Resting B cells as tolerogens in vivo but only for minor histocompatibility antigens: evidence for activation of resting B cells in vivo

BACKGROUND

Small, resting B cells (rB cells) express major histocompatibility complex (MHC) class II molecules but not the putative costimulatory molecules, B7-1 (CD80) and B7-2 (CD86); they are classified as nonprofessional antigen-presenting cells. rB cells have been shown to be capable of anergizing T cells in vitro and inducing the prolonged survival of skin grafts mismatched for a single minor histocompatibility (miH) antigen, H-Y. The aim of this study was to investigate ability of rB cells to induce unresponsiveness to multiple miH and MHC antigens.

METHODS

Mice were pretreated with 1 x 10(7) donor rB cells 14 days before transplantation of cardiac grafts mismatched for either a single or multiple miH and/or MHC antigens in vivo.

RESULTS

rB cells induced indefinite prolongation of cardiac grafts mismatched for H-Y antigen (C57BL/10 male to female). Moreover, 50% of grafts mismatched for multiple miH antigens (C3H to CBA) were accepted indefinitely in recipients treated with donor rB cells. In marked contrast, when grafts were mismatched for either a single MHC class I antigen, Kb (CBK to CBA), or multiple MHC and miH antigens (C57BL/10 to C3H), pretreatment with rB cells did not prolong graft survival. To investigate why rB cells were ineffective tolerogens for grafts mismatched for MHC antigens, we examined the fate of the cells in vivo. We demonstrate that, after intravenous injection of rB cells, expression of B7-2 was induced within 24 hr.

CONCLUSIONS

These data suggest that rB cells may be less effective at inducing specific unresponsiveness to MHC antigens because of their rapid activation in vivo.

Cytokine gene expression in pancreatic islet grafts in the rat

We examined the production of cytokine message in allogeneic and syngeneic rat pancreatic islet grafts using specific primers and polymerase chain reaction. Freshly isolated islet preparations contained transcripts for interleukin (IL)-1alpha, IL-6, IL-10, and interferon-gamma (IFN-gamma) but not for IL-2. IL-1alpha in allogeneic grafts showed increased and consistently high expression from 1 to 7 days after transplantation, but the level in syngeneic grafts fell quickly to pretransplant levels. IL-2 and IFN-gamma transcripts were found in allogeneic grafts at 1, 3, 5, and 7 days after transplantation with a peak at day 5, but these cytokines were almost absent from syngeneic grafts. The peak of IL-6 expression was 1 day after transplantation in both syngeneic and allogeneic grafts, and then the level fell quickly. IL-10 was produced at approximately the same high level at all time points in both syngeneic and allogeneic grafts. The results show that freshly isolated islet preparations contain IL-1alpha, IL-6, IL-10, and IFN-gamma transcripts at the time of transplantation. The initial production of cytokines in islet grafts, especially IL-1, may explain phenomena such as graft nonfunction, rapid rejection, and lack of response to immunosuppression.

Lack of association of angiotensin II type 1 receptor gene polymorphism with diabetic nephropathy in insulin-dependent diabetes mellitus

Several observations suggest that inherited factors are influential in the development of nephropathy in patients with insulin-dependent diabetes mellitus (IDDM). Genetic components of the renin angiotensin system are possible candidate genes. The aim of this study was to determine the role of the hypertension associated angiotensin II type 1 receptor (AT1R) gene A1166C polymorphism in susceptibility to nephropathy in IDDM. We examined 264 Caucasoid patients with IDDM and overt nephropathy (as defined by persistent proteinuria in the absence of other causes, hypertension and retinopathy), 136 IDDM patients with long duration of diabetes and no nephropathy (LDNN group), 200 recently diagnosed IDDM patients (Sporadic Diabetic group), and 212 non-diabetic subjects. The AT1R gene polymorphism was assessed using the polymerase chain reaction and restriction isotyping. Genotype frequencies did not differ significantly between the sporadic diabetic group and the nephropathy group (p = 0.245), nor between the long duration non-nephropathy group and the nephropathy group (p = 0.250). Allele frequencies were not significantly different between the three groups (p = 0.753). We conclude that there is no significant association between the hypertension associated AT1R gene polymorphism and diabetic nephropathy in patients with IDDM in the UK.

Merkel cell carcinoma arising after therapeutic immunosuppression

Azathioprine and cyclosporin have been used as immunosuppressants for many years, but long-term use has also been associated with neoplasia. We report three cases of rapidly fatal Merkel cell carcinoma in patients who had been treated with azathioprine for many years either for rheumatoid arthritis or following organ transplantation. Two of these patients had also received cyclosporin. We suggest that Merkel cell carcinoma may be seen more commonly in immunosuppressed patients than in the normal population and that the oncogenic potential of azathioprine and cyclosporin should be borne in mind when prescribing these drugs.

Vaccine-induced canine distemper in European mink, Mustela lutreola

This report describes vaccine-induced canine distemper virus (CDV) infection in four European mink (Mustela lutreola) induced by the administration of a multivalent, avian-origin vaccine. Clinical signs consisting of seizures, ataxia, facial twitching, oculonasal discharge, hyperkeratosis of footpads, and anorexia developed 16-20 days postvaccination. Conjunctival smears from one animal were positive for CDV antigen by direct fluorescent antibody testing, confirming the clinical diagnosis. The four mink died 16-26 days postvaccination. Gross and microscopic lesions that were diagnostic for CDV infection included interstitial pneumonia, lymphoid depletion, nonsuppurative encephalitis, and dermatitis. Vaccine-strain virus was isolated from tissues of three animals. Cases of vaccine-induced distemper in mustelids using avian-origin vaccine have seldom been reported.

The factor V Leiden (R506Q) mutation and risk of thrombosis in renal transplant recipients

BACKGROUND

Renal transplantation and chronic renal failure are associated with an increased risk of venous thrombosis and myocardial infarction (MI). We investigated whether resistance to activated protein C due to a mutation in the factor V gene (FV Leiden/FV506Q) may predispose patients to thrombosis.

METHODS

Three hundred patients who had undergone renal transplantation were genotyped for the FV mutation. Seventy-seven patients who had suffered thrombotic complications (42 venous, 28 arterial, and 7 both) were compared with 223 patients free of thrombosis.

