Multilocus Sequence Analysis Reveals Genetic Diversity in Xanthomonads Associated With Poinsettia Production

Xanthomonas axonopodis pv. poinsettiicola is traditionally identified as the primary causal agent of bacterial leaf spot on poinsettia (family Euphorbiaceae). Sixty-seven strains of xanthomonads isolated from lesions associated with several species within the family Euphorbiaceae were collected over a 64-year period. The pathogenicity of these strains was compared on several potential hosts and they were analyzed by multilocus sequence analysis (MLSA) using six housekeeping genes. The 67 Xanthomonas strains associated with poinsettia production were separated into three distinct clades based on MLSA. The first clade identified contained the X. axonopodis pv. poinsettiicola reference strain (LMG849^PT). A second clade was more closely related to X. hortorum pv. pelargonii (LMG7314^PT) and the third clade contained the X. codiaei type strain (LMG8678^T). This analysis indicated that there may also be other closely related pathovars or species of Xanthomonas that can infect poinsettia. Strains from the three clades could not be distinguished by symptoms or virulence on poinsettia plants. Strains capable of infecting geranium were found in all three clades, although the extent of leaf spot formation and number of systemic infections were significantly less than those produced by X. hortorum pv. pelargonii strains, typically the main causal agent of bacterial leaf spot on geranium. Clade III also contained strains isolated from zebra plant (Aphelandra squarrosa, family Acanthaceae), which is a newly recognized host for X. codiaei and X. axonopodis pv. poinsettiicola. Xanthomonas leaf spot is a serious threat to poinsettia production that can be caused by several Xanthomonas spp. that can infect different ornamental plant hosts. It is imperative that growers maintain a strict sanitation program because reservoirs of inoculum can occur on a number of ornamental hosts.

First Report of a Leaf Spot Disease of Golden Dewdrop (Duranta erecta) Caused by Pseudomonas cichorii and a Xanthomonas Species in Florida

Duranta erecta (Verbenaceae) is used extensively in southern states as an ornamental shrub and has replaced boxwood as the most common short hedge accenting flower beds. Over the past 2 years, during warm wet periods, dark necrotic leaf spots have been observed on golden dewdrop plants in Florida. Isolations from these spots on Difco nutrient agar (NA) consistently yielded two types of bacterial colonies that were not always simultaneously present: 1) round butyrous, bright yellow and 2) flat cream-colored. Both were 2 mm in size after 48 h, gram-negative, and produced a hypersensitivity reaction (HR) on tobacco cv Hicks. Yellow colony bacteria were oxidase negative and non-fluorescent on King's medium B (KMB) (1). Cream-colored colony bacteria were oxidase positive and fluorescent on KMB. Three isolates of both types were selected for further study. Partial 16S rDNA sequencing and fatty acid analysis (FAME) MIDI Microbial Identification System (Microbial ID, Inc., Newark, DE) were used for identification of strains. The 16S rDNA primers used were; forward primer AMB14 5'-TCCAGCAATGCCGCGTGTGT-3' and reverse primer AMB13 5'-CATCCACCGCTTGTGCGGGT-3'. The PCR program consisted of an initial denaturing cycle of 95°C for 2 min followed by 30 cycles of denaturing at 95°C for 30 s, annealing at 60°C for 40 s and extension at 72°C for 1 min and one final extension at 72°C for 10 min. Using FAME analysis, the three strains of the cream-colored colony type were identified as Pseudomonas cichorii with high similarity values (0.907, 0.961, 0.819) and this corresponded well with the 16S rDNA sequences where 99% sequence identity was observed with P. cichorii strain JBC1 16S ribosomal RNA gene, partial sequence GenBank Accession No. JF951725. Two of the three yellow colony strains were identified by MIDI FAME profiles as Xanthomonas axonopodis pv. manihotis with similarity coefficients of 0.767 and 0.826. The third strain had a low similarity match to X. a. pv. carotae (0.541). The 16S rDNA sequencing of these strains showed 98% sequence identity to X. citri subsp. citri strain SA1 16S ribosomal RNA gene only, partial sequence identity JQ890091.1, thus indicating a possible undescribed X. axonopodis pathovar. To satisfy Koch's postulates, three golden dewdrop 'Golden Mound' plants were sprayed with a suspension of 10⁸ CFU/ml of a 2-day NA culture of each strain, bagged for 24 h to raise humidity, and placed in a greenhouse. A strain of P. cichorii (P409) isolated from chrysanthemum was used as a positive control when comparing cream-colored strains. A saline buffered control was used as a negative control. Within 3 weeks, leaf spots developed on plants sprayed with each of the six strains, including positive control strain of P. cichorii. Reisolations yielded the same type of colony as the originally inoculated strain. Inoculation experiments were repeated three times with a minimum of three plants per isolate with similar results. To our knowledge, this is the first report in the United States of bacterial leaf spot caused by P. cichorii and X. axonopodis on golden dewdrop. An earlier morphological and physiological description of a Xanthomonas sp. was done on Duranta in India in 1962 (2). Due to the difficulty in controlling bacterial diseases and the popularity of Duranta spp. in the landscape, these diseases may present a problem in ornamental trade. References: (1) E. O. King et al. J. Lab. Clin. Med. 44:301, 1954. (2) M. C. Srinivasan et al. Proc. Indian Acad. Sci. 56:88, 1962.

