Serial evaluation of cell surface markers for immune activation after acute renal allograft rejection by urine flow cytometry--correlation with clinical outcome.

BACKGROUND: The use of urine flow cytometry (UFC) as a noninvasive tool for the diagnosis of acute and chronic rejection of the renal allograft has been previously reported. METHODS: We analyzed the expression of various cell surface antigens during a 30-day period after the diagnosis and treatment of 24 acute rejection (AR) episodes. UFC was performed on 59 urine specimens, from 17 patients meeting the diagnostic criteria for AR. UFC analysis was performed blinded to the clinical management utilizing the following fluorescinated monoclonal antibodies: anti-CD3, anti-CD14, anti-HLA-DR, anti-CD54, and anti-interleukin 2 receptor. Results were correlated with the patient's requirement for antilymphocytic drugs and increment in serum creatinine level (mg/dl) on day 30 after AR. RESULTS: HLA-DR was the most prevalent antigen noted during the first 2 days of AR (91.7% of the samples), followed by CD14 (50%) and CD54 (41.7%). After day 4 the degree of expression of HLA-DR-, CD14-, and CD54-positive cells correlated with the need for antilymphocytic drugs. CD54 was the best parameter with a sensitivity=100% and specificity=90.9% (P=0.001). Those patients who had permanent graft injury after treatment of the AR had persistence of CD54- and CD14-positive cells in the urine. CONCLUSION: Serial monitoring of urine sediments by UFC was predictive of the requirement for antilymphocytic therapy and irreversible graft damage.

A comparative analysis of the use of mycophenolate mofetil in pediatric vs. adult renal allograft recipients.

Mycophenolate mofetil (MMF) is a new immunosuppressive drug used in combination with cyclosporin A (CsA) or tacrolimus and prednisone to prevent rejection of renal allografts in both adult and pediatric recipients. It has been shown in several large studies that MMF significantly decreases the incidence of acute rejection in adults and has acceptable adverse effects. In this retrospective study, we compare the incidence of adverse events between pediatric and adult renal allograft recipients. Twenty-two children and 37 adult renal allograft recipients were included in the study. The initial dose of MMF was 1.5 g b.i.d. for the adult patients and ranged from 15 to 30 mg/kg/d for the pediatric patients. All patients received p.o. acyclovir as prophylaxis for cytomegalovirus (CMV). The two groups were similar regarding gender distribution and graft source. Acute rejections occurred in 10 of the 22 pediatric patients (45%) and in nine of the 37 adults (24%), p = NS. The incidence of infections was similar in both groups except for the occurrence of CMV (n = 5), which was seen only in adults. The incidence of GI symptoms was significantly higher in the pediatric population (54.5% vs. 21.6%; p = 0.02). Significant weight loss was seen more often in the smaller pediatric patients (weight < or = 15 kg) compared to the larger pediatric patients, 60% vs. 11.7%, p = 0.05. Among the patients who had significant GI symptoms 50% of the adults and 75% of the pediatric recipients required either dose reduction or, most commonly, discontinuation of the MMF. The need to discontinue MMF was significantly higher in the pediatric patients, especially in those that weighed less than 15 kg. We suggest the possibility that the optimum dose, dosing interval or preparation of MMF has not yet been established for pediatric patients. One should therefore monitor pediatric patients closely, especially the small ones, to avoid significant nutritional problems and other adverse GI events.

Urine flow cytometry as a tool to differentiate acute allograft rejection from other causes of acute renal graft dysfunction.

BACKGROUND: Recently, urine flow cytometry (UFC) was introduced as a useful noninvasive tool for the immunological monitoring of renal allograft recipients. The presence of an active urine sediment as determined by UFC was found to be associated with acute rejection (AR) episodes. METHODS: In the present study we assess the value of UFC in the setting of acute graft dysfunction. UFC was performed in 30 patients (32 events) at the time of admission to the hospital for the evaluation of rising creatinine (serum creatinine increment > or =0.6 mg/dl above baseline). UFC analysis was done blinded to the clinical diagnosis, and results were compared with the discharge diagnosis: AR, n=15; chronic rejection (CR), n=8; drug toxicity, n=4; urinary leak, n=2; recurrence of primary disease, n=1; lymphocele, n=1; and unknown, n=1. RESULTS: The presence of at least 5% of HLA-DR-positive cells and intercellular adhesion molecule-1-positive cells was detected in 100% and 53%, respectively, of the samples associated with AR (P<0.01 vs. others). The specificity value for the diagnosis of AR was: 100% for the presence of intercellular adhesion molecule-1 or CD3-positive cells and 88% for the presence of interleukin-2 receptor-positive or HLA-DR-positive cells. Half of the samples associated with CR had CD14-positive cells (P=0.03 vs. others) with a specificity value of 87.3%. The samples associated with drug toxicity, urological problems, or recurrence of primary disease were remarkable for the lack of expression of the antigens studied. CONCLUSION: UFC can clearly differentiate AR from other causes of acute renal allograft dysfunction. HLA-DR is revealed to be the most sensitive and intercellular adhesion molecule-1 the most specific marker for AR. The presence of CD14-positive cells was highly suggestive of CR. Due to its objective nature, UFC should be considered in the evaluation of graft dysfunction.