RESULTS

Thirty-two patients had suffered early renal allograft thrombosis (30 venous), and 33 patients had suffered MI. A higher proportion of the patients with thrombosis, compared to those without, had a family history of arterial cardiovascular disease (42% vs. 26%, P=0.04). Eighteen (6%) patients were heterozygous for FV506Q and seven (39%) of these had suffered venous thrombosis (including four primary allograft thromboses), compared with 15% of the patients without the mutation (P<0.05). The odds ratio for risk of venous thrombosis for FV506Q carriers was 3.6 (95% confidence interval: 1.3-9.9) or 4.0 (1.2-13.8) for primary allograft thrombosis. Only one of the FV506Q carriers had suffered an MI.

CONCLUSIONS

Carriers of the factor V 506Q mutation with chronic renal failure who have undergone transplantation are at an increased risk of venous but not arterial thrombosis. This mutation explained 14% of all venous and 20% of primary allograft thrombosis, suggesting that other unidentified genetic and environmental factors contribute to the risk of thrombosis in renal transplant recipients.

Coordinate induction of the three neurofilament genes by the Brn-3a transcription factor

The POU domain transcription factor Brn-3a is able to stimulate neurite outgrowth when overexpressed in the neuronal ND7 cell line, whereas the closely related Brn-3b factor does not have this effect. We show that Brn-3a overexpression also enhances the expression of the three neurofilament genes at both the mRNA and protein levels, whereas Brn-3b overexpression has no effect. In addition Brn-3a activates the three neurofilament gene promoters in co-transfection assays in both neuronal and non-neuronal cells. As observed for enhanced neurite outgrowth, the stimulation of neurofilament gene expression and activation of the neurofilament gene promoters is observed with the isolated POU domain of Brn-3a. A single amino acid change in the POU homeodomain of Brn-3a to the equivalent amino acid in Brn-3b abolishes its ability to activate the neurofilament promoters, whereas the reciprocal change converts Brn-3b to an activator of these promoters.

Deletion of alloantigen-reactive thymocytes as a mechanism of adult tolerance induction following intrathymic antigen administration

Direct injection of foreign antigen into the adult thymus is a potent route of antigen delivery for the induction of tolerance in vivo. In this report, we demonstrate that tolerance to C57BL/10 (H2b/BL10) alloantigens can be induced in CBA/Ca (H2k/CBA) mice by intrathymic (IT) administration of BL10 spleen leukocytes coincident with transient peripheral immunomodulation of CD4+ T cells using a depleting anti-CD4 monoclonal antibody. T cell receptor (TCR) transgenic mice (BM3.6; H2k) expressing a CD8-independent TCR specific for H2Kb were used as recipients to facilitate investigation of the mechanisms responsible for tolerance induction by allowing visualization of events in the thymus following IT injection. IT administration of 5 x 10(7) BL10 spleen leukocytes and concomitant transient peripheral T cell depletion in BM3.6 mice resulted in a substantial H2Kb-specific deletion of transgenic-TCR+ (tg-TCR) thymocytes which was dependent on the level of tg-TCR expression. IT deletion and the failure to export CD8+ T cells to the peripheral lymphoid organs correlated with the induction of tolerance to H2Kb; TCR transgenic mice that had received IT injection of BL10 splenocytes and peripheral T cell depletion accepted a H2Kb+ cardiac allograft indefinitely. Analysis of tolerant BM3.6 mice revealed that there were low numbers of CD8+ T cells in the periphery giving rise to a substantially reduced reactivity in vitro despite the fact that no donor cells or IT deletion were observed in the thymi of the majority of tolerant mice. These results demonstrate for the first time that IT injection of foreign alloantigen into an adult thymus results in the deletion of thymocytes expressing a TCR specific for the injected alloantigen and suggest that this is an important mechanism of tolerance induction following IT injection of alloantigen in vivo. Furthermore, analysis of tolerant TCR-transgenic mice suggests that IT deletion is not required for the maintenance of tolerance, and that peripheral mechanisms enforce continued hyporesponsiveness to H2Kb following transplantation.

Successful reversal of diabetes by single donor isologous islet transplantation in a mouse model

A method for isolating mouse islets which consistently gives a high yield with good purity is described. Using a bovine serum albumin gradient, the mean yield of islets per pancreas is 425 (SEM +/- 15) with a consistent purity of over 90%. Single donor to single recipient of islets transplanted under the renal capsule restores normoglycemia in the diabetic recipients within 2 to 5 days of transplantation.

A single residue within the homeodomain of the Brn-3 POU family transcription factors determines whether they activate or repress the SNAP-25 promoter

The closely related POU family transcription factors Brn-3a and Brn-3b differ in their effect on a number of different neuronally expressed promoters such as that of the gene encoding the synaptic vesicle component SNAP-25. Thus Brn-3a activates these promoters whilst Brn-3b represses both their basal activity and their activation by Brn-3a. We show here that alterations of a single amino acid at position 22 in the POU-homeodomain from the isoleucine found in Brn-3b to the valine found at the equivalent position in Brn-3a converts Brn-3b from a repressor to an activator of the SNAP-25 gene promoter. The converse mutation in Brn-3a abolishes its ability to activate the SNAP-25 gene promoter and allows it to repress the basal activity of the promoter and its activation by wild type Brn-3a. This is the first time that a single amino acid change has been shown to convert an activator of a naturally occurring promoter to a repressor and vice versa. These results are discussed in terms of the critical role of position 22 in the POU homeodomain in the protein-protein interactions of POU proteins.

Pretransplant administration of a single donor class I major histocompatibility complex molecule is sufficient for the indefinite survival of fully allogeneic cardiac allografts: evidence for linked epitope suppression

BACKGROUND

Allograft survival can be prolonged by the administration of alloantigen(s) before transplantation. Blood transfusion is the commonest form of alloantigen pretreatment currently used in clinical practice. However, for recipients of organs from cadaver donors, it is not possible to predict the identity of the organ donor in advance. Therefore, it is highly unlikely that all the alloantigens expressed by a cadaver organ donor will be represented in the alloantigen pretreatment inoculum. We have previously shown that it is not necessary to expose the recipient to the full complement of donor alloantigens to induce long-term survival of a subsequent cardiac allograft. Here, we investigated the in vivo mechanism responsible for this phenomena.

