Treatment of refractory rheumatoid arthritis with a monoclonal antibody to intercellular adhesion molecule 1.

OBJECTIVE: To assess the safety and efficacy of a monoclonal antibody (MAb) to intercellular adhesion molecule 1 (ICAM-1; CD54) in rheumatoid arthritis (RA). METHODS: A phase I/II, open-label, dose-escalation study of 32 patients. RESULTS: During treatment, a peripheral CD3+/CD4+ lymphocytosis was noted, and several patients demonstrated transient cutaneous anergy, which suggests that therapy modified T cell recirculation. Thirteen of the 23 patients who received 5 days of treatment demonstrated clinical improvement through day 29, and 9 of 23 through day 60. Adverse effects were minor and transient. CONCLUSION: Anti-ICAM-1 MAb therapy was well tolerated, resulted in a transient alteration in T lymphocyte recirculation, and effected clinical improvement in some RA patients.

A phase I trial of immunosuppression with anti-ICAM-1 (CD54) mAb in renal allograft recipients.

Several adhesion molecules contribute to the interaction between T cells and antigen presenting cells or target cells. Leukocyte function-associated molecule-1 (LFA-1[CD11a/CD18]) and intercellular adhesion molecule-1 (ICAM-1 [CD54]) are one such critical adhesive receptor-counter-receptor combination. The importance of ICAM-1 dependent adhesion in the rejection response was initially demonstrated in cynomolgus renal allograft recipients treated with the anti-ICAM-1 murine monoclonal antibody BIRR1. BIRR1 also appeared to limit ischemic damage in these animals. A Phase I clinical trial has subsequently been completed in 18 patients who received cadaver donor renal allografts at high risk for delayed graft function (prolonged preservation time, highly-sensitized recipient). An adequate BIRR1 serum level was associated with significantly less delayed graft function (P < .01) and rejection (P < .01). In 1-hr biopsies, mouse IgG was detected along the endothelium of the vessels and glomeruli in the graft. There were no instances of primary non-function (PNF), and current allograft survival (followup: 16-30 months) in these "high-risk" mAb-treated patients is 78%. There were 3 instances of PNF and a graft survival rate of 56% in the recipients of the contralateral kidney allografts treated with conventional immunosuppression. No significant "first-dose" effect was associated with BIRR1 administration. These results establish a dosing schedule and the clinical safety of BIRR1. They also suggest that inhibition of leukocyte adhesion by mAb therapy may be useful in controlling allograft rejection and possibly in limiting reperfusion injury. Thus, these observations support the clinical importance of accessory molecules in T cell function. We hypothesize that anti-CD54 mAb acts by blocking leukocyte adhesion to the endothelium, thereby interfering with sensitization or target cell interaction.

Effects of fish oil on glomerular function in rats with diabetes mellitus.

The mechanisms responsible for hyperfiltration in diabetes mellitus (DM) as well as for the initiation and progression of diabetic nephropathy are not fully elucidated. Enhanced prostaglandin E2 (PGE2) production has been invoked in the former and thromboxane (TXB2) and hyperlipidemia in the latter. Fish oil (FO)-enriched diets can favorably alter eicosanoid synthesis and serum lipid profiles. We therefore examined the effects of a FO-enriched diet on glomerular filtration (GFR), proteinuria, glomerular eicosanoid production, and serum lipids in rats with streptozotocin-induced DM (STZ-DM). Groups of 5-8 rats with STZ-DM were maintained on low insulin and then pair-fed with isocaloric diets enriched with either FO (20% w/w) or beef tallow (BT; 20% w/w). GFR was determined in the same animals at onset of diet and after 8 and 20 weeks on the respective diets by [14C]inulin clearance using implanted osmotic minipumps each time. Significant hyperfiltration was present initially and GFR did not change on either diet for 20 weeks, in spite of a significant and greater than 50% decrease in all prostaglandins (PGE2, TXB2, PGF2 alpha, 6-keto, PGF1 alpha) produced by glomeruli isolated from DM/FO as compared to DM/BT or control rats. FO diet completely corrected the hypertriglyceridemia of diabetes and significantly reduced the mild and early proteinuria of DM. The decrease in proteinuria and the correction of hyperlipidemia of DM by a FO-enriched diet may be beneficial in the long term not only for the development of diabetic glomerulopathy, but also for the accelerated atherosclerosis of DM.

