IgM antibodies in renal transplantation.

A prospective final crossmatch with patient serum and donor lymphocytes using the complement-dependent cytotoxicity assay to identify any performed anti-donor antibody is required for kidney transplantation. The presence of pre-existing antibody may lead to hyperacute rejection of the transplanted kidney. Certain anti-donor antibodies have previously been shown to be ineffective in promoting hyperacute rejection, such as IgM autoantibodies and non-specific IgM lymphocytotoxic antibodies. In this report, we present evidence that IgM HLA alloantibody specific to the donor does not lead to hyperacute rejection and produces graft survival results equivalent to transplants with negative pre-transplant final crossmatches. Forty-eight (48) of 402 patients transplanted over and 8 yr period were transplanted across a positive final crossmatch due to IgM antibodies alone. Three patients exhibited IgM autoantibodies and 26 patients demonstrated non-specific IgM antibodies to lymphocytes. In 15 patients, following a detailed serum screening analysis, a significant correlation (r > 0.9, p < 0.001) was observed between HLA Class I antigens and the presence of corresponding IgM alloantibodies. Five of these patients were subsequently transplanted despite a positive final crossmatch that was clearly demonstrated to be the result of IgM alloantibody to donor HLA Class I specificities. All of these patients continue to have graft function. These results suggest that hyperacute rejection is not mediated by any type of IgM antibody to donor lymphocytes and that kidney transplantation when only IgM antibody is present against donor lymphocytes represents a reasonable opportunity for a safe transplant and successful long-term graft survival.

Total lymphoid irradiation for pretransplant immunosuppression: nine year follow-up.

Total lymphoid irradiation (16 to 30 Gray units) was given to 12 patients (8 who had rejected previous grafts). We found a fall in T and B cell counts with a reversal of CD4/CD8, and a decrease in mitogeneic and allogeneic responses with recovery to pretransplant levels in 24 to 36 months. The total lymphoid irradiation patients (on low dose prednisone and cyclosporine) had nine year graft and patient survival rates of 50% and 81.5%, respectively, versus 56% and 69.8% for 65 patients on conventional immunosuppression. Complications included viral (7) and fungal (1) infections, immunological thrombocytopenia (3), hypothyroidism and radiation pneumonitis and pericarditis (1 each), and there were no non-skin malignancies. There was only one episode of acute rejection in the group with total lymphoid irradiation as compared to 18 in the other group. We believe that total lymphoid irradiation provides effective immunosuppression and has the potential for reducing and possibly eliminating other immunosuppressants.

Glucagon lowers canine biliary cholesterol output at physiologic doses.

Pharmacologic doses of glucagon affect canine bile secretion by increasing bile flow while simultaneously decreasing biliary cholesterol output. The present study was performed to determine if physiologic doses of glucagon reduce biliary cholesterol output. Awake dogs received both intravenous 1% sodium taurocholate (50 ml/hr) to stabilize bile flow and somatostatin (12 micrograms/kg/hr) to suppress endogenous pancreatic hormone release. Suppression was documented by significant decreases in portal plasma glucagon and insulin levels. During experimental trials, dogs received, in addition, glucagon (5 ng/kg/min) infused via a splenic vein catheter. Bile flow significantly decreased during the initial hour of somatostatin infusion but increased significantly only in experimental trials during subsequent glucagon infusion. Biliary cholesterol output showed no change during control studies (N = 9), but decreased significantly during glucagon infusion studies (N = 11). Biliary phospholipids and bile salts failed to show any changes during glucagon infusion. These data demonstrate that glucagon at physiologic levels influences both the volume and cholesterol content of bile and suggest the mechanism of decreasing cholesterol output must be independent of pathways for influencing bile salt or phospholipid secretion.

Effects of bombesin on fasting bile formation.