METHODS

Unresponsiveness to the mouse MHC class I molecule Kb was induced in CBA.Ca (H2k) recipients by administration of bone marrow cells from transgenic CBA mice, CBK (H2k + Kb) before transplantation of fully allogeneic and F1 vascularized cardiac allografts.

RESULTS

Pretreatment with CBK bone marrow cells resulted in the long-term survival of all cardiac allografts expressing H2-Kb. For example, C57BL/10 (H2b) and (CBKxBALB/c) F1 (H2k,d + Kb) cardiac allografts were accepted by recipients treated with CBK bone marrow cells before transplantation. In contrast, allografts that did not express Kb, such as BALB/c (H2d) or (CBAxBALB/c) F1 (H2k,d), were rejected acutely, with a median survival time (MST) of 7 and 6 days, respectively, in recipients treated with CBK bone marrow cells. Furthermore, when recipients pretreated with CBK bone marrow cells were grafted with a BALB/c heart and a CBK heart simultaneously, the BALB/c hearts were rejected (MST=10 days), whereas the CBK hearts were accepted. By contrast, in the maintenance phase (i.e., after transplantation), recipients with long-term surviving (CBKxBALB/c) F1 hearts (> 100 days) were found to accept BALB/c hearts indefinitely, whereas fourth-party B10.S (H2s) grafts were rejected (MST=7.5 days). This indicated that the allografts bearing Kb could tolerize recipients to other alloantigens expressed by the transplanted heart.

CONCLUSIONS

These data provide clear evidence for linked epitope suppression in the induction of operational tolerance in vivo.

Renal transplantation: a quarter century of achievement

Renal transplantation has become the treatment of choice for most types of end-stage renal failure. Immunosuppressive drug therapy has improved enormously over the past 25 years, and the advent of potent new drugs in addition to cyclosporine make multiple drug therapy for immunosuppression the direction of the immediate future. Monoclonal antibodies have so far had a limited role in immunosuppression, but are likely to prove of value in protocols aimed at inducing specific unresponsiveness to a renal allograft. This remains the goal of transplantation biology, because the long-term complications of all current nonspecific immunosuppressive protocols are formidable. In addition, the shortage of cadaver kidneys for transplantation has led to an increasing use of living related and unrelated donors, and stimulated a major research activity in xenotransplantation in an attempt to bring it to the clinic in the not too distant future.

The immune response following small bowel transplantation. II. A very early cytokine response in the gut-associated lymphoid tissue

The small bowel has a unique amount of closely associated lymphoid tissue in the form of mesenteric lymph nodes (MLNs) and Peyer's patches (PPs). It is rather unclear how this may affect the immune response to transplants involving small bowel. It is clear, however, that host-derived leukocytes infiltrate this lymphoid tissue very rapidly after transplantation of small bowel, which suggests the possibility of an early immune response within this compartment. To investigate this possibility, we analyzed, using a semiquantitative reverse transcriptase-polymerase chain reaction, the level of cytokine transcripts within isolated MLNs and PPs for the first 7 days after small bowel transplantation. Heterotopic small bowel (n=32) transplants were performed using the following rat strain combinations: syngeneic Lewis (Lew)-->Lew (n=8), blood group D Agouti (DA)-->DA (n=8), allogeneic Lew-->DA (n=8), and allogeneic DA-->Lew (n=8). Two rats from each group were killed at 1, 3, 5, and 7 days after transplantation. RNA was prepared separately from PPs and MLNs before analysis of transcripts for interleukin (IL) 2, IL-4, IL-10, IL-6, IL-1alpha, and interferon (IFN) gamma. No increase in transcripts for IL-2 or IL-10 was observed in either PPs or MLNs of syngeneic grafts. A small rise in IL-6, IL-1alpha, and IFN-gamma transcripts was seen in MLNs and IFN-gamma transcripts in PPs of syngeneic grafts. In contrast, in allografts an extremely early increase in cytokine transcripts was observed; all cytokine transcripts tested were elevated within the first 24 hr after transplantation. Indeed, the peak response of both IL-2 and IL-10 occurred within 1 to 3 days after grafting. This early immune response in the lymphoid tissue may not be controlled by immunosuppression delivered only at the time of transplantation, and therefore may be responsible for the difficulty in achieving adequate immunosuppression in small bowel transplantation.

Effect of one-HLA-haplotype-matched and HLA-mismatched blood transfusions on recipient T lymphocyte allorepertoires

BACKGROUND

Pretransplant blood transfusion has a well-known beneficial effect on posttransplant graft survival. Recently, it has been proposed that the clinical benefit of transfusion is due to HLA-DR antigen sharing between the blood donor(s) and the recipient. Immunological studies have suggested that this might result from a functional deletion of donor-reactive cytotoxic T lymphocytes.

METHODS

We investigated frequencies of alloreactive lymphocyte precursors with cytotoxic or interleukin-2-producing helper function by limiting dilution analysis in 10 renal dialysis patients before and after transfusion with fresh, allogeneic whole blood. Five patients received blood transfusions from donors matched for one HLA haplotype (or one HLA-B-DR antigen) and the other five patients received blood from fully HLA-mismatched donors.

RESULTS

Contrary to some previous reports, frequency analysis of cytotoxic T lymphocyte precursors revealed no significant differences between the two treatment groups in terms of development of blood donor-specific hyporesponsiveness after transfusion. Split-well analysis of cytotoxic T lymphocyte precursors reactive with single-mismatched HLA antigens demonstrated that the effects of transfusion on alloreactive specificity are complex and may vary depending on the particular antigens mismatched between the recipient and blood donor. Analysis of donor-specific helper T lymphocyte precursor frequencies revealed a significant decrease of interleukin-2-producing cells 3 months after transfusion in the total patient population. This effect was most prominent in the recipients of HLA-mismatched blood, but it also exhibited some degree of nonspecificity, as frequencies of third-party reactive helper T lymphocyte precursors were also significantly reduced.

CONCLUSIONS

Our overall results suggest that the degree of HLA matching between blood donor and recipient does not greatly influence the effect of blood transfusion on the T lymphocyte allorepertoire. The apparent induced down-regulation of helper T lymphocyte activity may play a role in the reported immunosuppressive effects of allogeneic blood transfusion.