A fish oil diet preserves renal function in nephrotoxic serum nephritis.

Fish oil diets preserve renal function in murine lupus, but we have found that these diets accelerate renal deterioration in renoprival nephropathy. In this study we examined the effects of dietary fish oil in accelerated nephrotoxic serum nephritis. For 1 month, 14 female rats were fed diets that differed only in fat composition, containing either menhaden (fish) oil or beef tallow (control). Rats were then preimmunized with rabbit IgG and, 5 days later, were injected with nephrotoxic serum. Glomerular filtration rate (GFR) was measured continuously in conscious animals by means of intraperitoneal 14C-labeled inulin minipumps. Fish oil-containing diets markedly attenuated the nephrotoxic serum-induced decline in GFR and the rise in proteinuria and significantly reduced glomerular prostaglandin E2 and thromboxane A2. The results of tests of renal histology showed no differences between the two groups. Five days after preimmunization, rats fed fish oil had more rabbit IgG remaining in their serum and had mounted less of an antibody response to the rabbit IgG. Fish oil diets also resulted in an attenuated disappearance of injected 14C-labeled rabbit IgG. In vitro, peritoneal macrophages from rats fed fish oil took up less rabbit IgG than macrophages from rats fed control diets. Thus the beneficial effects of a fish oil diet may result from defective immune surveillance and from alterations in eicosanoids.

Interactions of low density lipoprotein with rat mesangial cells.

Hyperlipidemia may contribute to the pathogenesis of glomerular sclerosis. We therefore studied binding and uptake of low density lipoprotein (LDL) by cultured rat mesangial cells. In addition effects of LDL on PGE2 synthesis and cell proliferation were determined. At 4 degrees C mesangial cells bound [125I] LDL in a time- and concentration-dependent manner with half-maximal binding observed at 5 micrograms/ml of LDL protein. Binding was blocked by excess unlabeled LDL and by heparin. Uptake (binding plus internalization) of LDL at 37 degrees C markedly exceeded binding at 4 degrees C, continued to increase even with longer periods of incubation, and showed no saturability, consistent with uptake of LDL by mesangial cells. Further evidence for LDL uptake by mesangial cells was obtained by use of the fluorescent probe 1,1'-dioactadecyl-3,3,3', 3'-tetramethylindocarbocyanine perchlorate-labeled LDL (Dil-LDL). Incubation of mesangial cells with Dil-LDL at 37 degrees C showed positive fluorescence for all mesangial cells, indicating uptake of the Dil-LDL. LDL had a biphasic effect on mesangial cell proliferation as determined by [3H] thymidine incorporation. LDL at 10 micrograms/ml enhanced [3H] thymidine uptake modestly, but significantly, whereas a progressive and marked inhibition occurred at LDL concentration from 100 to 500 micrograms/ml. While LDL at 10 and 100 micrograms/ml significantly stimulated PGE2 production, inhibition of PGE2 by meclofenamate did not influence the effects of LDL on [3H] thymidine incorporation. We conclude that mesangial cells show specific binding and uptake of LDL and that high concentrations of LDL markedly decrease mesangial cell proliferation. These findings may pertain to the pathogenesis of glomerular lesions in hyperlipidemia of renal disease.

Eicosapentaenoic and dihomo gamma linolenic acid metabolism by cultured rat mesangial cells.

To better understand the effects of dietary fatty acid manipulations on glomerular function, we compared mesangial incorporation, release, and metabolism of arachidonic (AA), eicosapentaenoic (EPA), and dihomo gamma linolenic (DHG) acids. We found marked differences in mesangial handling of these fatty acids. AA was incorporated into lipids of mesangial cells much more rapidly than EPA or DHG. Ionophore-induced stimulation of fatty acid release from mesangial cells prelabeled with [14C]AA, [14C]EPA, or [14C]DHG caused a release of labeled AA greater than DHG much less than EPA, respectively. Preloading mesangial cells with DHG or EPA for 24 h reduced subsequent basal, ionophore-, and hormone-stimulated prostaglandin E2 (PGE2) synthesis. Finally, unlike AA, neither EPA nor DHG was converted to a significant extent by mesangial cyclooxygenase or lipoxygenase. Thus the mesangial metabolism of DHG and EPA differs both quantitatively and qualitatively from that of AA. Furthermore, EPA and DHG inhibit metabolism of AA at the level of mesangial cyclooxygenase.