Genetic analyses of Xanthomonas axonopodis pv. dieffenbachiae strains reveal distinct phylogenetic groups

A comprehensive analysis of 175 Xanthomonas axonopodis pv. dieffenbachiae strains isolated from 10 Araceae hosts was done to identify pathogen variation. The strains were subjected to repetitive extragenic palindromic sequence polymerase chain reaction and four major phylogenetic clusters were generated. A subset of 40 strains isolated from Anthurium, Dieffenbachia, and Syngonium was further defined by amplified fragment length polymorphism and fatty acid methyl ester analysis and the same four phylogenetic clusters were observed. Comparison of representative strains in the first three clusters using DNA-DNA hybridization and multilocus sequence analysis supports the previous reclassification of strains in cluster I, including the X. axonopodis pv. dieffenbachiae pathovar reference strain (LMG695), to X. citri. Our research findings indicate that strains in cluster I, isolated primarily from anthurium, probably represent an undescribed pathovar. Other phylogenetic subclusters consisting primarily of strains isolated from xanthosoma and philodendron in clusters III and IV, respectively, may yet represent other undescribed species or pathovars of Xanthomonas.

A novel DRB1*04 allele

Discovery of the novel DRB1*0464 allele is described. This allele contains a nucleotide substitution in codon 13 that changes the amino acid histidine coded for in all other DRB1*04 alleles to tyrosine. This allele was found in a parent and one child of a North American Caucasian family with the haplotype: A*03, B*07, DRB1*0464, DRB4*0103, DQB1*0301.

Classification and Identification of Xanthomonas translucens Isolates, Including Those Pathogenic to Ornamental Asparagus

