Plasmapheresis followed by intravenous immunoglobulin in presensitized patients awaiting thoracic organ transplantation.

Four highly sensitized patients awaiting thoracic organ transplantation were treated immediately preceding transplantation with 1 plasmapheresis and infusion of high dose intravenous immunoglobulin (IVIG). All 4 underwent successful surgery and have had minor to no rejection episodes over a range from 5 1/2 to 12 months. All panel reactive antibodies (PRA) were dithiotheitol (DTT) resistant, and 1 patient had IgG specific alloantibodies to a donor alloantigen. All 4 patients had positive donor cross matches prior to transplantation, and 3 of the 4 patients remained PRA negative for up to 9 months after allografting. Possible mechanisms of this therapy include inhibition of proliferating alloreactive B cells or suppression by antiidiotypic antibodies. Further study is warranted.

Acute leukemia and related entities. Impact of new technology.

Twenty-seven cases of acute leukemia and related entities were evaluated by morphologic examination, cytochemical study, terminal deoxynucleotidyltransferase study, immunophenotyping, cytogenetic analysis, ultrastructural cytochemical study, and gene rearrangement analysis to determine the impact on the determination of the French-American-British (FAB) classification and the definitive diagnosis. The definitive diagnosis contained prognostic, diagnostic, and treatment information beyond the FAB classification that affected the disease course and patient management. All diagnostic variables were evaluated in each case and were labeled essential, ambivalent, supportive, or noncontributory. Except for gene rearrangement analysis, all variables we studied contributed essential data to establish the definitive diagnosis. Ambivalent findings were rare but could be explained with the knowledge of the total data. All variables, except cytochemical study, whose results were almost always essential, contributed supportive data. Noncontributory data only occurred with cytogenetic analysis in cases that demonstrated normal karyotypes. The FAB classification was established in 20 (74%) of the cases by use of morphologic examination, cytochemical study, and terminal deoxynucleotidyltransferase study. With use of the same variables, however, the definitive diagnosis, whose determination required all data, was established in only 15 (55.5%) of the cases. The addition of immunophenotyping increased the definitive diagnosis to 25 (92.5%) of the cases. The use of ultrastructural myeloperoxidase and platelet peroxidase analysis enabled us to definitively diagnose the remaining two cases (27 cases [100%]). Cytogenetic analysis revealed four cases in which essential information was added to the diagnosis. However, because the cytogenetic information usually was not immediately available, the result did not affect the immediate diagnosis or treatment. Surprisingly, the gene rearrangement studies did not yield essential data in any case and in a few cases contributed ambivalent data. This finding should not exclude gene rearrangement analysis in selected cases; however, the data should always be interpreted in light of all clinical and laboratory findings. This study clearly demonstrates the importance of a multifaceted approach to the understanding of the acute leukemias and related entities and shows the impact of newer technologies on reaching a definitive diagnosis.

Donor-specific transfusions. Donor-recipient HLA compatibility, recipient HLA haplotype, and antibody production.

HLA profiles of 25 donor-specific transfusion (DST) kidney donor-recipient pairs were analyzed for HLA antigen compatibility. Serum samples collected during and after DST were tested for cytotoxic antibodies against T and B lymphocytes of the donors and 30 normal individuals. Eleven recipients did not produce cytotoxic antibodies to the antigens of their DST donors, and eight produced cold and/or warm, broadly reactive B-cell antibodies. Six patients (24%) produced HLA-A, B, C, and/or DR antibodies. Three of these individuals produced antibodies after two immunizations, while others required three immunizations. Three of the 11 antibody nonproducers (17%) had not received previous transfusions, as compared to three of the eight antibody producers (43%). Comparison of HLA profiles revealed 22 percent of the HLA-A, B, DR identities between the transfusion donor and recipient in antibody nonproducers as compared to 9 percent of the HLA-A, B, DR identities in antibody producers. The HLA-A2, B40, DR4 haplotype and HLA-DRW6 antigen were more common among antibody producers than among nonproducers, who had an excess of the HLA-B8, DR3 haplotype. These results are consistent with the hypothesis that there may be high- and low-responder HLA haplotypes that control immunologic responsiveness to histocompatibility antigens.

Prenatal effects of maternal-fetal HLA compatibility.