Comparison of glomerular and mesangial prostaglandin synthesis and glomerular contraction in two rat models of diabetes mellitus.

Enhanced prostaglandin production is postulated to contribute to altered vascular reactivity and glomerular hyperfiltration in early insulin-deficient diabetes mellitus. Rats with streptozocin-induced diabetes (STZ-D) show glomerular hyperfiltration and develop renal disease. BB rats with genetic diabetes (BB-D) also hyperfilter but have only minor renal lesions. We therefore compared glomerular and mesangial prostaglandin E2 (PGE2) production and glomerular contractility in response to pressors as a reflection of in vitro vascular reactivity in these models. Glomeruli isolated from rats with 3 wk of STZ-D produced significantly more PGE2 under basal and ionophore A23187-stimulated conditions than those from control rats. Glomeruli from BB-D rats under basal and stimulated conditions, however, generated amounts of PGE2 that were comparable to either those of nondiabetic littermates or of normal Wistar rats. Mesangial cells cultured from glomeruli of STZ-D, BB-D, and control rats all had identical prostaglandin profiles judged by conversion of [14 C]arachidonic acid. They also produced comparable amounts of PGE2 under basal conditions and after stimulation with angiotensin II or A23187, as determined by radioimmunoassay. Planar surface area of glomeruli isolated from control rats showed a dose-dependent decrease in response to angiotensin II (10(-11)-10(-9) M). This response to angiotensin II was at least as great in glomeruli from STZ-D rats. Contraction of glomeruli from control and STZ-D rats was also comparable after vasopressin or norepinephrine. Similarly, glomeruli from BB-D and BB control rats contracted in a comparable fashion to angiotensin II and norepinephrine.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of dietary fish oil on renal insufficiency in rats with subtotal nephrectomy.

We studied the effects of fish oil on the progression of renal insufficiency in rats with subtotal nephrectomy. Five weeks after a 1-2/3 nephrectomy, sixteen rats were fed two different diets which differed only in fat composition. Lipid in the control diet was primarily beef tallow; that of the experimental diet, menhaden oil. Fish oil-fed rats had significant increases in plasma creatinines, decreases in urinary PGE2 and accelerated death rates. An additional twelve rats underwent 1-1/3 nephrectomies, and the same dietary manipulations, followed by renal clearance, histologic and biochemical studies after 12 weeks on the diets. Fish oil-fed rats again did worse, with decreased glomerular filtration rates and filtration fractions, more proteinuria and more glomerular sclerosis. Glomeruli and slices of cortex, medulla and papillae from rats fed fish oil produced much less PGE2 and TXB2 than dietary controls. Fish oil-induced suppression of renal PGE2 may be deleterious in this model and may outweigh the beneficial effect derived from TXA2 suppression. In contrast to fish oil's potentially therapeutic role in cardiovascular and immune-mediated renal disease, this diet is detrimental in rat renoprival nephropathy. This illustrates the importance of examining the effects of fatty acid manipulation individually for each disease entity.

Contraction and relaxation of cultured mesangial cells on a silicone rubber surface.

Glomerular mesangial cells (MC) in culture are believed to contract or relax in response to agents such as angiotensin II and cyclic AMP. However, cells grown on glass or plastic surfaces are limited in their response to vasoactive agents because of the rigid surfaces to which they adhere; thus, interpretation of a change in shape as contraction, relaxation, or detachment is difficult. We have grown MC on a flexible silicone rubber (dimethylpolysiloxane) substrate (DMPS), and studied with sequential photographs several models of cell contraction, relaxation, and detachment. When the cells contracted, the DMPS became wrinkled; when the cells relaxed, the DMPS lost wrinkles. In contrast, if the cells detached, the sheet lost wrinkles as the cells became smaller and rounder. Angiotensin II (5 X 10(-7) M), and calcium ionophore A23187 (2 X 10(-6) M) increased wrinkles in more than 30% of cells at 22 degrees C and more than 40% of the cells at 36 degrees C. The earliest effect was visible within five to 10 minutes at 22 degrees C and within one minute at 36 degrees C and increased until 40 minutes; thereafter, the cells relaxed and wrinkles were reduced. 10(-1) M Na azide prevented the increase in wrinkles produced by angiotensin II. Seventy-two percent of the angiotensin II-treated cells whose margins could be seen in their entirety, and 78% of the calcium ionophore-treated cells showed a reduction in surface area at a time when new wrinkles were appearing or wrinkles were increasing in size. Dibutyryl cyclic AMP, a known smooth muscle relaxant, produced a decrease or loss of wrinkles in 90% of the cells, and an accompanying increase in surface area. Untreated control cells, observed in conjunction with the above series, showed little change in wrinkles. Ten percent DMSO, an actin-translocating agent, produced a reversible disappearance of wrinkles. These models of contraction and relaxation could be distinguished from cell detachment; EDTA, for example, in the presence of zero calcium, diminished both cell size and wrinkles, with an accompanying lifting of cells from the surface. Similar results were obtained with cytochalasin B and chlorpromazine. Thus, the silicone rubber system accurately reflects the contraction, relaxation and detachment of cultured mesangial cells in response to a variety of agents.