ABSTRACT In order to confirm and refine the current classification scheme of Xanthomonas translucens and to identify novel strains from ornamental asparagus, a collection of field and reference strains was analyzed. Rep-polymerase chain reaction (PCR) genomic fingerprint profiles were generated from 33 isolates pathogenic to asparagus as well as 61 X. trans-lucens reference strains pathogenic to cereals and grasses. Amplified ribo-somal gene restriction analysis profiles were obtained from most of these and 29 additional Xanthomonas reference strains. Rep-PCR genomic fingerprint profiles of all strains were compared with those in a large Xanthomonas database using computer-assisted analysis. Rep-PCR ge-nomic fingerprinting facilitated the characterization and discrimination of X. translucens, including the pathovars arrhenatheri, graminis, phlei, phleipratensis, and poae, as well as a number of strains received as X. translucens pv. cerealis. Strains received as pathovars hordei, secalis, translucens, undulosa, and other cerealis strains were grouped in two subclusters that correspond to the recently redefined pathovars X. trans-lucens pvs. undulosa and translucens. All 33 novel isolates from ornamental asparagus (tree fern; Asparagus virgatus) were identified as X. translucens pv. undulosa. Moreover, a unique amplified small subunit ribosomal gene MspI/AluI restriction profile specific for all X. translucens strains tested, including those pathogenic to asparagus, allowed discrimination from all other Xanthomonas spp. Although phage tests were inconclusive, the classification of the asparagus strains within the X. translucens complex was supported by pathogenicity assays in which all the isolates from ornamental asparagus induced watersoaking on wheat. Surprisingly, several X. translucens reference strains affected asparagus tree fern as well. That the novel asparagus isolates belong to X. translucens pv. undulosa is extraordinary because all hosts of X. translucens pathovars described to date belong only to the families Gramineae and Poaceae, whereas asparagus belongs to the phylogenetically distant family Liliaceae.

Cardiovascular events following renal transplantation: role of traditional and transplant-specific risk factors

Cardiovascular mortality is increased in transplant recipients. However, studies including non-fatal events are critical to assess the burden of disease and to identify novel risk factors. We described the incidence of fatal and non-fatal events, and explored associations and interactions among traditional and transplant-specific risk factors and cardiovascular events (CVE) in a cohort of 922 patients transplanted between 1993 and 1998. One hundred and seventy-six patients experienced 201 CVE (111 cardiac, 48 cerebrovascular, 42 peripheral-vascular). Most CVE were non-fatal. Factors associated with cardiac events were (adjusted hazard ratios) tobacco (3.53; P<0.001), obesity (2.92; P<0.001), diabetes (2.63; P<0.001), multiple rejections (2.19; P=0.008), prior CVE (2.0; P=0.004), dialysis >1 year (1.91; P=0.007), and overweight status (1.68; P=0.04); with cerebrovascular events: diabetes and peritoneal dialysis (11.95; P<0.001), age >45 (6.77; P<0.001), diabetes (4.87; P<0.001), prior CVE (3.73; P<0.001), creatinine >141 micromol/l (3.16; P=0.001), peritoneal dialysis (3.06; P=0.027), and obesity (0.32; P=0.046); with peripheral-vascular events: diabetes (8.48; P<0.001), tobacco and cytomegalovirus (3.88; P<0.001), age >45 (2.31; P=0.019), and prior CVE (2.25; P=0.016); with mortality: tobacco and deceased-donor (3.52; P<0.001), age >45 (1.81; P=0.002), diabetes (1.76; P=0.002), pulse pressure (1.64; P=0.029), prior CVE (1.52; P=0.04), and dialysis >1 year (1.47; P=0.04). The majority of CVE post-transplant were non-fatal. Previous CVE was strongly associated with CVE post-transplant. Interactions among transplant-specific and traditional risks impacted significantly the incidence of CVE. Modifiable factors such as duration of dialysis, deceased-donor transplantation, and acute rejection should be viewed as cardiovascular risks.

Control of Bacterial Wilt of Geranium with Phosphorous Acid

Various bactericides were screened for efficacy in protecting geranium plants (Pelargonium hortorum) from Ralstonia solanacearum infection. Many of these bactericides were found to slow the disease progress; however, they were not able to protect the plants from infection and subsequent death. Potassium salts of phosphorous acid were found to be effective in protecting plants from infection when applied as a drench. The active portion of the potassium salts was found to be phosphorous acid (H₃PO₃). Phosphorous acid was found to inhibit in vitro growth of R. solanacearum. It is thought to be protecting plants from infection by acting as a bacteriostatic compound in the soil. The plants, however, are not protected from aboveground infection on wounded surfaces. Phosphorous acid drenches were shown to protect geranium plants from infection by either race 1 or 3 of R. solanacearum. Other phosphorous-containing products commonly used in the industry, such as phosphorus pentoxide (P₂O₅) and phosphoric acid (H₃PO₄), were not able to protect plants from bacterial wilt infection.