Urine flow cytometry as a predictor of renal allograft function.

The value of urine flow cytometry (UFC) in diagnosing acute renal allograft rejection (AR) was recently established in a prospective double-blind study. In this study, we report the 1-year follow-up of three groups of patients identified during the previous study: group 1--stable patients (no ARs) with persistently negative UFCs (n=7); group II--patients who had early ARs (<3 months after transplantation), with positive UFCs that completely normalized with antirejection therapy (n=8); group III--stable patients (no ARs) with positive UFCs (n=7). By definition, group III consists of patients previously considered to have "false positive" UFCs. All patients received standard immunosuppressive therapy, with regimens that included cyclosporine at doses adjusted to maintain target levels. Serum creatinine (SCr) levels (mg/dl) were similar in all three groups at 1 month after transplantation. However, at 1 year after transplantation, SCr was 1.4 +/- 0.2 in group I, 2.0 +/- 0.9 in group II, and 1.9 +/- 0.3 in group III (P=0.004 group I vs. group III). There were no ARs clinically diagnosed during this follow-up period in any of the three groups of patients, but there were significantly higher SCr increments among group III patients after the 1 year of follow-up. The detection of an active urine sediment by flow cytometry in "clinically stable" allograft recipients may indicate ongoing, subclinical acute rejection activity, which in this study was found to be associated with worse renal function at the end of the first posttransplant year as compared with patients with persistently negative UFCs. Increased immunosuppression may be indicated for these patients with persistently positive UFCs.

Comparative value of urinalysis, urine cytology and urine sIL2R in the assessment of renal disease in patients with systemic lupus erythematosus (SLE).

Serial immunological testing has been recently proposed for monitoring patients with lupus nephritis as routine serological tests have shown sub-optimal correlation with clinical status. To assess the value of urine cytology and urine sIL2R in the evaluation of patients with SLE, in particular those with lupus nephritis, we conducted a prospective double-blind study of 31 patients with SLE, during an 18-month period. A comparison of routine urinalysis with urine cytology and urine sIL2R was performed in 84 samples: 15 from patients without a history of renal involvement and 69 from patients with a history of renal involvement. A high urine cytology score (> or = 6), particularly in the presence of lymphoblasts, plasma cells or monocytes, was significantly associated with lupus nephritis in relapse. Urine sIL2R levels were significantly elevated during all SLE relapses, unrelated to the presence of renal involvement. Fifteen urine specimens were obtained at the time of a kidney biopsy: 9 with active lesions and 6 with inactive renal disease. UC score was 2.0 +/- 1.89 for those with absent activity, 8.4 +/- 3.4 for mild activity and 11.0 +/- 2.4 for moderate/severe activity (p < 0.001 between active vs inactive disease). No urinalysis parameter alone permitted distinguishing the degree of renal disease activity. In the subgroup of patients with renal disease urinalysis was overall less accurate than urine cytology or urinary sIL2R levels for predicting renal disease activity defined by biopsy. Urine cytology and urine sIL2R proved to be reliable measures of lupus activity.

Renal biopsy: why and when.

The purpose of this paper is to emphasize the importance of information obtained by renal biopsy in the diagnosis, prognosis, and therapy of patients with renal disease. Because controversy persists regarding the value of renal biopsy as an aid in determining prognosis and in choosing appropriate therapy, there has been some reluctance to use it early after the onset of obvious signs, symptoms, and laboratory findings indicative of renal disease with or without involvement of other organs. Although all such patients may not benefit from the information provided by a proper biopsy, we will illustrate some of the characteristic histologic details found in specific circumstances in our experience where the biopsy has been particularly helpful in reaching a diagnosis, in assessing prognosis, and in choosing therapy.

Modulation of interleukin-1 secretion by immunosuppressive drugs, alone and in combination.