Dopamine attenuates the contractile response to angiotensin II in isolated rat glomeruli and cultured mesangial cells.

Recent evidence suggests that dopamine may alter kidney function by actions not only in the renal vasculature but also at the glomerular-mesangial level. We studied this phenomenon by examining the ability of dopamine to antagonize the contractile properties of angiotensin II in isolated rat glomeruli and cultured mesangial cells. In isolated rat glomeruli angiotensin II caused a decrease in the planar surface area, indicating glomerular contraction, an effect that was abolished by coincubation with dopamine. Angiotensin II also mediated shape changes in cultured mesangial cells, which resulted in a decline in their planar areas. Simultaneous addition of dopamine prevented these decreases in cell size. In mesangial cells grown on a flexible silicone rubber support, angiotensin II addition enhanced wrinkling of the mobile surface. This indicated that the angiotensin-II-induced decrease in cell size observed in cells grown on conventional substrata represented contraction. Conversely, dopamine caused a rapid reduction in wrinkling of the surfaces from control cells as well as those previously treated with angiotensin II, actions consistent with cell relaxation. The prostaglandin inhibitor indomethacin did not alter the ability of dopamine to attenuate angiotensin-II-associated reductions in mesangial cell surface area. Direct determination of mesangial cell prostaglandin-E2 production showed that dopamine did not change either basal synthesis or angiotensin-II-stimulated synthesis of prostaglandin. The results demonstrate that dopamine antagonizes the constrictor effect of angiotensin II at the glomerular-mesangial level. This action of dopamine is prostaglandin independent. These findings support a role for dopamine in the regulation of glomerular filtration and may provide a rationale for its use during states of renal vasoconstriction.

Glomerular prostaglandins, angiotensin II, and nonsteroidal anti-inflammatory drugs.

The glomerulus can, in part, regulate its own flow and filtration characteristics, both of which are determinants of the glomerular filtration rate. This occurs in part as the result of interactions between vasoconstrictors, e.g., angiotensin II (AII), and the vasodilatory prostaglandins E2 or I2. It is well accepted that these prostaglandins modulate the constrictor effects of AII on systemic and renal vasculature. Experimental data accumulated from micropuncture studies, analyses of isolated glomeruli in vitro, and glomerular mesangial cell cultures also support the hypothesis that AII-stimulated production of vasodilatory prostaglandins attenuates AII-induced constriction at the glomerular level as well. These studies help to explain the deleterious actions of nonsteroidal anti-inflammatory drugs on glomerular filtration in clinical conditions associated with a decreased effective blood volume and, therefore, activation of AII and other neurohormonal constrictors. These results have also furthered our understanding of the role of prostaglandins in maintaining renal function in human and experimental renal diseases that may be associated with enhanced hormonal constrictor activity.

Sublimed (inorganic) sulfur ingestion. A cause of life-threatening metabolic acidosis with a high anion gap.

We describe a 66-year-old woman undergoing hemodialysis treatment who developed life-threatening metabolic acidosis (pH of 6.67) with a high anion gap (41 mEq/L [41 mmol/L]) and marked hyperkalemia (9.1 mEq/L [9.1 mmol/L]) after consuming sulfur. Because of an increasing number of patients with chronic renal failure and dialysis-dependent end-stage renal disease, as well as persistence of folk remedies using sulfur, recognition of the potential dangers of self-administered sulfur seems appropriate.

Effects of leukotrienes on isolated rat glomeruli and cultured mesangial cells.