Characterization of Erwinia Populations from Nursery Retention Ponds and Lakes Infecting Ornamental Plants in Florida

Water shortages in Florida are occurring due to intense utilization of the aquifer system by municipalities and agriculture, and because of continued deficits in annual rainfall. Water districts therefore, are, recommending the use of recycled irrigation water, stormwater runoff, reclaimed municipal sewage water, and lakes for agricultural use. With recycled water, however, there is potential for both introducing and concentrating plant pathogens. In Florida, Erwinia soft-rot bacteria (synonym Pectobacterium) cause extensive crop losses in ornamental plant production. To determine Erwinia spp. population levels, samples were taken monthly for 1 year from four hypereutropic lakes and eight nursery retention ponds. Seventy-seven Erwinia strains were collected by both direct plating and by an enrichment process. With the direct plating method, 0 to 29 CFU/ml were detected on sodium polypectate medium. Significantly higher populations of Erwinia were detected in retention ponds of nurseries that were actively reutilizing their water. Erwinia strains were identified to species by fatty acid analysis and biochemical tests. Strains were further characterized by repetitive element-polymerase chain reaction (rep-PCR) and compared with 120 strains of Erwinia collected from ornamentals over a 17-year period in Florida. Using rep-PCR, most strains were clustered into two heterogeneous populations of E. chrysanthemi and E. carotovora subsp. carotovora in a 1:2 and a 1:4 ratio for isolates from ornamentals and from water, respectively. Within each population of E. chrysanthemi and E. carotovora, genetically different subpopulations could be identified that contained high percentages of Erwinia strains from water sources. Even though genetic differences exist, 99% of the strains from water sources were found to be pathogenic on dieffenbachia. Without water treatment of irrigation and stormwater runoff, there is a potential for both introducing and concentrating Erwinia populations within these water sources.

First Report of Xanthomonas axonopodis Infecting Agapanthus in Florida

Agapanthus praecox subsp. orientalis, commonly called African lily or lily-of-the-Nile, bears large, round, blue or white flowers above attractive dark green foliage. Because of these horticultural features, this member of the family Liliaceae, has become a popular perennial bedding plant. For the past 2 years during warm wet periods, symptoms of chlorotic, water-soaked, leaf-streaks have been observed on agapanthus production in Florida. Round butyrus, bright yellow colonies were consistently isolated on nutrient agar. Bacteria were characterized as gram negative, catalase positive, motile, strictly aerobic, and not hydrolytic on starch. Using fatty acid analysis (FAME) and the MIDI Microbial Identification System with software version TSBA 3.90 (Microbial ID, Inc., Newark DE), three strains were further characterized and identified as Xanthomonas axonopodis with similarity coefficients to X. axonopodis pv. dieffenbachiae (0.907, 0.915, and 0.944) and to X. axonopodis pv. poinsetticola (0.912, 0.922, and 0.916). The three isolates were each inoculated on three plants each of agapanthus cv. Blue African lily, Dieffenbachiae maculata cv. Camille, and poinsettia, Euphorbia pulcherrima cv. PeterStar Red. Plants were sprayed with a suspension of each isolate at 1 × 10⁸ CFU/ml, bagged for 24 h to raise humidity, and placed in a glasshouse for symptom development. Strains of X. axonopodis pv. poinsetticola (NZTCC 5779) and X. axonopodis pv. dieffenbachiae (X1718) were used as positive controls. Within 3 weeks, isolates from agapanthus produced leaf streaks on agapanthus plants, small, scattered, water-soaked lesions on dieffenbachia leaves, and no symptoms on poinsettia. No symptoms developed on the agapanthus plants when inoculated with either control strain. Both control strains formed lesions on leaves of their original host species. Xanthomonas was reisolated from treatments with symptomatic leaves. Plant inoculations were repeated with similar results. Although the agapanthus isolates were highly similar in FAME profiles to X. axonopodis pv. dieffenbachiae, symptoms produced on dieffenbachia were mild as compared with those produced by the dieffenbachia isolate. Therefore, these isolates may represent a distinct pathovar.