Both retrospective studies of idiopathic aborters, as well as prospective studies of normal couples, have shown reduced fertility among couples sharing HLA antigens. However, the effects of maternal-fetal histocompatibility on surviving embryos are largely univestigated. We thus prospectively studied 53 healthy, fertile women whose timed pregnancies were verified within 21 days of conception. Maternal-fetal histocompatibility status was determined for HLA-A,-B, and -DR locus antigens. Fetal growth rates were monitored by ultrasound at 8, 12, and 20 weeks gestation. Neonates were weighed, measured (birthlength, chest circumference, head circumference), and examined within 72 h of delivery (116 major and minor anomalies) in standardized fashion by one of two geneticists. Although no significant differences were found between infants compatible and incompatible at the HLA-A or HLA-B locus, significant differences were observed between HLA-DR compatible and incompatible infants for sex ratios (p less than .003) and minor anomaly rates (p less than .05). Although differences in mean birthweights between HLA-DR compatible and incompatible infants were not significant in this sample, HLA-DR compatible infants were on average 200 grams smaller than HLA-DR incompatible infants. We interpret these findings as evidence for selection against histocompatible fetuses throughout gestation, particularly with respect to HLA-DR compatibility. Potential immunologic and genetic mechanisms are discussed.

Lymphocyte subpopulation profiles and mitogen kinetics in immunological deficiency testing.

The correlation between lymphocyte proliferative responses to mitogens and T4/T8 ratios was analyzed in a cross section of patients who either were in a high-risk group for HTLV-III infection or fulfilled clinical criteria for acquired immune deficiency syndrome (AIDS). The patient results showed that, correlated with decreased T4/T8 ratios, there was a decrease in mitogen responsiveness first to pokeweed mitogen (PWM), followed by concanavalin A (Con A) and then phytohemagglutinin (PHA). Parallel to this decrease there was a shift toward higher concentrations of mitogens needed for optimal proliferation. In comparison, depletion of T4+ lymphocytes from normal healthy controls also decreased lymphocyte proliferative responses to all three mitogens but shifted the amount of mitogen needed for optimal proliferation toward lower concentrations. The differences in mitogen-induced proliferation between patients and healthy controls suggest a model whereby there is a functional defect(s) in mitogen responsiveness of the remaining T4- lymphocyte population that can be overcome when higher concentrations of mitogen are used.

The human sex ratio: increase in first-born males to parents with shared HLA-DR antigens.

Maternal-fetal HLA-DR antigen sharing has been reported to affect the sex ratio of first-born. We therefore studied offspring sex ratios and birth orders in 66 families in which parents shared one or more HLA-DR antigens as compared to 61 families with no parental HLA-DR sharing. A significant excess of males was found among first-born children who were HLA-DR compatible with their mothers compared to first-born HLA-DR incompatible children of couples sharing HLA-DR antigens and couples not sharing HLA-DR antigens. Increased numbers of males may persist among children of higher birth orders in families where parents share both HLA-DR antigens, but not among couples sharing only one HLA-DR antigen. We hypothesize that the presence of the H-Y antigen in the male fetus may provide the necessary stimulus for a successful pregnancy in HLA-DR compatible pregnancies and may explain the excess of male births in the general population.

Gestational diabetes mellitus. Heterogeneity of maternal age, weight, insulin secretion, HLA antigens, and islet cell antibodies and the impact of maternal metabolism on pancreatic B-cell and somatic development in the offspring.

We have examined gravida with gestational diabetes mellitus (GDM), as defined by the National Diabetes Data Group (Diabetes 1979; 28:1039), for phenotypic and genotypic heterogeneity. Fasting plasma glucose (FPG) at diagnosis was used for further stratification of GDM according to putative metabolic severity into class A1 (FPG less than 105 mg/dl [N = 129]), class A2 (FPG 105-129 mg/dl [N = 47]), and class B1 (FPG greater than or equal to 130 mg/dl [N = 23]). All GDM classes tended to be older and heavier than consecutive gravida with documented normal glucose tolerance (controls, N = 148). Subdivision into "lean" and "obese" indicated that plasma immunoreactive insulin (IRI) was greater after overnight fast in the obese of all groups except B1. However, absolute increases in IRI above fasting levels in response to glucose during OGTT were significantly enhanced by obesity only in class A2 gravida. Adjustment for the effects of age and weight by covariate analysis indicated that the IRI response to glycemic stimulation is usually attenuated in all forms of GDM. Mean values for increases in IRI above fasting values during the first 15 min and IRI increments relative to the increases in plasma glucose throughout the 180-min OGTT were below control values in all GDM groups and progressively so, i.e., A1 less than A2 less than B1. The absolute insulinopenia was not invariable; a small number of gravida from all GDM groups displayed well-preserved IRI responses to oral glucose. Genotypic evaluation of the GDM population disclosed an increased occurrence of "markers" known to be associated with type I diabetes mellitus.(ABSTRACT TRUNCATED AT 250 WORDS)

Gestational diabetes mellitus. Correlations between the phenotypic and genotypic characteristics of the mother and abnormal glucose tolerance during the first year postpartum.

