Development of cytotoxic antibodies following renal allograft transplantation is associated with reduced graft survival due to chronic vascular rejection.

We prospectively followed 64 patients who had had no cytotoxic antibodies prior to first cadaveric renal allograft transplantation for post-transplant antibodies. During a mean follow-up period of 62 months (range 45-92) cytotoxic antibodies developed in 36 patients (56%). Sixteen grafts were lost due to chronic vascular rejection in the group of patients who developed antibodies compared to two in those who remained antibody negative, P < 0.01. Renal function was worse in the antibody-positive group, median serum creatinine 215 mumol/l (131-256) (interquartile range) versus 111 mumol/l (98-127) in the antibody-negative group, P = 0.002, and creatinine clearance 39 ml/min (25-55) versus 90 ml/min (55-104), P < 0.001. There were no significant differences in immunosuppressive protocol, HLA-mismatching, blood transfusion history, the number of acute rejection episodes, mean arterial blood pressure, or proteinuria between the groups. The presence of cytotoxic antibodies predated the classical manifestations of chronic vascular rejection. This suggests that humoral mechanisms may play a role in the development of chronic vascular rejection.

Molecular characterization of a recombinant HLA-DR1/DR2 haplotype.

Serologic analysis of two families identified an HLA-DR haplotype in which DR1 and DR2 cosegregated. DNA-RFLP analysis of these families with an HLA-DRB probe revealed a pattern of hybridization suggestive of a recombination between DR1 and DR15. Following amplification, cloning, and nucleotide sequencing of HLA-DRB-gene second-exon DNA sequences, three DRB amplification products associated with the novel haplotype were identified: these corresponded to DRB1*0101, DR2 pseudogene, and DRB5*0101. Clones representing the DRB1*1501 and DR1 pseudogenes were not identified: oligonucleotide typing with DRB1*1501-specific probes confirmed the absence of this gene within the DR1/DR2 haplotype. We postulate that the DR1/DR2 haplotype represents a recombinant between those of DR1-Dw1 and DR15-Dw2, and that the crossing-over may have been between the DRB1*0101 gene and the DR2 pseudogene. This is further supported by DNA-RFLP analysis with HLA-DQB and DQA CDNA probes, which revealed conserved linkage genes between the DQB1*0501, DQA1*0101, and DRB1*0101 genes.

Renal transplantation in highly sensitized patients: five years of the SOS Scheme.

1. One-year graft survival of 218 patients transplanted through the SOS Scheme for highly sensitized recipients was 65%. There was significant improvement in the graft survival of 135 patients transplanted from 1986 to 1988, compared to the 83 patients transplanted from 1984 to 1985 (70% vs 56% at 1 year). 2. Of the 513 patients entered into the SOS Scheme, 218 (42%) received a graft, and of those 218, 179 were transplanted within 1 year. 3. Sex and previous graft history influenced the patient's sensitization status. Males with previously failed grafts and females waiting for their first transplant appeared at greater risk of becoming highly sensitized. 4. HLA matching improved graft survival in highly sensitized patients. The effect of matching was most evident for DR and for HLA-B and DR combined. The effect of matching for HLA-A was minimal. 5. HLA-DR1-positive individuals appeared to be at lower risk of becoming highly sensitized. In addition, DR1-positive highly sensitized patients had superior graft survival compared to DR1 negative recipients.

The origin of HLA-DR"Br": exon 2 nucleotide sequence implicates possible gene conversion of DR1 by DR4-Dw10, DR5, or DRw6-Dw18.

The exon 2 nucleotide sequences of HLA-DQwl-associated and DQw3-associated HLA-DR"Br" alleles were determined from genomic DNA amplified by the Taq polymerase chain reaction technique. Both alleles reveal identical exon 2 nucleotide sequences. Comparison with other DR alleles suggests that DR"Br" may have originated from DR1 by gene conversion with DR4-Dw10, DR5, or DRw6-Dw18 third hypervariable region sequences.

Destructive arthritis, rheumatoid factor, and HLA-DR4. Susceptibility versus severity, a case-control study.