This study evaluates the ability of the immunosuppressive drugs dexamethasone, cyclosporine, FK506 and rapamycin, alone and in combination to suppress interleukin-1 beta (IL-1 beta) secretion in vitro by THP-1 cells when stimulated by lipopolysaccharide. All four drugs, when added to cell culture medium at therapeutic concentrations, significantly decrease secretion of the monokine to well below control levels. However, only dexamethasone completely suppresses IL-1 beta secretion in a dose-dependent fashion. Cyclosporine, FK506 and rapamycin only partially suppress secretion of IL-1 beta at concentrations within their therapeutic ranges and increasing concentrations of the drugs do not result in further suppression of secretion. Likewise, the combination of any two of these three drugs does not provide any additional suppressive effect. Dexamethasone, however, when added in increasing concentrations in combination with any of the other drugs, results in further suppression of IL-1 secretion in a dose-dependent fashion. These data suggest that cyclosporine, FK506 and rapamycin all share a common effect on the production of IL-1 beta, different from that of dexamethasone.

Urine cytology and urine flow cytometry in renal transplantation--a prospective double blind study.

Urine cytology (UC) has proved to correlate well with core and fine-needle aspiration kidney biopsies of renal allograft recipients undergoing acute rejection (AR). This study was undertaken to compare the relative usefulness of urine flow immunocytometry (UFC) (using fluorescinated antibodies anti-HLA-DR, anti-CD3 and antirenal epithelial cells) with UC in its ability to diagnose AR by analyzing 200 urine specimens during a prospective double-blind study of 40 renal transplant recipients. Clinical diagnosis was retrospectively assigned to one of the following categories: group I--AR, 15; group II--ischemic injury period (first 5 days postop.), 12; group III, 173 (including 168 stable grafts, 1 pyelonephritis and 4 cyclosporine toxicity), by investigators blinded to the urine results. Both tests were highly sensitive for the diagnosis of AR (UC = 86.6% vs. UFC = 100%; P = NS) with a specificity after the ischemic injury period of 78% by UC and 87.9% by UFC. Samples obtained during AR revealed higher levels of expression of HLA-DR as well as higher numbers of CD3-positive cells. These tests had specificity values of 95.3% and 97.6%, respectively, for the diagnosis of AR. The degree of immune activation (established by numbers of lymphocytes/lymphoblasts seen by UC) correlated with the severity of biopsy-proven ARs and with response to antirejection therapy. In conclusion, both test are highly accurate in diagnosing AR. The highest specificity value was obtained when both UC and UFC were utilized together (93%). We suggest that the routine use of these tests can provide an important adjunct to the evaluation of renal transplant recipients.

Risk of steroid withdrawal in pediatric renal allograft recipients (a 5-year follow-up).

Withdrawal of steroid therapy in renal allograft recipients remains controversial despite the many side effects of this treatment. We have previously presented data on 16 pediatric renal transplant recipients in whom prednisone was withdrawn 6 months or later post-transplantation. To assess the impact of steroid withdrawal, we retrospectively compared this group of patients (Group 1) with a group of 12 patients (Group 2) with renal transplants who continued on prednisone. The groups were compared as to age, sex, ethnicity, source of graft, number of HLA-DR mismatches and incidence of ATN in the immediate postoperative period. The only significant difference was that Group 2 was older. Group 1 had significantly fewer episodes of early acute rejection in the first 6 months post-transplantation than the control group (3/16 vs 8/12, p = 0.009) but nevertheless, without prednisone, had significantly more late acute rejections (11/16 vs 3/12, p = 0.03). Acute rejections occurred as late as 4 years after withdrawal of steroids. Only 5 of the 16 patients in Group 1 have maintained stable graft function without steroids. All of these patients are now alive more than 5 years after steroid withdrawal. In comparing these patients to the other 11, who failed a trial of steroid withdrawal, we found that a serum creatinine of less than 1.7 mg/dl at the time of withdrawal of steroids was predictive of a successful outcome (p = 0.03). In conclusion, withdrawing steroids in pediatric renal allograft recipients has a high risk of late acute rejection and subsequent graft loss, especially for those who have higher baseline creatinine levels.

Vasculitis in childhood.

Systemic vasculitic syndromes are rare in childhood. Vasculitis is the predominant feature of a large number of different clinical entities that are linked by the presence of inflammatory changes in the blood vessels. The nature of these diseases and their relationship to each other remain unclear. The clinical presentation associated with the size of the affected vessels and epidemiological data are very helpful for the diagnosis of those diseases. Recent advances are beginning to shed some light on the etiology and pathogenetic mechanisms involved in the various vasculitides. There is good evidence to support roles for circulating immune complexes, cell-mediated immunity, anti-neutrophil cytoplasmic antibodies and anti-endothelial cell antibodies in the pathogenesis. Renal involvement in vasculitis in children is commonly seen in Henoch-Schönlein purpura, microscopic polyarteritis, Wegener's granulomatosis, Churg-Strauss syndrome and polyarteritis nodosa. However, kidney disease can also be part of the clinical picture of Kawasaki disease and Takayasu arteritis. Recently, with the institution of early and aggressive immunosuppressive treatment of severe cases, significant improvement in the long-term survival of patients has been achieved. This review article addresses the pathological and clinical features (particularly renal involvement), therapeutic intervention and prognosis of the above-mentioned diseases.