Adult dogs were previously prepared by cholecystectomy, ligation of the lesser pancreatic duct, and insertion of cannulae into the duodenum and stomach. After a 2-week period of postoperative recovery and an overnight fast, bile ducts were cannulated, gastric cannulae placed to open drainage and sodium taurocholate 500 mg hr-1 was administered to replace bile acids lost from the interrupted enterohepatic circuit. Bombesin was infused IV for 1 hour over the dose range, 0.625-10 ng kg-1 min-1. In control experiments 0.15 N NaCl was infused. Bombesin caused a significant increase in fasting bile flow, 3.0 +/- 0.2 ml/15 min to 4.2 +/- 0.3 ml/15 min (40%). Bile acid and phospholipid outputs were unchanged during bombesin. Bile cholesterol output decreased significantly during bombesin, 1029 +/- 142 micrograms/15 min to 856 +/- 109 micrograms/15 min (17%). The increase in bile flow was linearly related to the logarithm of the bombesin dose. In dogs with pyloric occlusion, to prevent acid from reaching the duodenum, bombesin increased bile flow and bicarbonate output but had no effect on 14C erythritol biliary clearance. Bombesin stimulated ductular bile acid independent bile formation in a dose-dependent manner. Bombesin also inhibited bile cholesterol output.

Effects of serotonin on canine bile formation.

Long-term studies were performed on dogs previously prepared by cholecystectomy, ligation of the lesser pancreatic duct, and insertion of a duodenal cannula. After an overnight fast, bile duct cannulation and stabilization of bile flow with intravenous (IV) sodium taurocholate, serotonin, 10 micrograms/kg/min, or 0.15 N NaCl was infused. In similar experiments, animals were fed a standard meal, and serotonin or 0.15 N NaCl was infused IV beginning simultaneously with or 30 minutes after the meal. Short-term experiments were performed on dogs anesthetized with pentobarbital and prepared by abdominal evisceration, cholecystectomy, and bile duct cannulation. Serotonin caused significant inhibition of fasting bile formation (3.8 +/- 0.3 ml/15 min to 3.2 +/- 0.3 ml/15 min), meal-stimulated choleresis (4.0 +/- 0.3 ml/15 min to 3.5 +/- 0.3 ml/15 min), and bile flow in eviscerated animals (1.6 +/- 0.1 ml/15 min to 1.1 +/- 0.2 ml/15 min). Bile acid output and 14C erythritol clearance were stable while bile bicarbonate output was decreased during serotonin infusion. A similar inhibitory effect was demonstrated with serotonin, 5 micrograms/kg/min, but the inhibition was not statistically significant with 2.5 micrograms/kg/min. These studies demonstrate that serotonin inhibits bile acid-independent bile formation, possibly at the ductular level, and the inhibition occurs independently of endogenous gastrointestinal tract hormone secretion.

Is somatostatin a directly acting cholestatic hormone?

Previous experiments have demonstrated the cholestatic effects of somatostatin administration in several animal species. These effects were confirmed in the rat. Nine pairs of intact awake rats received intravenous sodium taurocholate (23 mg hr-1) to stabilize bile flow, and half were later given somatostatin at doses of 185 micrograms hr-1. After 1 hr of somatostatin the experimental group showed a significant decrease in bile flow compared to the control group. Cholestasis reversed when somatostatin infusion was stopped. An in situ isolated perfused rat liver technique was used to assess the direct effects of somatostatin on biliary flow. In 10 pairs of rat livers, after achieving stable bile flow, half of those perfused (the "experimentals") received continuous (370 micrograms hr-1) somatostatin infusion, while the controls received saline. The percentage change in bile flow from baseline in the somatostatin group was not significantly different from that in controls for any test period. Bile analysis revealed no significant differences between groups for cholesterol, phospholipid, or bile salt concentrations or outputs. These data suggest that somatostatin inhibits bile secretion by some mechanism other than direct inhibition of bile secretory mechanisms.

Apoprotein C effect on triglyceride transport in tandem-perfused rat hind end and liver.