We evaluated glucose tolerance during the first year postpartum in 113 women with gestational diabetes mellitus (GDM) diagnosed according to the criteria of the First International Workshop-Conference on GDM and the National Diabetes Data Group. The high incidence of abnormal postpartum glucose tolerance (38% "diabetes mellitus" plus 19% "impaired glucose tolerance") was correlated with certain of the heterogeneous characteristics of the population at the time of antepartum diagnosis. Virtually all women with antepartum fasting plasma glucose (FPG) greater than or equal to 130 mg/dl (GDM class B1) remained abnormal postpartum (21/22 [95%]), which suggests that this group may include women with preexisting glucose intolerance unrecognized before pregnancy. In the remainder, those with FPG greater than or equal to 105-129 mg/dl (GDM class A2) were more likely to be abnormal postpartum than those with FPG less than 105 mg/dl (GDM class A1). Within the A1 and A2 groups, increasing maternal age, relative insulinopenia, and hyperglycemia at 2 h during antepartum OGTT were also associated with a greater likelihood of abnormal glucose tolerance postpartum. The presence of HLA-DR3 and/or -DR4 antigens was not predictive of the status of glucose tolerance during the first year postpartum, although the increased frequency of cytoplasmic islet cell antibodies in A2 and B1 subjects was associated with a high incidence of abnormal postpartum glucoregulation. The high incidence of abnormal postpartum glucose tolerance in all GDM classes makes a compelling case for careful, early, and continuing follow-up of all women with a diagnosis of GDM.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunogenetic studies of juvenile dermatomyositis. III. Study of antibody to organ-specific and nuclear antigens.

Ninety children with definite juvenile dermatomyositis (JDMS), who had been HLA typed, were tested for the presence of tissue or organ-specific antibodies. Sixty had active disease at the time of study. The mean disease duration was 4 years, and 30 had soft tissue calcifications. The following autoantibodies were sought: thyroid, gastric parietal cells, smooth muscle, striated muscle, microsomes, mitochondria, DNA, extractable nuclear antigen, Sm, PM-1, antinuclear antibody (ANA), and rheumatoid factor. Only the ANA and PM-1 were more frequent in patients than in controls (P less than 0.0002 and P less than 0.001, respectively). Higher levels of immune complexes (P less than 0.01) were found in sera from patients with JDMS than in sera from controls and were correlated with the presence of ANA in patients (P less than 0.01). Soft tissue calcification was not associated with any autoantibody or HLA antigen, but with disease duration and activity (P less than 0.001 and P less than 0.05, respectively). There was no association between the occurrence of any autoantibody and the presence of HLA-B8 or DR3 among the white patients with JDMS. The frequency of autoantibodies in 43 full siblings of children with JDMS was not increased. We conclude that children with JDMS, with or without HLA-B8/DR3, do not show evidence of a generalized nonspecific antibody response to tissue antigens. The significance of the increased antibody to nuclear antigens ANA and PM-1 remains to be determined.

HLA-DR typing as a predictor of MLC compatibility.

Mixed lymphocyte culture reactions between HLA-identical siblings, HLA-DR-identical parent-child and sibling pairs, HLA-DR identical unrelated normal individuals, and cadaver kidney graft donor and recipient pairs were compared for MLC compatibility. Of 34 HLA identical sibling pairs, 31 (91%) showed a percentage of relative response (RR%) of less than 5%. Forty-two of 79 HLA-DR-identical parent-child and sibling pairs (53%), 8 of 61 unrelated individuals (13%) and 4 of 7 cadaver transplant donor-recipient pairs showed %RR values of less than 20%, which is consistent with MLC compatibility. An additional 7 parent-child and sibling pairs and 8 unrelated combinations were in the borderline range yielding %RRs of 20-30%. Median %RR values were significantly increased in the DR-compatible unrelated group as compared with the DR-compatible related group (p less than .001). In the related group pairs matched for HLA-B in addition to HLA-DR had a significantly lower median %RR than pairs matched for HLA-DR only (p less than .001). In addition, a higher frequency of MLC-compatible combinations was found when B/DR-compatible antigens were present in a positive linkage disequilibrium. The same trend was observed in the unrelated population, but the number of B/DR compatible pairs in the population was low. The data demonstrate the range of MLC reactions between HLA-DR-compatible related and unrelated individuals and support the hypothesis that individuals compatible for HLA-B and DR antigens in a strong linkage disequilibrium are more likely to be MLC-compatible.