Evidence that the systematic analysis of bile cytology permits monitoring of hepatic allograft rejection.

Cytologic analysis was performed on 128 bile specimens collected by schedule from 12 liver transplant recipients over a 4-month period. Clinical diagnoses at the time of specimen collection were determined retrospectively, as follows: clinically stable, 75; acute rejection, 15; CMV hepatitis, 1; systemic infection, 8; ischemic injury, 24 (all within the first 4 days postop); nonclassifiable, 5. Bile analysis was done by a blinded investigator. Specimens contained ductal epithelial cells (EC) and inflammatory cells (IC), which were counted using Cytospin slide preparations. Greater than 10 cells/slide were seen in 93.3% of rejections, 91.7% of ischemic injuries, 100% of systemic infections, and 14.6% of stable patients. In samples collected after POD 4, IC were seen in 86.7% of rejections, yielding a specificity of 94.4% (P less than 0.001). If lymphoblastic cells were also seen, the specificity increased to 96.6%. Five specimens were obtained the day before the clinical diagnosis of rejection; all demonstrated IC. Seven specimens were obtained 3 days after beginning therapy for rejection. In 5 the bile contained no IC, and clinical improvement occurred; in the 2 in whom IC were found, further therapy was subsequently required. IC were seen in 5 of 8 specimens taken when systemic infection was present; the clinical setting allowed differentiation from rejection. Only 1 case of CMV hepatitis was included, thus no conclusions can be drawn for this entity. Cytoplasmic vacuolization of EC was observed in 30% of cases, in these, cyclosporine levels were significantly higher (989.9 +/- 356.9 vs. 672.8 +/- 421.2, P = 0.02). In summary, bile cytology analysis aides in the monitoring of the onset and duration of rejection. It may be an indicator of persistent rejection, and it may help prevent overimmunosuppression in those cases with normal cytological findings.

IgA nephritis in a child with human immunodeficiency virus: a unique form of human immunodeficiency virus-associated nephropathy?

A 9-year-old boy is presented who was antibody positive for human immunodeficiency virus (HIV) and who had recurrent episodes of gross hematuria. Renal biopsy revealed findings typical of IgA nephropathy but also showed electron-microscopic abnormalities seen with HIV-associated nephropathy. In addition, IgA antibodies to multiple HIV proteins were detected in serum by Western blot analysis, and circulating immune complexes of the IgA class were present. Although HIV-associated nephropathy and IgA nephropathy are thought to be distinct conditions, five adults with a similar combination of findings have been reported, and our patient adds to the evidence for a link between these two entities in some patients. We propose that the histological parallels between the conditions may merely represent the limited renal responses available to multiple types of injuries, and we support the attempts underway to probe renal tissue for the HIV genome.

Mt. St. Anonymous; the adolescent living-related donor.

Seventeen-year-old David is a perfect organ match for his younger brother, Ken, who has kidney failure. David understands that the procedure presents some risk for him and that after surgery he may no longer be able to continue playing football. His idols all have been football players and he now plays on his high school's team. Nevertheless, he wants to donate a kidney to his brother and agrees to being a donor as soon as the option is mentioned. He never displays any ambivalence and says, "I want to donate my kidney because then I'll be a hero to my family." This close family--of two parents and five older siblings--strongly supports the seventeen-year-old's decision, especially after an older brother, who was also a perfect organ match, is found medically (anatomically) unsuitable. The parents and two of the older siblings could still be medically acceptable donors: their organs are likely to be better grafts (one haplotype matches) than a non-related cadaveric kidney would be, but less compatible than the perfect organ match (haploidentical) that could be provided by David, the adolescent brother. Studies have shown that in the short run there is little difference in the survivability of organs from different classes of donors. After several years, however, there is a significant difference with perfectly matched kidneys being much less prone to rejection than the less ideally matched organs.

Association of hematuria and mycobacterial infection.

Hematuria has been noted to be a presenting symptom of urinary tuberculosis. In the last few decades because of the decreasing incidence of tuberculosis in the United States, the association of tuberculosis and hematuria has been neglected. Now that the incidence of tuberculosis is again on the rise, it is timely to remind the medical community of this association. We present 3 children with hematuria associated with positive tuberculin tests. Mycobacterium tuberculosis was cultured from the urine of one patient. Mycobacterium avium-intracellulare was cultured from a second patient. All 3 patients showed clearing of their hematuria with antituberculosis therapy. A tuberculin test should once again be considered part of the standard work-up of hematuria.