The metabolism of double-labeled triglyceride in a synthetic emulsion was defined in an in vitro perfusion system of rat hind end and liver described previously [Am. J. Physiol. 245 (Gastrointest. Liver Physiol. 8): G106-G112, 1983]. The metabolism of [3H]glycerol-[14C]triolein was defined in the absence of added apoproteins and with additions of human CII and both CII and CIII. Without apoprotein, a pronounced lipolysis of the triglyceride was recognized by high concentrations of radiolabeled glycerol and free fatty acid in the perfusate. The removal of an aliquot of hind-end venous effluent 5 min after adding the labeled triglyceride emulsion to the arterial inflow demonstrated a brisk lipolysis of the substrate when incubated outside the perfusion system. The addition of CII protein to the emulsion before its introduction into the tandem system eliminated perfusate lipolysis, both within the perfusion system and in incubations of aliquots withdrawn from the system. Intravascular lipolysis was not seen with triglyceride emulsions containing both CII and CIH or when an aliquot of hind-end venous effluent was incubated with triglycerides that had not been exposed to the perfusion system. The intravascular lipolysis observed for the [14C]triglyceride added to the tandem system without apoproteins was associated with relatively greater recoveries of 14C-fatty acyl in liver, fat, and muscle and relatively greater recoveries of 14CO2 than when CII alone or both CII and CIII were added with the triglyceride. The addition of CIII to CII in a 1:1 molar ratio increased the recovery of 14C-fatty acyl in muscle and the recovery as 14CO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatic uptake of chylomicrons and triglyceride emulsions in rats fed diets of differing fat content.

The hepatic removal of plasma chylomicrons was determined for rats fed the following diets: a) containing no triglyceride, b) regular chow diet with 4.5% of its mass as lipid and, c) a corn oil-supplemented chow with triglyceride accounting for 20% of the mass. The fractional hepatic uptake of either radiolabeled chylomicrons or a triglyceride emulsion was reciprocally related to the amount of lipid in the diet. The animals receiving only carbohydrate and protein calories had the most active hepatic uptake of particulate triglyceride and were observed to have a significant decrease in the plasma concentration of the C apolipoproteins. The addition of either C-I, C-II, or C-III apoproteins to the triglyceride emulsion prior to intravenous injection produced a significantly lower hepatic triglyceride recovery of emulsions containing apoC-III. When the plasma of animals fed a fat-free diet was supplemented with human C-III-1 apolipoprotein, the distribution into the liver of either enterally administered fatty acid or parenteral triglyceride was diminished. The triglyceride content in the liver of the rats fed fat-free or corn oil-supplemented diets was significantly greater than that of the control rats and composition was somewhat similar to that of lymph triglyceride. The studies indicate an important influence of dietary lipid on both the partition of plasma triglyceride into the liver and the steady state hepatic triglyceride content.

Hepatic resection for metastatic cancer.

One-year survival is infrequent in patients with metastatic cancer to the liver. This report includes 21 patients who underwent hepatic resection between 1974 and 1981. Operative procedures included one trisegmentectomy, 12 right hepatic lobectomies, two left hepatic lobectomies, two left lateral segmentectomies, and four wedge resections. Operative morbidity and mortality rates were 43% and 5%, respectively. Life-table analysis revealed an overall 7-year survival rate of 34%. The subset of patients (16) with colorectal adenocarcinoma had a 7-year survival rate of 29% after hepatic resection. In three patients with colorectal adenocarcinoma, frequent CEA determinations were made after surgery in order to calculate the serum half-life of CEA. The data fitted a biexponential function yielding two half-lives for CEA disappearance, 0.8 +/- 0.5 days and 25.9 +/- 10.3 days. We conclude that hepatic resection for isolated hepatic metastases can be performed with acceptable morbidity, low mortality, and prolongation of patient survival.

Effects of dibutyryl cyclic AMP and theophylline on biliary cholesterol secretion.