Factors responsible for successful HLA-DR typing of mononuclear cells from cord blood.

Of 115 cord blood samples tested, both HLA-DR antigens were identified in 79% of fresh samples, 66% of older samples and 55% of freshly frozen samples. Because of weak reactions, one or two questionable antigens were present in 21% of fresh samples as compared to 34% of older samples and 45% of freshly frozen samples. Older samples showed lower cell viability, more extra reactions, and a high frequency of weak reactions. Comparison of cord blood DR antigens with parental DR antigens revealed that antigens were missed or inappropriately assigned in 5 known cases. This was more frequent with older blood samples. The critical factors in successful DR typing of cord blood samples were 1) dilution of cord blood samples with medium, 2) processing of the samples as soon as possible, and 3) overnight incubation to remove adherent cells.

Linkage analysis in von Willebrand disease.

We studied a 3-generation kindred to determine whether the gene responsible for one form of von Willebrand disease (vWD) is linked to 1) the HLA locus, or 2) a polymorphic locus for a serum enzyme or red cell antigen. HLA haplotypes were determined in 12 affected family members, in 10 cases by direct analysis and in 2 cases by deduction. Seven of 12 affected individuals were A2, B7, as compared to 0 of 9 unaffected. However, the maximum lod score was only 0.41 at a recombination frequency of 0.2. Of the 17 serum red cell and plasma protein markers studied, 5 (Kell, ADA, AK1, BF, GC) did not segregate, and 12 (ABO, Rh, JK, Fy, P, PGM1, ACP1, ESD, GLO1, MN, HP, GPT) gave lod scores less than + 1.0. We conclude that there is no strong evidence for linkage between the locus for vWD and any of the markers studied.

Positive autologous crossmatches and a successful transplant with an HLA-identical, but not with an HLA-nonidentical, kidney.

A kidney graft from an HLA-nonidentical donor following a positive crossmatch in the presence of autoantibodies was rejected, but a subsequent graft from an HLA-A, B, C, DR-identical donor, also following a positive crossmatch, survives. Cytotoxic reactivity was present at 4 C and 37 C, and required complement. Sucrose gradient fractionation showed that most of the reactivity resided in the IgM fraction of the serum. Reactivity with donor T and B lymphocytes was not removed by absorption with platelets. Absorption with autologous lymphocytes failed to remove reactivity to lymphocytes of the first (non-HLA-identical) donor and T and B cells of another individual with the same HLA type as the first donor, although removing reactivity to T, but not to B cells of the second (HLA-identical) donor. This case demonstrates that the presence of a multitude of cold-reactive and warm-reactive T and B cell autoantibodies and non-HLA alloantibodies creates an immunological environment in which only the optimally matched graft will survive.

Human leukocyte antigens in women with recurrent urinary tract infections.

The HLAs of the major histocompatibility complex in humans have been associated statistically with many diseases [1]. The possibility that recurrent UTIs in women are controlled in part by genotypic traits was suggested by the observation that adherence of Escherichia coli in vitro to both vaginal and buccal cells was greater for patients with such infections than for healthy control subjects and that there was a strong correlation between vaginal cell and buccal cell receptivity [2]. A3 antigen was identified in 12 (34%) of the patients. This frequency was significantly higher in patients than in healthy control subjects, but it was not significantly different from the frequency observed in the reference population. After correction for the number of comparisons made, there was no statistically significant difference between patients and control subjects with any other antigen. These data suggest that HLA A3 may be associated with increased risk of recurrent UTIs.

Identification of a 17-hydroxyprogesterone-binding immunoglobulin in the serum of a woman with periodic rashes.

A 30-year-old patient with primary infertility had a history of recurrent oral and perineal rashes that appeared just prior to the midcycle rise in basal body temperature and subsided with the onset of menses. The rashes did not appear during periods of treatment with oral contraceptives or danazol, and were suppressed by administration of cortisol. Sera obtained during the follicular and luteal phases of her cycle were found to contain a progestin-binding component with high affinity for 17-hydroxyprogesterone and a somewhat lower affinity for progesterone. Analysis of these sera showed the progestin-binding component to have properties of IgG, with an apparent binding affinity for 17-hydroxyprogesterone of 2 X 10(10) M-1. This report is the first characterization of an antibody to an endogenous steroid in human serum.