Treatment with an HLA-peptide and cyclosporine A prolongs rat small bowel allograft survival

BACKGROUND

The ultimate treatment for severe short bowel syndrome is small bowel transplantation (SBT). Current immunosuppression for SBT is relatively ineffective and toxic. Peptides derived from residues 75-84 of the HLA-B7 molecule are immunomodulatory in vitro, and in rodents, when combined with subtherapeutic doses of cyclosporine (CsA), prolong cardiac and skin allograft survival without altering the recipient's rejection kinetics to third party allografts. We investigated the effects of HLA-B7 peptide fragment in a rat model of SBT.

METHODS

Heterotopic allogeneic SBT was performed in Dagouti (RT1a) to Lewis (RT1l) high-responder rat strain combination. B7.75-84 (40 mg/kg/d) and subtherapeutic CsA (10 mg/kg/d) were administered alone, or in combination, by gavage to allograft recipients on days 0 to 4 after SBT. Recipient pretreatment with B7.75-84 on days -14, -12, -10, and -7 followed by subtherapeutic CsA on days 0 to 4 after SBT was also carried out. Graft rejection was determined by the presence of a palpable abdominal mass on daily examination or by loss of more than 10% initial body weight.

RESULTS

Without immunosuppression allografts rejected at a median time of 6 days (range, 5 to 7; n = 7). This was not significantly altered with either CsA therapy alone (median 6 days; range, 6 to 7; n = 6) or B7.75-84 alone (median, 5 days; range, 5 to 6; n = 6). Recipient combination therapy with B7.75-84 and CsA after allografting significantly prolonged allograft survival (median, 11 days; range, 9 to 13; n = 9), as did recipient B7.75-84 pretransplant therapy (median, 10 days; range, 9 to 12; n = 6), when administered over a 2-week period before allografting.

CONCLUSION

Post-SBT recipient treatment with B7.75-84 produced statistically significant improvement in allograft survival only after combination with subtherapeutic CsA. Recipient pre-SBT treatment with B7.75-84 alone however, resulted in statistically significant improvement in allograft survival in combination with post-SBT subtherapeutic CsA. These synergistic effects may be valuable in achieving improved SBT survival clinically and warrant further exploration.

Patterns of graft infiltration and cytokine gene expression during the first 10 days of kidney transplantation

Understanding of the events preceding acute cellular rejection of kidney transplants would be useful in the development of immunosuppressive strategies to prevent rejection. Information about these events in humans has been scarce, because of the lack of early, serial, biopsy samples. We took daily fine needle aspirates from kidney allografts for the first 10 days after transplant. Samples were analyzed by morphological cytology of graft-infiltrating cells, and reverse transcriptase-polymerase chain reaction for detection of interleukin (IL)-2, IL-4, IL-6, IL-10, and gamma-interferon gene expression. During the first 4 days, all of the grafts developed a low-grade monocyte-rich mononuclear cell infiltrate, accompanied by IL-10 gene expression. Thereafter, the infiltrates either remained stable or intensified. Of the 13 grafts with dense infiltrates, seven developed graft dysfunction. The remaining six did not, despite significant interstitial infiltrates. Both rejecting and nonrejecting dense infiltrates were associated with a biphasic pattern of IL-2 and gamma-interferon gene expression, preceding and accompanying lymphocytic graft infiltration. Grafts that did not develop dense infiltrates had no detectable IL-2 or gamma-interferon gene expression and did not suffer cellular rejection during the study period. The development of both rejecting and nonrejecting infiltrates was strongly associated with DR mismatches between donor and recipient. IL-2 and gamma-interferon gene expression are necessary, but not sufficient, for the development of acute cellular rejection in the first 10 days of kidney transplantation, and are more closely associated with the period leading up to rejection than with the period of graft dysfunction.

Management of severe pancreatitis in renal transplant recipients

OBJECTIVE

The authors determine if any aspects of the treatment of renal transplant patients with pancreatitis were of particular benefit with regard to graft and patient survival.

BACKGROUND

The incidence of pancreatitis in renal transplant patients is low (1%-2%), but the mortality of the disease approaches 100%. Although several descriptive reports have been published, there is no consensus-regarding management.

METHODS

The authors conduct a retrospective chart review.

RESULTS

Twenty-one patients were identified with posttransplant pancreatitis (1.3% incidence). The cause of pancreatitis was presumed to be maintenance immunosuppression in all cases. Patients were classified by dynamic computed tomography (CT) scans having 1) mild/edematous disease (4 patients), 2) localized abscess or pseudocyst (6 patients), or 3) severe disease (11 patients). Patients with mild/edematous pancreatitis did well with medical management. The six patients with localized abscess or pseudocyst were successfully treated with standard operative intervention. Of the 11 patients with severe disease, 6 had several days of intensive medical management before operation, and all died. The other five patients underwent early operative intervention based principally on CT scan findings, and all survived. The latter group had multiple operations and four of five had functioning renal allografts at discharge.

CONCLUSION

The severity of pancreatitis in the posttranplant patients may be difficult to assess by clinical criteria. Dynamic CT scanning is, therefore, essential in defining the extent of disease. Early, and perhaps repeated, operations may be lifesaving in those patients having CT scan findings of severe pancreatitis.

Suicide and suicidal ideation after marrow transplantation

Two cases of patients who attempted suicide following BMT and one case of a patient with suicidal ideation during his isolation period for BMT are reviewed. The factors which contributed to this situation are investigated. Finally, issues relating to psychological interventions are briefly discussed.

Killer cell inhibitory receptor interactions with HLA class I molecules: implications for alloreactivity and transplantation

Human killer cell inhibitory receptors (KIR) are novel members of the immunoglobulin superfamily of cell surface glycoproteins, which are expressed by lymphocytes with natural killers (NK) and cytotoxic T-cell (CTL) phenotypes. These receptors have specificity for relatively conserved epitopes of HLA-A, -B, and -C class I antigens. Recent studies have identified KIR as being involved in the transmission of negative, inhibitory signaling events to the cytotoxic cell which prevent or diminish target cell lysis. KIR are thus likely to play an important role in the responses of alloreactive NK cells and CTL to allogeneic HLA antigens. In this article, we review the known structural and functional characteristics of KIR, suggest a possible mechanism for the transmission of intracellular negative signaling by these receptors, and discuss the relevance of KIR function and HLA specificity to the clinical transplantation of allogeneic tissues.