In response to the continuing debate as to whether seronegative rheumatoid arthritis (RA) and seropositive RA are part of the same disease spectrum or are distinct disorders, we evaluated 720 patients with definite and classic RA, of whom 53 subjects had definite persistently seronegative destructive disease. For all but 1 seronegative RA patient, a seropositive RA case control was identified and matched for age, disease duration, degree of destruction on hand radiographs, and disease-modifying drug therapy. DR typing was undertaken on these 105 patients, together with scoring of hand radiographs. The frequency of DR4 was 69% in seropositive RA patients and 60% in seronegative RA patients (P = 0.22), versus 36% in 318 healthy controls (P = 0.008 and P = 0.007 versus seropositive and seronegative RA, respectively). Patients were matched and rematched with different controls in a series of subanalyses in order to make comparisons of hand radiograph scores. We found that HLA-DR4 was associated with destructive RA in both seropositive and seronegative RA patients. In general, DR4+ patients had more severe disease by radiologic criteria than did DR4- patients. Thus, HLA-DR4 may be an additive factor to the serologic status and may be more closely related to disease severity than to disease susceptibility.

HLA-DO-related restriction fragment length polymorphisms in rheumatoid arthritis: evidence for a link with disease expression.

Eighty-three patients with rheumatoid arthritis (RA) were investigated for HLA-DQ and DR locus restriction fragment length polymorphisms (RFLP). Of the 83 patients, 61 (73%) possessed the DR4 allele and within this group we have investigated the relative frequencies of two DQ beta gene variants of DQw3, DQw7 and DQw8, one of which we had previously found to be raised in Felty's syndrome. This analysis revealed a significantly higher frequency of DQw7 containing haplotypes in DR4 positive rheumatoid patients (64%) than in DR-matched healthy controls (42%). Furthermore, the distribution of DQw7 was biased towards those patients with greater disability indicated by the HAQ score, more systemic disease and higher titres of rheumatoid factor, suggesting that DQw7 may contribute to disease expression.

Association between keratoconus and atopy.

Sixty-seven patients with keratoconus were classified according to atopic status. Keratoconus patients with and without atopy did not differ significantly with regard to sex, age of onset, or rate of keratoplasty, but patients with very high IgE levels were more prone to graft rejection. Atopy was less common in patients with unilateral keratoconus, and keratoconus occurred more frequently on the side of the dominant hand. There was a significantly lower frequency of HLA B7 in the keratoconus group than in the controls. No abnormalities of essential fatty acid metabolism were found in keratoconus patients with or without atopy. There was no social class bias in the group. The study included a brother and sister with keratoconus and atopy, and a non-atopic patient whose identical twin did not have keratoconus.

Clinical manifestations of human parvovirus B19 in adults.

Human parvovirus B19 has been associated with various clinical effects in a number of uncontrolled reports. To define the usual manifestations of B19 infection in adults and the factors that influence them we present a clinicoepidemiological study of an outbreak of B19 infection centered on a junior school. Four hundred fifty-three of 475 adults in this community were interviewed and blood was obtained for serological diagnosis. Fifty-four cases of recent infection were identified and were HLA typed. Fourteen of the cases were asymptomatic; 32 had an influenzalike illness; 23 a rash; and 26 an acute-onset polyarthropathy that was more common in women and lasted for up to 7 months. HLA-A, -B, and -C antigen frequencies were similar to a local control population and showed no association with symptoms except that HLA-DR1 was absent in those with persistent arthropathy.

Applications of automated simultaneous double fluorescence (SDF). II. HLA class I phenotyping using immunomagnetically separated T lymphocytes.

HLA class I phenotyping was performed using T-lymphocyte populations isolated by immunomagnetic beads (IMBs) coated with monoclonal antibodies with specificity for CD2, CD4 or CD8. The results were compared to those obtained using density gradient-separated lymphocytes (PBL). The typing trays were read by the automated simultaneous double-fluorescence (SDF) technique previously established in our laboratory using an Astroscan 2100 system. The aims of the present study were to establish whether the advantages of IMB lymphocyte separation and automated plate reading by SDF were complementary and whether the results obtained by IMB-SDF and PBL-SDF were concordant. Similarity coefficients for paired results obtained by IMB-SDF and PBL-SDF varied between 0.825 using anti-CD8-coated IMBs and 0.914 using anti-CD4-coated IMBs with a consistent excess of stronger results observed with the PBL-SDF technique. The variations observed did not result in incorrect phenotype assignment but would significantly influence a cross-matching test. These results illustrate the feasibility of using IMB-separated lymphocytes for HLA phenotyping by SDF.