Phase I trial of HuM291, a humanized anti-CD3 antibody, in patients receiving renal allografts from living donors

BACKGROUND

HuM291 is a humanized anti-CD3 monoclonal antibody engineered to reduce binding to Fcgamma receptors and complement fixation. HuM291 has a long serum half-life and mediated profound depletion of circulating T cells in chimpanzees; HuM291 also has significantly less mitogenic and cytokine-releasing activity than OKT3 in vitro.

METHODS

A phase I dose-escalation study was conducted in 15 end-stage renal disease patients scheduled for renal allografts from living donors. Patients received one i.v. HuM291 injection before transplantation. Five doses were tested: 0.015 microg/kg, 0.15 microg/kg, 0.0015 mg/kg, 0.0045 mg/kg, and 0.015 mg/kg. Patients were followed for adverse events, laboratory abnormalities, serum cytokine levels, pharmacokinetics, and CD2+, CD3+, CD4+, and CD8+ T cell counts.

RESULTS

HuM291 was well tolerated; most adverse events were mild to moderate in severity and included headache, nausea, chills, and fever. These occurred within the first few hours after HuM291 administration, resolved within 24 to 48 hr, and were likely related to cytokine release. In general, peak tumor necrosis factor-alpha, interferon-gamma, and interleukin-6 levels were detected 1 to 6 hr postdosing only at the three highest doses and were generally undetectable by 24-hr postdosing. Serious adverse events possibly related to HuM291 included clotting of a fistula (two patients), chemical cellulitis (one patient), and increased serum creatinine/decreased hematocrit (one patient). At doses > or = 0.0015 mg/kg (0.1 mg/70 kg), HuM291 induced rapid, marked depletion of peripheral T cells within 2 hr; duration of T cell depletion was dose dependent. At the two highest dose levels, T cells remained depleted for approximately 1 week.

CONCLUSIONS

A single HuM291 dose rapidly depleted circulating T cells in a dose-dependent manner and was associated with only mild to moderate symptoms of cytokine release.

Valaciclovir prophylaxis of cytomegalovirus infection and disease in renal transplantation: an economic evaluation

BACKGROUND

Cytomegalovirus (CMV) disease is a major cause of morbidity and mortality in solid organ transplant patients and is associated with large additional healthcare expenditures. An economic evaluation of valaciclovir CMV prophylaxis in a renal transplant population is reported.

METHODS

Medical resource use data were collected alongside a multicenter multinational randomized, placebo-controlled, double-blind trial of valaciclovir CMV prophylaxis in renal transplantation. Patients were stratified into donor seropositive/recipient sero-negative (D+R-) and recipient seropositive (R+) groups. Patients were followed-up 6 months posttransplant. A cost-effectiveness analysis from the perspective of the French health care system was performed using the number of cases of CMV disease avoided at 6 months as the clinical endpoint.

RESULTS

Resource use was significantly increased among patients who developed CMV disease compared to those who did not develop disease. In the high risk D+R- group, valaciclovir prophylaxis was associated with an average of 5.5 fewer inpatient hospital days (P < OR =0.05) and with significantly lower use of other healthcare resources. In the R+ group, valaciclovir prophylaxis prevented cases of CMV disease at a marginally greater mean cost per patient compared with placebo. For D+R- patients valaciclovir prophylaxis was therefore an economically superior strategy, resulting in fewer cases of CMV disease and lower total mean healthcare expenditures.

CONCLUSIONS

Valaciclovir CMV prophylaxis in renal transplantation is a more cost-effective therapy compared with placebo, in the high-risk D+R- patient population. For the R+ group, the incremental cost per case of CMV disease was modest.

