lymphocyte preparations to treat episodes of acute renal functional deterioration attributable to acute rejection. This is due to the perception that such episodes are less likely to be reversible, and to concern regarding the potential adverse effects of anti-lymphocyte antibodies, including opportunistic infections, lymphoproliferative disorders, and the development of human anti-mouse antibodies. Records were reviewed for all 365 renal transplants performed in 267 patients at our center from 1971 to 1996. Anti-lymphocyte antibodies were used in an attempt to reverse 6 episodes of corticosteroid-resistant acute rejection in 5 children at a mean interval of 24.5 months following transplantation. The mean serum creatinine at initiation of therapy with the anti-lymphocyte agents was 2.9 mg/dl. Following treatment, the mean serum creatinine decreased to 1.3 mg/dl (P=0.03, Student’s t-test). Two patients developed uncomplicated opportunistic infections after completion of anti-lymphocyte therapy; none have developed lymphoproliferative disorders or antibodies to OKT3. We conclude that in the correct clinical setting with corticosteroid-resistant acute rejection, the use of anti-lymphocyte antibodies should not be withheld solely on the basis of length of time since transplantation. Received: 27 January 1998 / Revised: 19 May 1998 / Accepted: 6 July 1998