Differential regulation of genes encoding synaptic proteins by members of the Brn-3 subfamily of POU transcription factors

The three members of the Brn-3 subfamily of POU transcription factors have distinct effects on target gene expression. We show that the promoter of the gene encoding the presynaptic nerve terminal protein SNAP-25 resembles previously characterised target genes in being activated by Brn-3a and Brn-3c, but being repressed by Brn-3b. Unlike other target genes, however, the SNAP-25 promoter can be activated by either the N- or C-terminal activation domains of Brn-3a. In contrast to the SNAP-25 gene, the gene encoding the synaptic vesicle protein synapsin 1 is activated by all the Brn-3 factors, the first gene for which this activation pattern has been reported Interestingly, however, similar activation by all three Brn-3 factors can be observed if the SNAP-25 promoter is truncated by removal of sequences from -2200 to -288 relative to the transcriptional start site. Moreover, a region of the SNAP-25 promoter from -283 to -126 can render a heterologous promoter responsive to activation by all three Brn-3 factors. Differences in promoter structure may thus result in differences in the response to different Brn-3 factors, thus allowing these factors to produce diverse activation patterns of neuronally expressed genes, such as those encoding different synaptic proteins.

Syngeneic bone marrow expressing a single donor class I MHC molecule permits acceptance of a fully allogeneic cardiac allograft

Bone marrow cells may be a useful vehicle for pretransplant delivery of alloantigen to induce tolerance in vivo. However, infusion of fully allogeneic bone marrow cells carries the risk of graft-versus-host disease. In order to reduce this risk while retaining the tolerogenic potential of the bone marrow infusion, we have investigated the ability of recipient bone marrow cells expressing a single donor MHC class I antigen to induce specific unresponsiveness in vivo. We show that 5x10(7) and 5x10(6) bone marrow cells from a transgenic strain of CBA mice, CBK, that express a single donor class I MHC gene, H2Kb (H2k + H2Kb), were able to induce long term survival of a fully allogeneic C57BL/10 (H2b) cardiac allograft in 80% and 20% of unmanipulated CBA (H2k) recipients, respectively, when administered intravenousely on the day of transplantation. In contrast, the same doses of fully allogeneic C57BL/10 donor bone marrow were completely ineffective at prolonging graft survival. When the interval between bone marrow infusion and transplantation was increased to 14 days, CBK bone marrow at either dose (5x10(6) and 5x10(7)) induced long term survival of C57BL/10 cardiac allografts in all recipients (MST>100 days) while fully allogeneic donor bone marrow was ineffective (MST=7, 5x10(6) cells; MST=6, 5x10(7)). Only when 27 or 42 days had elapsed between bone marrow infusion and transplantation did fully allogeneic bone marrow exert a beneficial effect on graft survival. Administration of 5x10(6) C57BL/10 bone marrow cells 27 and 42 days before transplantation resulted in long term survival of C57BL/10 hearts in 67% and 75% of CBA recipients. Next, we investigated whether manipulating the periphery of the recipient with a depleting anti-Cd4(4) monoclonal antibody before bone marrow infusion would facilitate the induction of unresponsiveness. When pretreatment with bone marrow cells was combined with anti-Cd4 monoclonal antibody 28 days before transplantation, a 10-fold reduction in the number of either C57BL/10 or CBK bone marrow cells required to induce tolerance was observed. These data confirm that bone marrow is a suitable vehicle for alloantigen delivery at the time of, or before, transplantation, on its own or in combination with anti-Cd4. The use of recipient type bone marrow cells expressing one or more donor MHC genes may be more effective than fully allogeneic, donor bone marrow cells in inducing tolerance in vivo. This difference may have important clinical implications for the current trials of donor bone marrow given at the time of transplantation in order to augment chimerism and to prolong graft survival.

Preemptive cadaveric renal transplantation--clinical outcome

Preemptive cadaveric renal transplantation (PCRT) maximizes the chance of maintaining high quality of life and may avoid the morbidity of dialysis and the associated financial costs. These benefits are offset by disadvantages, which include the possibility of transplantation many months before the need for dialysis, resulting in wasted organ function; an immediate risk of graft failure with conversion to a dialysis-dependent state; and uncertainty of the safety of PCRT. Patients who underwent PCRT between June 1976 and December 1994 at the Oxford Transplant Centre were compared with a matched cohort of first cadaveric transplant recipients who were dialysis-dependent when transplanted. The 116 patients in the PCRT cohort were well matched to the control group with respect to sex, age, blood group, HLA match, degree of sensitization, donor age, immunosuppression, and year of transplantation. Patient and graft survival were significantly better in the PCRT group. The difference in graft survival did not appear to be completely explained by better patient survival, as suggested by a trend toward better graft survival after excluding death with a functioning graft as a cause of failure. Among surviving grafts there were no significant differences in graft function as assessed by 1, 2, and 3 year plasma creatinine levels. In conclusion, PCRT appears to be safe and may even be associated with superior graft survival when compared with conventional transplantation. Early inclusion on a transplant waiting list with a view to PCRT can be justified with respect to the clinical outcome but the financial costs and implications for the utilization of cadaveric donor kidneys must also be considered.

Death of the Escherichia coli K-12 strain W3110 in soil and water

Whether Escherichia coli K-12 strain W3110 can enter the "viable but nonculturable" state was studied with sterile and nonsterile water and soil at various temperatures. In nonsterile river water, the plate counts of added E. coli cells dropped to less than 10 CFU/ml in less than 10 days. Acridine orange direct counts, direct viable counts, most-probable-number estimates, and PCR analyses indicated that the added E. coli cells were disappearing from the water in parallel with the number of CFU. Similar results were obtained with nonsterile soil, although the decline of the added E. coli was slower. In sterile water or soil, the added E. coli persisted for much longer, often without any decline in the plate counts even after 50 days. In sterile river water at 37 degrees C and sterile artificial seawater at 20 and 37 degrees C, the plate counts declined by 3 to 5 orders of magnitude, while the acridine orange direct counts remained unchanged. However, direct viable counts and various resuscitation studies all indicated that the nonculturable cells were nonviable. Thus, in either sterile or nonsterile water and soil, the decline in plate counts of E. coli K-12 strain W3110 is not due to the cells entering the viable but nonculturable state, but is simply due to their death.

