Posttransplant therapy using high-dose human immunoglobulin (intravenous gammaglobulin) to control acute humoral rejection in renal and cardiac allograft recipients and potential mechanism of action.

BACKGROUND: Intravenous gammaglobulin (i.v.IG) contains anti-idiotypic antibodies that are potent inhibitors of HLA-specific alloantibodies in vitro and in vivo. In addition, highly HLA-allosensitized patients awaiting transplantation can have HLA alloantibody levels reduced dramatically by i.v.IG infusions, and subsequent transplantation can be accomplished successfully with a crossmatch-negative, histoincompatible organ. METHODS: In this study, we investigated the possible use of i.v.IG to reduce donor-specific anti-HLA alloantibodies arising after transplantation and its efficacy in treating antibody-mediated allograft rejection (AR) episodes. We present data on 10 patients with severe allograft rejection, four of whom developed AR episodes associated with high levels of donor-specific anti-HLA alloantibodies. RESULTS: Most patients showed rapid improvements in AR episodes, with resolution noted within 2-5 days after i.v.IG infusions in all patients. i.v.IG treatment also rapidly reduced donor-specific anti-HLA alloantibody levels after i.v.IG infusion. All AR episodes were reversed. Freedom from recurrent rejection episodes was seen in 9 of 10 patients, some with up to 5 years of follow-up. Results of protein G column fractionation studies from two patients suggest that the potential mechanism by which i.v.IG induces in vivo suppression is a sequence of events leading from initial inhibition due to passive transfer of IgG to eventual active induction of an IgM or IgG blocking antibody in the recipient. CONCLUSION: I.v.IG appears to be an effective therapy to control posttransplant AR episodes in heart and kidney transplant recipients, including patients who have had no success with conventional therapies. Vascular rejection episodes associated with development of donor-specific cytotoxic antibodies appears to be particularly responsive to i.v.IG therapy.

Nephrotic syndrome and renal insufficiency associated with lithium therapy.

Although the therapeutic administration of lithium in the psychiatric setting has been associated with various renal side effects, only a few reported cases have suggested a possible link to glomerular disease. We report two patients who, while taking lithium, developed heavy proteinuria caused by minimal change disease and acute renal insufficiency attributable to acute tubular necrosis. These clinical findings resolved on discontinuation of the drug, suggesting a role for lithium in their development. We also postulate that lithium, with its unique properties as a modulator of the phosphoinositol pathway, may play a key role in the pathogenesis of minimal change disease.

Interleukin-12 mRNA levels in renal allograft fine-needle aspirates do not correlate with acute transplant rejection.

TH1 cytokines, including gamma-interferon (IFN), are critical in the initiation and progression of allograft rejection. As interleukin (IL)-12 up-regulates gamma-IFN, we assessed the role of IL-12 in human transplant rejection. Twenty renal allograft fine-needle aspirates from 19 patients were obtained, evaluated in the standard fashion, and assessed for gamma-IFN and IL-12p40 subunit mRNA levels using nested reverse transcriptase polymerase chain reaction. Ten aspirates demonstrated acute rejection by clinical criteria, and 9 of the 10 aspirates contained gamma-IFN while only 3 demonstrated IL-12; there were no distinguishing characteristics for these 3 patients with regard to therapy, or time of onset and severity of rejection. Seven patients without clinical or morphologic rejection failed to demonstrate gamma-IFN or IL-12. Three patients had discrepant findings; there was no morphologic rejection, yet all 3 patients contained gamma-IFN and 1 patient demonstrated rejection on subsequent biopsy. However, only 1 aspirate exhibited IL-12 and this patient had no documented subsequent rejection. This study confirms the association of gamma-IFN mRNA with acute rejection. In contrast, IL-12 mRNA does not appear to play a key role early in the rejection process.

Effect of hemodialysis on uterine and umbilical artery Doppler flow velocity waveforms.

A case of a pregnant woman with membranous glomerulonephropathy requiring hemodialysis is described. During hemodialysis the patient underwent Doppler flow studies of the uterine and umbilical arteries. In spite of avoidance of hypotension and major fluid shifts, hemodialysis was accompanied by a significant increase in the systolic/diastolic ratio of the proximal uterine artery. There was no significant change in the umbilical artery systolic/diastolic ratio.