Glucagon increases hepatocellular cAMP and decreases biliary cholesterol output. In these experiments, we examined the relation between cAMP and biliary cholesterol secretion. Bile flow and composition were measured in conscious dogs previously prepared by cholecystectomy, ligation of the lesser pancreatic duct, and placement of duodenal and gastric cannulae. Sodium taurocholate (500 mg/hr) was given intravenously to stabilize bile flow. After 2 hr of taurocholate infusion, dibutyryl cyclic AMP (160 mg kg-1 hr-1) or theophylline (20 mg kg-1 hr-1) was administered intravenously. Dibutyryl cAMP caused a decrease in both cholesterol concentration (242 +/- 25 micrograms/ml to 81 +/- 11 micrograms/ml) and cholesterol output (692 +/- 102 micrograms/15 min to 382 +/- 47 micrograms/15 min). Theophylline decreased cholesterol concentration (282 +/- 39 micrograms/ml to 221 +/- 21 micrograms/ml), but there was no significant change in cholesterol output. Bile flow increased significantly with both dibutyryl cAMP (2.8 +/- 0.2 ml/15 min to 4.9 +/- 0.2 ml/15 min) and theophylline (2.6 +/- 0.4 ml/15 min to 4.2 +/- 0.4 ml/15 min). In additional experiments, aminophylline (85% theophylline, 15% ethylenediamine) was administered intravenously (24.7 mg kg-1 hr-1). Aminophylline reduced cholesterol concentration (59 +/- 6 micrograms/ml to 36 +/- 5 micrograms/ml), but cholesterol output was stable. Bile flow increased significantly (3.7 +/- 0.2 ml/15 min to 6.5 +/- 0.4 ml/15 min). The mechanisms of these changes remain unknown. The effect of dibutyryl cAMP on biliary cholesterol secretion supports but does not prove the hypothesis that glucagon decreases biliary cholesterol output via the second messenger, cAMP.

Somatostatin-induced cholestasis can be independent of portal blood flow.

Short-term experiments were performed on adult mongrel dogs (15 to 25 kg) anesthetized with sodium pentobarbital. The operative procedure included cholecystectomy, side-to-side mesocaval shunt with ligation of the portal vein, and cannulation of the common bile duct. Intravenous sodium taurocholate (500 mg/hr) was administered to prevent depletion of bile salts. Somatostatin (125 micrograms over 30 minutes) was given to six dogs after 2 hours of bile salt infusion, while six additional dogs received saline to serve as control. Bile flow decreased significantly during administration of somatostatin (206 +/- 28 to 150 +/- 21 microliters kg-1 15 min-1, P less than 0.001) and was unchanged during administration of saline (216 +/- 45 to 216 +/- 46 microliters kg-1 15 min-1). This decrease persisted for 1/2 hour after cessation of the somatostatin infusion. Bile salt outputs were similar for both groups throughout the experiment. The data demonstrate that somatostatin-induced cholestasis can be independent of portal blood flow.

The direct effect of insulin on canalicular bile flow.

Previous experimental studies in dogs have demonstrated the choleretic effects of insulin administered in physiologic doses. In our experiment the isolated perfused rat liver was used as an in situ model for demonstrating the direct effects of insulin on bile salt independent canalicular bile flow. Livers were initially perfused with oxygenated Krebs-Ringer buffer solution of 20% hematocrit after which sodium taurocholate (18.3 mg hr-1) was infused to stabilize bile flow. Insulin (0.5 unit kg-1 hr-1) or saline was then given for a 90-min test period. Control (C) and experimental (E) rats were perfused simulataneously (n = 11). Bile flow was significantly greater in the experimental (21.76 +/- 2.16 microliters g liver-1 15 min-1) than the control (16.87 +/- 2.08 microliters g liver-1 15 min-1) group (P less than .01). In addition, the percentage change in flow in individual rats from baseline values was significantly different with peak effect occurring 45 min after start of hormone infusion (E = +19 +/- 3%, C = -5 +/- 7%) (P less than 0.003). Bile analysis revealed stable bile salt concentrations (E = 7.41 +/- .25, C = 7.8 +/- .24 mM ml-1) and stable bile salt outputs (E = 1.68 +/- .14, C = 1.33 +/- .13 mM 15 min-1) for both groups. Biliary cholesterol outputs did not differ between groups (E = 42.6 +/- 4.8, C = 38.2 +/- 7.4 micrograms 15 min-1), nor did phospholipid outputs (E = 3.56 +/- .63, C = 2.71 +/- .57 mg 15 min-1). These data support the hypothesis that the choleretic action of insulin is a direct one on the hepatocyte, requiring no intermediate step or mediator.