The immune response following small bowel transplantation: I. An unusual pattern of cytokine expression

Acute cell mediated graft rejection is frequently associated with an immune response dominated by cytokines like IL-2 and IFNgamma. While small bowel grafts are rejected acutely, there is little information on the type of immune response generated following transplantation and, in particular, whether the cytokine profile resembles that seen during the rejection of other solid organ grafts. In this paper we compare the expression of cytokines in isolated gut tissue following experimental small bowel transplantation with that in heart grafts. Heterotopic small bowel (n=32) and cardiac (n=32) transplants were performed using the following rat strain combinations: syngeneic Lewis (Lew) > Lew (n=8), blood group D Agouti (DA) > Lew (n=8) and allogeneic Lew > DA (n=8), DA > Lew (n=8). Two rats from each group were sacrificed at 1, 3, 5, or 7 days after transplantation. RNA was prepared separately from gut wall, after removing the Peyer's patches (PPs) and mesenteric lymph nodes (MLNs) and from heart. Cytokine (IL-1alpha, IL-2, IL-4, IL-6, IL-10 and IFNgamma) transcripts were analyzed using semiquantitative RT-PCR. Most notably, transcripts of only a single cytokine, IFNgamma, became progressively elevated with time in the rejecting small bowel grafts. This is in marked contrast to the findings presented here for rat cardiac grafts in which transcripts of all cytokines tested show an increase with rejection. This significant and steady increase in IFNgamma expression occurred before there was any clinical or histological evidence of rejection. These data demonstrate that the mechanisms of rejection in small bowel and other solid organ grafts are likely to be different. Further, the unique rise in IFNgamma expression in the gut wall may be a valuable and early indicator of graft rejection.

Evidence that the continued presence of the organ graft and not peripheral donor microchimerism is essential for maintenance of tolerance to alloantigen in vivo in anti-CD4 treated recipients

The source of donor alloantigen required to maintain tolerance in vivo was evaluated in anti-Cd4 monoclonal antibody (mAb) treated mice. Treatment with a depleting anti-Cd4 mAb at the time of transplantation (day -1,0) induces tolerance to C57BL/10 (H2b) vascularized cardiac allografts in C3H.He (H2k) mice. The presence of the vascularized allograft was found to be essential for the induction of tolerance in this experimental model; it is the only source of donor alloantigen during the induction phase of unresponsiveness (0-50 days). In the maintenance phase (>50 days) donor alloantigen is potentially available from two sources, the organ graft itself or donor cells that have migrated out of the graft and are resident in the periphery (donor microchimerism). We show that the vascularized cardiac allograft is essential for the maintenance of tolerance to donor alloantigen in vivo. When the primary heart graft remained in situ, tolerance to donor alloantigens, as assessed by the survival of a second heart graft, was maintained indefinitely (>250 days) (MST of second C57 heart grafts >100 days). However, when the primary heart graft was removed 50 days after transplantation, a time point when tolerance to donor alloantigens was demonstrable in vivo, tolerance was lost 200 days later (MST of second C57 heart grafts 31 days). No evidence of donor microchimerism in the recipient was obtained using allele specific polymerase chain reaction (pcr) analysis for donor class I antigen. Persistence of donor alloantigen in the form of the vascularized organ graft is therefore required for both the induction and maintenance of tolerance to alloantigen in vivo in this experimental model.

Cytomegalovirus infection and colonic perforation in renal transplant patients

Cytomegalovirus (CMV) infection in immunocompromised patients is a major cause of morbidity and mortality. A well-documented manifestation of gastrointestinal CMV infection is gastrointestinal haemorrhage. In contrast, CMV-associated intestinal perforation has rarely been reported after transplantation, although it is well documented in AIDS patients. Three patients are reported who received their first cadaveric renal transplant in 1994 and subsequently developed CMV disease. During the course of their CMV illness, which was treated with ganciclovir, each presented with clinical suspicion of peritonitis and proceeded to laparotomy. All three were found to have sigmoid colon perforations with histological evidence of CMV infection. Following bowel resection and defunctioning, two patients made an uneventful recovery and have had the continuity of their bowel restored, but one died of overwhelming sepsis within hours of surgery. The explanation for the apparent clustering of this rare condition in transplant patients is uncertain.

Primary alloreactive cytotoxic T-lymphocytes are not commonly restricted by self-HLA class I antigens

To assess the role of HLA Class I molecules in the indirect presentation of alloantigen, we have investigated the fine specificity and MHC restriction of in vitro primary alloreactive cytotoxic T-lymphocytes (CTL), using limiting dilution analysis of CTL precursor frequencies in HLA-mismatched responder-stimulator pairs. By employing split-well analysis of limiting dilution (LD) microcultures and third-party target cells bearing a stimulatory HLA Class I antigen alone or in combination with a single responder HLA antigen, we demonstrate that self-Class I restriction of HLA-A- or HLA-B-specific CTL precursors is not a common feature of the primary in vitro alloresponse. Higher frequencies of alloantigen-specific CTL precursors in the presence of self-HLA antigens were only detected in 5 of 31 limiting dilution assays established from seven different responder-stimulator pairs. In two cases, the higher precursor frequencies could be explained on the basis of Class II-restricted presentation of Class I-derived antigenic peptide and are supported by flow cytometric analysis of HLA antigen expression on target cells. The remaining 3 assays of this type were suggestive of Class I restriction but revealed only marginally higher frequency estimates. All other LD assays revealed lower CTL precursor frequency estimates in the presence of self-HLA Class I antigens. A higher antigen-specific CTLp frequency was not detected when targets shared three HLA Class I antigens with the responder, demonstrating that we had not biased the responses by selecting single HLA antigen-sharing targets in the other assays. Analysis of reactivity against PHA blast targets at the single cell per well level demonstrated that CTL reactive only with the original stimulator comprised the majority of lytic reactions. Heteroclitic CTL (i.e., CTL that recognize single HLA targets only and not the original stimulator) formed only a small fraction of total reactivity. Our results confirm the role of Class II antigens in the indirect presentation of alloantigen in vitro but suggest that HLA Class I antigens play a limited role in this phenomenon.