Several vasoactive substances influence glomerular function in vivo and alter glomerular surface area and prostaglandin (PG) synthesis in vitro. Leukotrienes (LT) LTC4 and LTD4 may also influence glomerular function in vivo and in the isolated perfused kidney. We therefore compared the effects of LT with those of angiotensin II (ANG II), arginine vasopressin (AVP), and platelet activating factor (PAF) on planar surface area of isolated rat glomeruli and the shape change of cultured mesangial cells and their PG synthesis. ANG II, AVP, and PAF decreased the surface area of isolated rat glomeruli by 10-14% with comparable changes induced by LTC4 and LTD4. Half-maximal effects of LTs were observed at approximately 10(-7) M. Incubation of cultured rat mesangial cells with LTC4 or LTD4 at 10(-7) and 10(-8) M was also associated with shape changes of the cells resulting in significant reductions in planar surface area in a dose- and time-dependent fashion similar to that noted previously with other vasoactive agents. In cells grown on a flexible silicone rubber support, LTD4 resulted in rapid increases in wrinkling of the mobile surface indicating that the shape change may represent cell contraction. The LT-mediated decrease in surface area of glomeruli and mesangial cells was partially antagonized by the LT inhibitor FPL-55712. In contrast to the 11- and 7-fold enhancement of PGE2 synthesis in cultured mesangial cells by ANG II or PAF, neither LTC4 nor LTD4 affected PGE2 production. These results demonstrate that LTC4 and LTD4 cause mesangial shape changes that in the whole glomerulus may decrease glomerular surface area.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin II and eicosanoids in the control of glomerular size in the rat and human.

We examined the possibility that glomerular prostaglandin E2 (PGE2) regulates the action of angiotensin II (ANG II) on mesangial contraction and filtration surface area. Using isolated rat glomeruli we indirectly assessed mesangial contraction and filtration surface area through measurements of glomerular planar surface area (GPSA) by image-analysis microscopy. ANG II reduced GPSA by approximately 20% in human and rat glomeruli, with threshold concentrations of 1 X 10(-13) M and maximum effect at 5 X 10(-11) M ANG II. Inhibition of glomerular PG synthesis with indomethacin or meclofenamate potentiated the threshold response of ANG II to reduce GPSA. Arachidonic acid (5 micrograms/ml) blunted both the threshold and the maximum responses of GPSA to ANG II. PGE2, 10(-8) and 10(-9) M, also decreased glomerular contraction to ANG II. Endoperoxide (EP) analogues decreased GPSA and EP 045, a thromboxane A2 (TXA2) receptor blocker, eliminated the contractile responses of glomeruli to the EP analogues. Authentic TXA2, synthesized from sheep platelet microsomes, also reduced GPSA. We conclude that glomerular products of arachidonate cyclooxygenation may either relax or contract the mesangium, thereby preserving or reducing filtration surface area. PGE2 exerts protective actions to reduce the mesangial contraction of ANG II, primarily through postreceptor effects. TXA2 may decrease glomerular filtration rate in certain diseases through direct actions on the mesangium.

Priapism and dialysis.

Ninety-three dialysis units located in the tri-state area were surveyed for the prevalence of priapism. Seventeen of 3,337 male patients experienced an episode of priapism. All of these episodes occurred either during or 2-7 h after dialysis, suggesting a cause-and-effect relationship. The use of heparin during dialysis seemed to play a role in its induction; none of the patients on peritoneal dialysis experienced priapism, and heparin was not used in their exchanges. Eleven of 17 patients also received androgen therapy which might have been a contributing factor. Additional considerations included dialysis-induced hypoxemia and acidosis which have been known to precipitate priapism in patients with sickle cell disease or trait. In our study, 2 of 10 patients, including our case report, were black males with sickle cell trait. The calculated prevalence in the male population is 1:196, and in blacks and Caucasians 1:128 and 1:293, respectively. Except for 2 cases of sickle cell trait in the 10 black males, no particular subpopulation at risk was identified. In view of the absence of a proven etiologic agent and the relatively low prevalence of priapism we do not recommend changes in dialysate, anticoagulant, or the use of androgen therapy.

Membranous nephropathy associated with primary biliary cirrhosis and bullous pemphigoid.

Membranous nephropathy has been shown to be an immune-mediated lesion in both human and experimental animal models. Primary biliary cirrhosis and bullous pemphigoid are also diseases of probable autoimmune origin. In this brief report, a woman with all three disease entities is described and an interrelationship among the three is discussed.