Antibody-mediated pure red-cell aplasia (PRCA): the Spanish experience.

BACKGROUND: The incidence of antibody (Ab)-mediated pure red-cell aplasia (PRCA) in patients with chronic kidney disease (CKD) has increased between 1998 and 2002. After initially responding to treatment with recombinant human erythropoietic agents for CKD-associated anemia, patients became treatment-refractory and severely anemic. Although most PRCA cases have occurred in Europe, the varying epidemiologies among individual countries have not been well characterized. METHODS: We investigated Ab-mediated PRCA in 12 Spanish patients treated with epoetin alfa alone or prior to treatment with epoetin beta (n=1) or darbepoetin alfa (n=1). Serum Abs against epoetin alfa were detected by radioimmunoprecipitation (RIP) assay or bioassay. Following diagnosis of PRCA, erythropoietic treatment was stopped and patients received immunosuppressive therapy alone (n=11) or in combination with renal transplant (n=1). RESULTS: Treatments were administered for 16 months (average) before diagnosis of PRCA in bone marrow aspirates (n=8) or biopsies (n=4). At diagnosis, patients had an average of 0.68% blood reticulocytes and blood hemoglobin (Hb) level of 7.13 g/dL. Eight patients had anti-epoetin Abs detected by RIP, and 5 had neutralizing Abs measured in the bioassay. As of December 2003, 4 patients had died, 3 had no recovery, and 5 had recovered from anemia (blood Hb level, 9.9 g/dL). All 5 recovering patients received corticosteroid therapy alone, and 1 received a renal transplant as well as corticosteroids. CONCLUSIONS: Sudden onset of treatment-refractory anemia in CKD patients suggests a course of treatment cessation followed by diagnostic procedures for Ab-mediated PRCA, and immunosuppressive therapy. This study may serve as a model for a centralized global PRCA registry.

The influence of the progression of secondary hyperparathyroidism on the set point of the parathyroid hormone-calcium curve.

The influence of secondary hyperparathyroidism (2 HPT) on the set point of the parathyroid hormone (PTH)-Ca(2+) curve is controversial. In vitro experiments have shown an increase in the set point. However, clinical studies with hemodialysis patients have provided a variety of results (increases, decreases and no changes in the set point have been reported). The present study was designed to investigate the influence of the progression of 2 HPT on the set point of the PTH-Ca(2+) curve. The PTH-Ca(2+) curve and the expression of parathyroid calcium receptor (CaR mRNA) and vitamin D receptor (VDR mRNA) have been studied in normal rabbits (group I, n=9) and in nephrectomized rabbits (group II, n=18) at two stages after inducing 2 HPT: 2-3 weeks (group IIA) and 5-6 weeks (group IIB). In group I, the set point of the PTH-Ca(2+) curve was 1.63+/-0.03 mM. A progressive hypocalcemia was detected during the evolution of 2 HPT (groups IIA and IIB). Rabbits from group IIA had a significant (P<0.001) decrease in the set point to values of 1.45+/-0.02 mM. However, the set point increased significantly in group IIB (P<0.001) to 1.56+/-0.03 mM. CaR mRNA was similarly decreased in groups IIA (39+/-12%) and IIB (48+/-7%). No changes were detected in VDR mRNA. In conclusion, a reduction in the set point of the PTH-Ca(2+) curve in response to decreased extracellular Ca(2+) was detected in the early phases of 2 HPT. However, with the progression of 2 HPT the set point tended to increase even though extracellular Ca(2+) was markedly decreased. The increase in the set point in the course of 2 HPT seems to be a complex process that cannot be fully explained by changes in parathyroid CaR mRNA or VDR mRNA.

Pre-emptive oral ganciclovir can reduce the risk of cytomegalovirus disease in liver transplant recipients.