Cysteine scanning mutagenesis of the N-terminal 32 amino acid residues in the lactose permease of Escherichia coli.

Using a functional lactose permease mutant devoid of Cys residues (C-less permease), each amino acid residue in the hydrophilic N-terminus and the first putative transmembrane helix was systematically replaced with Cys (from Tyr-2 to Trp-33). Twenty-three of 32 mutants exhibit high lactose accumulation (70-100% or more of C-less), and an additional 8 mutants accumulate to lower but highly significant levels. Surprisingly, Cys replacement for Gly-24 or Tyr-26 yields fully active permease molecules, and permease with Cys in place of Pro-28 also exhibits significant transport activity, although previous mutagenesis studies on these residues suggested that they may be required for lactose transport. As expected, Cys replacement for Pro-31 completely inactivates, in agreement with previous findings indicating that "helix-breaking" propensity at this position is necessary for full activity (Consler TG, Tsolas O, Kaback HR, 1991, Biochemistry 30:1291-1297). Twenty-nine mutants are present in the membrane in amounts comparable to C-less permease, whereas membrane levels of mutants Tyr-3-->Cys and Phe-12-->Cys are slightly reduced, as judged by immunological techniques. Dramatically, mutant Phe-9-->Cys is hardly detectable when expressed from the lac promoter/operator at a relatively low rate, but is present in the membrane in a stable form when expressed at a high rate from the T7 promoter. Finally, studies with N-ethylmalemide show that 6 Cys-replacement mutants that cluster at the C-terminal end of putative helix I are inactivated significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute renal allograft dysfunction in the setting of deep venous thrombosis: a case of successful urokinase thrombolysis and a review of the literature.

Acute renal allograft vein thrombosis is a rare but serious complication of renal transplantation. When occurring in the early posttransplant period it is usually associated with surgical complications and often results in the loss of the graft. At later stages, when graft function has stabilized, its development may then be associated with underlying disorders such as glomerulonephritis, immunosuppressive therapy, increased hematocrit, acute rejection, or extension of lower extremity venous thromboses. We report a case of acute allograft dysfunction occurring in the setting of extensive deep vein thrombosis. In our patient, thrombosis in the setting of acute graft tenderness and swelling, anuria, and an increasing creatinine strongly suggest a diagnosis of acute allograft renal vein thrombosis. We describe a successful reversal of acute renal failure through urokinase thrombolysis and review the current literature on the use of thrombolytic agents for the treatment of acute renal allograft vein thrombosis.

[N-phosphorylated amino acids as potential cytostatics]. / N-Phosphorylierte Aminosäuren als potentielle Zytostatika.

Phosphoramidic dichlorides 3 are synthesized by nucleophilic attack of methyl 2-(1-ethylenimino)-alkanoates 1 on POCl3 or by the reaction of amino acid methyl ester hydrochlorides 2 with POCl3. Subsequent treatment of 3 with ethylenimine affords the TEPA-analogs 4, and with 3-(1-ethylenimino)-1-propanol (6) the IFOSFAMID analogous 1,3,2-oxaza-phosphorines 5, the cytostatic activity of which was tested in the P388-leukemia of the CD2F1-mouse.

Renal hypertrophy, growth factors, and nephropathy in diabetes mellitus.

In early type 1 diabetes mellitus, hypertrophy of the kidney is a consistent finding. It is easily diagnosed using current noninvasive methods, especially ultrasonography. Renal functional changes occur in association with hypertrophy, most notably glomerular hyperfiltration. The structural counterpart of this functional change is an early increase in capillary filtration surface area. In most forms of nondiabetic renal hypertrophy, kidney size is closely linked to GFR, but in diabetes, hypertrophy persists after the clinical onset of overt kidney disease (microalbuminuria, hypertension, decreased GFR, etc). The fact that growth factors produced by the kidney can act in both an autocrine and paracrine fashion raises the possibility that the local effects of such substances may act as local mediators of kidney growth, but no such factor has been identified as the initiating or sustaining factor in diabetic hypertrophy. Failure of renal hypertrophy to reverse following strict glycemic control for a few months may turn out to be an important prognostic indicator of future progression of the renal disease, but this remains to be studied in a large group of patients.