Enumeration of human alloreactive helper T lymphocyte precursor frequencies by limiting dilution analysis of interleukin-2 production

We describe a limiting dilution assay for the enumeration of alloreactive interleukin-2 (IL-2) producing helper T lymphocyte precursors (HTLp). In place of the commonly used CTLL cell line, we have employed concanvalin A (ConA) stimulated rat thymocytes as IL-2 responsive indicator cells in a proliferation assay to detect IL-2 levels in limiting dilution microculture supernatants. The proliferation of ConA stimulated thymocytes induced by either recombinant IL-2 or culture supernatants could be blocked by co-incubation with a monoclonal antibody against the rat IL-2 receptor alpha chain, demonstrating the specificity of the response. Our investigations of alloantigen-induced IL-2 production show that (i) a minimum stimulator cell irradiation dose of 50-60 Gy is required to prevent backstimulation of microcultures; (ii) frequencies of alloreactive HTLp are significantly associated with HLA-DR antigen matching between responder and stimulator; (iii) HTLp frequencies detected in assays using B lymphoblastoid cell line stimulators are significantly higher than in assays employing peripheral blood lymphocyte stimulators but possibly reflect a degree of non-specific activation; and (iv) allosensitized responders exhibit altered kinetics of IL-2 production which may permit discrimination between sensitized and naive individuals. Our results both confirm and extend previous reports concerning such features of the alloresponse in humans and demonstrate that ConA stimulated thymocytes are a suitable alternative to CTLL as IL-2 responsive indicator cells in limiting dilution assays for HTLp analysis.

Randomised controlled trial of steroid withdrawal in renal transplant recipients receiving triple immunosuppression

BACKGROUND

The combination of cyclosporin, azathioprine, and prednisolone (triple immunosuppression) is the most commonly used immunosuppressive regimen early after renal transplantation, but the risks and benefits of maintaining the steroid component of this regimen in the long term are uncertain.

METHODS

A randomised controlled trial of steroid withdrawal was conducted among renal transplant patients receiving triple immunosuppression. Between one and six years after transplantation, 100 such patients were randomised either to reduce prednisolone treatment to zero over about four months or to maintain their triple immunosuppression unchanged. Outcome was analysed according to "Intention-to-treat".

FINDINGS

In 42 (86%) of 49 patients allocated to steroid withdrawal, complete steroid withdrawal was achieved. Although these patients did not experience defined acute rejection episodes, insidious increases in plasma creatinine were observed more frequently in this group than in the controls. In 97 patients surviving one year after trial entry, plasma creatinine exceeded the baseline by more than 25% at some time in the first year in 25 (53%) of 47 in the steroid withdrawal group compared with 9 (18%) of 50 in the control group (p < 0.001, chi-square test). In some cases these increases were transient. However, when corrected for the baseline (entry) value significant differences between groups were apparent in both mean plasma creatinine and mean creatinine clearance; mean (SD) plasma creatinine values at entry, immediately after withdrawal, and at one year were 138 (27), 151 (36), and 150 (36) mumol/L in the steroid withdrawal group versus 138 (34), 140 (51), and 139 (47) mumol/L in the control group (p = 0.017, analysis of covariance). Steroid withdrawal patients showed a further rise in mean plasma creatinine to 160 (44) and 161 (65) mumol/L at two and three years from trial entry. Changes in several clinical and metabolic indices were also observed in association with steroid withdrawal. Blood pressure declined but the reduction was incompletely sustained, being more evident immediately after steroid withdrawal than at one year. Total cholesterol declined about 1 mmol/L in the steroid withdrawal group. Other changes associated with steroid withdrawal were reductions in white cell count and haemoglobin and increases in plasma phosphate and alkaline phosphatase.

INTERPRETATION

Late steroid withdrawal is feasible in most patients with stable graft function on triple immunosuppression and has potentially beneficial metabolic effects. However, a substantial proportion of patients show a reduction in graft function, indicating a need for caution in considering the long term outcome.

Examination of two genetic polymorphisms within the renin-angiotensin system: no evidence for an association with nephropathy in IDDM

Premature cardiovascular disease is common in insulin-dependent diabetic (IDDM) patients who develop diabetic nephropathy. Genetic polymorphism within the renin-angiotensin system has been implicated in the aetiology of a number of cardiovascular disorders; these loci are therefore candidate genes for susceptibility to diabetic renal disease. We have examined the angiotensin converting enzyme insertion/deletion polymorphism and angiotensinogen methionine 235 threonine polymorphism in a large cohort of Caucasian patients with IDDM and diabetic nephropathy. Patients were classified as having nephropathy by the presence of persistent dipstick positive proteinuria (in the absence of other causes), retinopathy and hypertension (n = 242). Three groups were examined for comparison: ethnically matched non-diabetic subjects (n = 187); a geographically defined cohort of newly diagnosed diabetic patients (n = 341); and IDDM patients with long duration of disease (> 15 years) and no evidence of overt nephropathy (n = 166). No significant difference was seen in distribution of angiotensin converting enzyme or angiotensinogen genotypes between IDDM patients with nephropathy and recently diagnosed diabetic subjects (p = 0.282 and 0.584, respectively), nor the long-duration non-nephropathy diabetic subjects (p = 0.701 and 0.190, respectively). We conclude that these genetic loci are unlikely to influence susceptibility to diabetic nephropathy in IDDM in the United Kingdom.

Late reflush in clinical renal transplantation. Protection against delayed graft function not observed

Mechanical flushing of cadaveric kidneys with organ preservation fluid immediately before transplantation has been reported to be associated with improved early graft function. We report here the results of a prospective randomized controlled study of cadaveric renal transplantation after late reflush with organ preservation fluid in which no benefit with respect to delayed graft function was observed and, indeed, the protocol may have been harmful. The study was terminated after recruitment of only 18 patients (9 to each arm) because postreperfusion biopsies of reflushed kidneys contained unusual features, including abnormal cellular debris within the tubules or eosinophilic proteinaceous material within Bowman's capsule. These features were not present in the control kidneys. Acute tubular necrosis and biopsy-proven acute rejection episodes were more frequently seen in the reflushed kidneys, but at 1 year there was no significant difference in the function of the surviving grafts.