A cohort of 65 liver transplant recipients was prospectively monitored with qualitative polymerase chain reaction (PCR) in plasma. The first 25 patients did not receive prophylaxis. From a consecutive group of 40 recipients, 11 high-risk patients donor CMV-seropositive/receptor CMV-seronegative (D+/R-), persistent CMV replication) received pre-emptive oral ganciclovir (1000 mg three times daily), when a marker of risk was identified, until day 90. The overall incidence of cytomegalovirus (CMV) disease at six months was 20% (five of 25 patients) in the non-prophylaxis group and 2.5% (one of 40 patients) in the group treated with pre-emptive oral ganciclovir (relative risk, 0.11; 95% confidence interval; 0.01-0.96; P = 0.04). The PCR sensitivity for detecting CMV disease was 80%, the specificity was 90%, and the positive and negative predictive values were 66% and 95%, respectively. Adverse events, graft rejection and survival were similar between groups. We conclude that pre-emptive oral ganciclovir in high-risk patients can reduce the risk of CMV disease.

Role of adhesion molecules in mononuclear cell apoptosis induced by cuprophan hemodialysis membranes.

BACKGROUND/AIM: Hemodialysis with Cuprophan (CU) membranes induces mononuclear cell activation, leading to increased expression of adhesion molecules, formation of cell aggregates, and apoptosis. It is likely that structure(s) of the CU membrane interact with mononuclear cell surface molecules which transduce biochemical signals to the cell. Interactions between adhesion molecules and extracellular matrix have been implicated in cell activation, proliferation, and/or apoptosis. In the present work, we study whether adhesion molecules may be involved in CU-induced mononuclear cell aggregation and/or apoptosis. METHODS: The present study was performed using THP-1 cells, a human monocytic cell line, cultured in the presence of the CU membrane. CD11b and CD54 expression was studied with fluorescent monoclonal antibodies. Cell aggregation was quantified using a phase-contrast microscope. Apoptosis was evaluated by either light microscopy or annexin V labeling. RESULTS: The results show that incubation of CU membranes with the proteins CD11b, CD18, and CD54 or the blockade of these cell surface molecules with specific monoclonal antibodies inhibited the CU-induced aggregation and apoptosis in a dose-dependent manner. CONCLUSION: These results suggest that CU membranes interact selectively with these specific proteins to induce cell activation which ultimately results in apoptosis.

Allergens induce apoptosis in lymphocytes from atopic patients.

Repeated stimulation of immune cells may induce an "activation-induced cell death" (AICD) program. Allergy is characterized by the cyclic activation of allergen-reactive immune cells. To study the effects of allergen stimulation in cell proliferation and apoptosis in atopic subjects, peripheral blood mononuclear cells (PBL) from 40 atopic patients with positive reactivity to the allergens Olea Europaea (OE) and Lollium Perenne (LP) (20 without immunotherapy and 20 with specific immunotherapy) and 10 normal subjects were cultured with the allergens OE and LP. PBL from atopic patients proliferate more vigorously than cells from normal subjects after culture in vitro with both allergens, although PBL from atopic subjects without immunotherapy proliferate more than PBL from atopic subjects with immunotherapy. The study of cell proliferation shows that in atopic patients PBL mainly exhibit the CD4/CD45RO phenotype. This preferential proliferation is more evident in PBL from atopic patients treated without immunotherapy. Cell culture with specific allergens induces apoptosis in PBL from atopic patients. The percentage of apoptosis increased when atopic patients had been previously treated with immunotherapy. In addition to the observed increase in cell proliferation, apoptosis mainly occurs in the CD45RO cells that support the involvement of these cells in allergy. Furthermore, results obtained in cells from immunized patients suggest that an AICD process may partly at least explain the mechanism of action of allergen immunotherapy.

Human herpesvirus-6 and the course of human immunodeficiency virus infection.

The aim of this study is to investigate the relationship between human herpesvirus type 6 (HHV-6) and cytomegalovirus (CMV) infection and progression of AIDS disease. A group of 52 HIV-1-seropositive patients was examined for HHV-6 DNA expression in peripheral blood mononuclear cells and for CMV DNA in serum. We found that 21.1% (n = 52) and 12% (n = 25) of them tested positive for HHV-6 and CMV DNA, respectively. In contrast, only 3.3% (n = 29) and 0% (n = 29) of control healthy HIV-1-seronegative donors tested positive for HHV-6 and CMV, respectively. In light of these results, the possible role of HHV-6 as a cofactor in AIDS development has also been assessed by closely following, over 6 years, the course of an HIV-1-seropositive person who had a dramatic loss in the total number of CD4+ cells along with a spontaneous production of HIV-1 p24 antigen in vitro and who also showed progression to AIDS when coinfected with HHV-6. These observations have spurred our prospective analysis of the possible clinical significance of coinfection with HHV-6 and HIV.