Alpha-1-antitrypsin (Pi) types in multiple sclerosis and lack of interaction with immunoglobulin (Gm) markers.

Susceptibility to multiple sclerosis is thought to involve several genetic loci apart from the HLA region on chromosome 6. No Pi allotype nor phenotype was associated with the disease in 125 unrelated patients from the Grampian region of northeast Scotland. Despite a previously reported Gm-HLA association in this population there was no apparent interaction between Pi alleles and Gm type which influenced disease susceptibility.

Natural course of penicillamine nephropathy: a long term study of 33 patients.

To elucidate the natural course of the nephropathy associated with penicillamine and thereby facilitate its clinical management 33 patients with rheumatoid arthritis who developed proteinuria during treatment with oral penicillamine were studied in detail throughout their renal illness. Renal biopsies were performed, and creatinine clearance and proteinuria were measured serially for 74 months (range 16-148 months). Fourteen patients developed proteinuria within six months after the start of treatment and 27 within 12 months. When treatment was stopped the proteinuria reached a median peak of 4.2 g/24 h (range 0.3-15.0 g/24 h) at one month (range 0-7 months) before resolving spontaneously by six months (12 patients), 12 months (21), or 18 months (29). In all patients but one, who developed carcinoma of the renal pelvis, proteinuria resolved by 21 months and its median duration was eight months. The median first and last measurements of creatinine clearance showed no appreciable change (80 ml/min and 78 ml/min), and no patient died from or needed treatment for renal failure. The HLA-B8 or HLA-DR3 alloantigen, or both, were identified in 10 patients. Renal biopsy specimens showed membranous glomerulonephritis in 29 patients, minimal change nephropathy in two, and electron dense deposits in the mesangial regions in two. In all the patients whose nephropathy was due solely to treatment with penicillamine the proteinuria resolved completely when the drug was withdrawn; renal function did not deteriorate, and corticosteroids were unnecessary.

A DNA-RFLP typing system that positively identifies serologically well-defined and ill-defined HLA-DR and DQ alleles, including DRw10.

A single enzyme/multiple probe system of HLA-DR and DQ typing using restriction fragment-length polymorphism (RFLP) analysis is presented. TaqI-digested genomic DNAs are hybridized sequentially with short DR beta, DQ beta, and DQ alpha cDNA probes. The DR beta probe discriminates between the DR allelic specificities DR1 to DRw14, with the two exceptions of some DR3/DRw13 and some DR7/DRw9 combinations. We describe the positive identification of a DRw10-specific RFLP and demonstrate its segregation in families. The DQ beta probe defines an allelic system that identifies the alleles DQw1, DQw2, and DQw3. This permits the resolution of DR3/DRw13 and DR7/DRw9 alleles by defining the DR/DQ association caused by linkage disequilibrium. The DQ alpha probe defines another allelic series interrelated with, but independent from, the DQ beta series. Specific DQ beta/DQ alpha RFLP combinations correlate with known Dw splits of DR2, DRw6, and DR7. Combined use of the three probes permits the identification of HLA-DR, DQ, and certain Dw specificities and provides an effective and easily interpretable system for major histocompatibility complex class II allogenotyping.

Chronic pancreatitis, HLA and autoimmunity.

HLA-A and B antigens were studied in 88 Caucasoids with chronic pancreatitis resident in the Manchester area. In the subgroup of 52 patients with alcohol-related chronic pancreatitis HLA-B21 was significantly increased in frequency compared with 344 local controls (Pc = 0.0128). In the non-alcoholic sub-group of 36 patients, the incidence of HLA-A1 was significantly higher than in controls (Pc = 0.0021); whilst HLA-B8 was present in 38.8% of patients and 27.9% of controls. When these data are amalgamated with data from Lyon (France), the antigen HLA-A1 is significantly associated with non-alcoholic chronic pancreatitis.