Semi-allogeneic (F1) versus fully allogeneic blood transfusions: differences in their ability to induce specific immunological unresponsiveness

The beneficial effect on graft survival achieved by pretransplant blood transfusions is well established. However, the type of major histocompatibility complex (MHC) mismatch between transfusion donor and recipient seems to play a role in determining the outcome. The hypothesis that this sharing of MHC antigens is correlated with the level of sensitization or tolerization was studied in mice by pretreatment with semi-allogeneic (F1) or with fully allogeneic whole blood transfusions. Limiting dilution analysis (LDA) in vitro for donor-specific T helper (Thp) and cytotoxic T lymphocyte precursors (CTLp) performed on splenocytes isolated from transfused recipients 2 or 4 weeks after transfusion showed that the duration and magnitude of the response was reduced after a semi-allogeneic compared to a fully allogeneic transfusion. After a semi-allogeneic transfusion, both Thp and CTLp frequencies had returned to naive levels 4 weeks after transfusion, whereas after infusion of fully allogeneic blood, they remained elevated after 4 weeks. When a fully allogeneic heart was transplanted 2 or 4 weeks after transfusion, a small but significant improvement in graft prolongation (2 weeks, not significant, 4 weeks: p < 0.01) was observed following pretreatment with a semi-allogeneic transfusion (2 weeks: median survival time (MST) 30 days, 4 weeks: MST 29 days) compared to that obtained after fully allogeneic transfusion (2 weeks: MST 23 days, 4 weeks: MST 12 days). The semi-allogeneic transfusions were correlated with a statistically significant prolonged (7 days) persistence of donor-derived MHC class II+ cells in the recipient and with reduced levels of anti-donor MHC class I-specific antibody formation compared to these responses after transfusion with fully allogeneic cells. These results demonstrate that pretreatment with a semi-allogeneic blood transfusion is more tolerizing and less sensitizing than pretreatment with a fully allogeneic blood transfusion. These findings may be explained by the sharing of MHC antigens between recipient and transfusion donor.

Kinetics of induction of transplantation tolerance with a nondepleting anti-Cd4 monoclonal antibody and donor-specific transfusion before transplantation. A critical period of time is required for development of immunological unresponsiveness

The combination of a depleting anti-Cd43 monoclonal antibody (mAb) and a single donor-specific transfusion before transplantation has been shown to induce operational transplantation tolerance in the majority of cardiac allograft recipients in a mouse model. To examine a protocol which might be more clinically relevant, we have modified this tolerance-inducing protocol by substituting the depleting with a nondepleting anti-Cd4 mAb. We show that this form of pretreatment can also induce immunologic unresponsiveness in most recipients (C3H/He, H2(k)), provided a critical period of time, in this case 28 days, is allowed between pretreatment and transplantation of a fully mismatched heart graft (H2(b)). When only 1 or 2 weeks were allowed between pretreatment and transplantation, only slight graft prolongation was obtained when compared with recipients receiving anti-Cd4 mAb alone, at these time points. Maintenance of tolerance in this model was due, at least in part, to active mechanisms as immunologic unresponsiveness to donor antigens could be transferred to naive syngeneic mice by splenocytes from recipients bearing long-term functioning grafts. These findings suggest that a population of regulatory cells develop after pretreatment with nondepleting anti-Cd4 mAb and donor-specific transfusion, and that it takes at least 1 month for these cells to expand and effectively drive the recipient's immune system toward immunologic unresponsiveness.

Carotid artery bifurcation advancement: an alternative to patching

Carotid bifurcation advancement uses the in situ external carotid artery to patch the internal carotid after carotid endarterectomy. This avoids the potential complications of patch rupture and pseudo-aneurysm formation seen with vein and synthetic patches. In 25 cases a Dacron patch was used to close and nine bifurcation advancement closures were compared retrospectively with 30 cases using simple primary closure and 13 using a saphenous vein patch. Follow-up with carotid duplex scanning revealed six restenoses > 50% in the primary closure group, whereas the patch angioplasty and bifurcation advancement groups had no restenoses (P = 0.002). No significant difference in post-endarterectomy flow increase was shown between the patch angioplasty groups and the bifurcation advancement group. Operation times did not differ significantly between the patch closure and the bifurcation advancement groups. Carotid bifurcation advancement is an alternative method of vessel closure with comparable rates of restenosis, post-endarterectomy flow increase, and operation time as compared with conventional patch angioplasty closure techniques.

Recipient cells expressing single donor MHC locus products can substitute for donor-specific transfusion in the induction of transplantation tolerance when pretreatment is combined with anti-Cd4 monoclonal antibody. Evidence for a vital role of Cd4+ T cells in the induction of tolerance to class I molecules

Syngeneic cells expressing single donor MHC locus products have been shown to induce specific immunological hyporesponsiveness, but not tolerance, to an allograft. In this study we have attempted to potentiate the beneficial effect of pretreatment with single donor MHC locus products by the addition of anti-Cd4(2) monoclonal antibody to the pretreatment protocol. We show that pretreatment with recipient L cells expressing the products of a single donor locus (K, D, or IA) can induce tolerance to a C57BL/10 (H2b) cardiac allograft in C3H/He (H2k) mice, when given in combination with the depleting anti-Cd4 monoclonal antibody YTA 3.1.2. Both the induction and maintenance phases of tolerance were found to be antigen-specific. Cells expressing donor class II antigens, IA(b) were found to be most effective. Interestingly, donor class I molecules were also found to be capable of inducing specific unresponsiveness in combination with anti-Cd4, provided an optimal antigenic load was delivered at the time of pretreatment. Pretreatment with cells expressing donor class I and anti-Cd8 monoclonal antibody had no beneficial effect on graft survival. These data show that single donor MHC locus products can induce immunologic tolerance to fully MHC and minor histocompatibility antigen-mismatched heart grafts when given under the cover of anti-Cd4 mAb. They also show that Cd4+ T cells play an important role in the induction of specific unresponsiveness to class I alloantigen in vivo and suggest that the blockade of T cells capable of recognizing class I alloantigen presented indirectly is important in the induction of tolerance.

A single amino acid change converts an inhibitory transcription factor into an activator

The closely related POU family transcription factors Brn-3a and Brn-3b differ in their functional activity with Brn-3a activating several target promoters, which are repressed by Brn-3b. Brn-3b also prevents promoter activation by Brn-3a. Here we have altered a single isoleucine residue in the POU homeodomain of Brn-3b to the valine residue found at the equivalent position in Brn-3a. This change not only abolishes the ability of Brn-3b to repress basal and Brn-3a-stimulated promoter activity but also converts it to an activator of similar potency to Brn-3a. Hence a single amino acid difference determines the difference between an activator and a repressor in the Brn-3 family.