The CD26 antigen is coupled to protein tyrosine phosphorylation and implicated in CD16-mediated lysis in natural killer cells.

The levels of CD26 expression, their capacity to induce protein tyrosine phosphorylation and their functional implication in natural killer (NK) cytolysis have been studied. It was found that only a small fraction (12-15%) of peripheral NK cells expresses CD26 compared with the high expression (99%) found in NK clones. The protein tyrosine phosphorylation mediated by means of CD26 activation was studied in NK cells treated with the anti-CD26 MoAb 134-2C2, and two new proteins of 50 and 21 kDa appeared phosphorylated in tyrosine residues. To study the influence of CD26 antigen in NK lysis, we analysed the lytic capacity of NK cells stimulated with different anti-CD26 MoAbs or after separation into CD26+ and CD26- subsets and using K562 as target cells. Under these conditions, no differences were found in the chromium release by the target cells. Redirected lysis through CD16 was also measured by arming the effector cells (CD26+ and CD26-) with anti-CD16 antibody and using K562 as target cells. It was found that CD26- cells showed significantly less CD16-dependent lysis than CD26+ cells. These results indicate that CD26 is related to the CD16-dependent lysis but not to NK cytolysis which may be caused by mediation of protein tyrosine phosphorylation.

Selective decrease of CD26 expression in T cells from HIV-1-infected individuals.

The decrease of CD4+ cells in AIDS patients is widely documented, although the selective loss within different subsets of CD4+ cells and the mechanisms involved in this phenomenon are controversial. In the present report we have analyzed the proliferative response to Ag and mitogen of peripheral blood T lymphocytes from HIV-infected individuals, the phenotype profile of CD26+ and CD26- subset of cells and their infectivity by the HIV. The expression of CD26 Ag, either in CD4+ or CD8+ cells, was clearly diminished in all the patients tested. On the other hand, the expression of CD29 seems not to be affected, nevertheless T cells from these patients were unable to generate a proliferative response against soluble Ag. In 11 out of 13 patients, polymerase chain reaction studies demonstrated that the CD26- subset of CD4+ cells was the main reservoir for HIV-1 in infected individuals and HIV-1 virus preferentially infected in vitro CD4+/CD26- subpopulation. This capacity for preferential infectivity, together with the selective loss of cells expressing CD26 Ag, helps to explain the progressive impairment in the immune system of these patients and sheds new light on our understanding of the AIDS pathophysiology.

CD26 induces T-cell proliferation by tyrosine protein phosphorylation.

CD26 antigen distribution among lymphoid cells and its participation in the process of lymphocyte activation and proliferation has been widely documented. However, the molecular and biochemical mechanisms coupled to the CD26 molecule are not yet known. With different monoclonal antibodies (mAb) we have detected that approximately 56% of CD4+ and 35% of CD8+ cells from peripheral blood lymphocytes express CD26 and the expression of this antigen is required for antigen- but not for mitogen-induced proliferation unless exogenous interleukin-2 (IL-2) is added to the culture. The stimulation of nylon wool-separated T cells and T-cell clones by the anti-CD26 mAb, 134-2C2, induced tyrosine phosphorylation on a subset of proteins of 50,000, 46,000, 26,000, 24,000 and 21,000 MW. This pattern of phosphorylation was not affected by the presence of 12-myristate 13-acetate (PMA), although this cofactor is required for CD26-mediated IL-2 mRNA expression and T-cell proliferation. When a specific tyrosine kinase inhibitor, Tyrphostin, was used in CD4+ cells cultures stimulated with 134-2C2 and PMA, the proliferation and the expression of IL-2 mRNA were inhibited. Thus, protein tyrosine phosphorylation seems to play a major role in CD26-mediated T-cell proliferation.