Somatostatin suppression of canine fasting bile secretion.

Somatostatin, a peptide present in hypothalamus, gastric mucosa, and pancreas, suppresses several gastrointestinal functions. We evaluated the effect of graded doses of intravenous somatostatin on taurocholate-stimulated bile flow awake fasting dogs. Somatostatin doses of 1.5-200 ng . kg-1 . min-1 significantly suppressed fasting biliary flow. Biliary lipid concentration showed progressive elevations approaching 200% with 200 ng . kg-1 . min-1 somatostatin, while lipid outputs were not altered. The data suggest that somatostatin inhibited bile salt-independent canalicular or ductular secretion, because bile flow, chloride, and bicarbonate output, and the biliary clearance of erythritol were significantly reduced, while bile salt output remained unchanged. In addition, suppression of basal insulin concentration occurred at somatostatin infusion of 200 ng . kg-1 . min-1. Additional studies in anesthetized dogs demonstrated that somatostatin could suppress bile secretion without altering hepatic blood flow.

Production and characterization of a cytotoxic monoclonal antibody reacting with rat islet cells.

We have produced a murine monoclonal antibody (F43 A1D2) that binds to the cell surface of both rat islet tumor cells (RINm clone 5F and RINm clone 14B) and normal rat islet cells. This antibody is cytotoxic in the presence of complement for RIN tumor cells as well as A, B, and D pancreatic polypeptide rat islet cells. Antibody A1D2 does not bind to rat thymus cells, pancreatic acinar cells, or fibroblasts. Antigen A1D2 (termed ICSAn-1 [islet cell surface antigen 1]) is a trypsin-sensitive glycoprotein with a molecular mass of approximately 24,000 daltons. In addition to purification of its islet cell antigen, antibody A1D2 can be used to identify and isolate living islet cells from pancreatic digests.

Marginal ulcer. A difficult surgical problem.

One hundred sixty-six patients with documented recurrent or marginal ulcers following previous ulcer operations were seen at Duke Medical Center and the Durham VA Hospital from 1950 through 1980. Patients with the diagnosis of gastrinoma were excluded from the series. Evaluation of initial operation for recurrent ulcer showed that the highest recurrence rate occurred following non-acid-reducing operations. Analysis of the symptom-free interval following initial ulcer operation showed a significantly longer interval prior to recurrent ulcer development following gastroenterostomy than other procedures, while resection and Billroth I reanastomosis showed a significantly shorter symptom-free interval than did other procedures. Endoscopy proved 85% sensitive in making the diagnosis of marginal ulcer, while upper GI series was 71% sensitive. Surgical treatment of 132 patients resulted in a 20.4% recurrence rate of second marginal ulcer, with a 2.3% mortality rate and a 10.6% morbidity rate. Second operation for recurrent ulcer in 24 patients yielded no deaths, a 12.5% morbidity rate, and a 29.2% recurrence rate. Average follow-up for the series was 12.3 years, and ultimate outcome of treatment showed, of patients not lost to follow-up, a 58.2% satisfactory to excellent rating, while 42.8% of patients had an unsatisfactory result of treatment.