Reversible acute renal allograft dysfunction due to gabapentin

BACKGROUND

The use of gabapentin as an effective analgesic agent for neuropathic pain has expanded considerably. Its lack of both anticholinergic side effects and interference with the metabolism of drugs via the cytochrome P450 pathway make it especially useful for transplant recipients.

METHODS AND RESULTS

We describe the case of a renal transplant recipient with a long-term stable functioning allograft who developed reversible acute renal dysfunction after beginning gabapentin therapy for chronic pain due to diabetic neuropathy.

CONCLUSIONS

We suggest that gabapentin may cause acute renal dysfunction by a mechanism involving renal afferent vasoconstriction. Caution should be employed when considering the use of gabapentin in transplant recipients, especially when combined with other agents that may potentiate renal vasoconstriction.

Heterogeneity of Xanthomonas campestris pv. hederae Strains from Araliaceous Hosts

ABSTRACT Xanthomonas campestris pv. hederae (synonym X. hortorum pv. hederae) strains (59 total) were collected from plants in the araliaceae family. Strains were isolated from Hedera helix, Schefflera arboricola, Brassaia actinophylla, and Polyscias spp. from Florida, California, Hawaii, and New Zealand. All strains produced yellow mucoid growth; hydrolyzed esculin, starch, casein and gelatin; were pectolytic; produced urease; and grew on minimal media containing asparagine. All bacterial strains were pathogenic on H. helix (English ivy), B. actinophylla (dwarf schefflera), and Polyscias fruticosa (ming aralia). No differences in symptomatology were detected among strains; however, severity of symptoms usually was greatest on the host of origin. In planta growth rates of representative strains isolated from H. helix, B. actinophylla, and Polyscias spp. also were compared among these three hosts. In all cases, populations grew more rapidly when strains were inoculated to their original host species. All 59 bacterial strains were compared by 95-carbon source GN microplate, fatty acid methyl ester (FAME), and restriction fragment-length polymorphisms (RFLP), with the pulse-field gel electrophoresis method, analyses. All three analyses grouped strains into two distinct groups that correlated with the host of origin. Using metabolic profiles, 75% of the H. helix strains were separated from strains isolated from Brassaia and Schefflera and 95% of the Polyscias strains. FAME analysis separated strains into two distinct groups, with 96% of the H. helix strains placed in one group. RFLP analysis placed all of the H. helix and Schefflera strains in one group, as well as 33% of the Brassaia strains, whereas the other group contained all of the Polyscias strains and the remainder of the Brassaia strains. It is apparent that the pathovar hederae is made up of heterogeneous populations that can be separated by biochemical, pathological, genetic, and physiological analyses into two groups that are closely associated with the host of origin.

Factors in cardiac risk stratification of candidates for renal transplant

BACKGROUND

Renal transplant candidates are at high risk of fatal and nonfatal cardiac events.

METHODS

This study evaluated five clinical risk factors--age at least 50 years, insulin-requiring diabetes mellitus, angina, congestive heart failure and an abnormal electrocardiogram (ECG) (excluding left ventricular hypertrophy)--that had been used in the first tier of a two-tiered prospectively applied risk stratification algorithm.

RESULTS

Using multiple logistic regression analysis, age at least 50 years, abnormal ECG, and diabetes mellitus were independently predictive of cardiac death. Of the two remaining clinical risk factors, the presence of angina had independent predictive value for nonfatal cardiac events (myocardial infarction, coronary angioplasty, bypass surgery, and unstable angina). The independent predictive value of congestive heart failure approached statistical significance.

CONCLUSION

Clinical risk-factor analysis is helpful in identifying renal transplant candidates at high risk for fatal or nonfatal cardiac events.

Renal transplantation across the ABO barrier using A2 kidneys

BACKGROUND

The waiting list for cadaveric kidney transplantation has continued to grow, and with the relative scarcity of cadaver donors, the median waiting time for patients in the United States increased to 824 days in 1994. The median waiting times for patients with blood groups B or O were 1329 and 1007 days, respectively. Allocation of blood group A2 kidneys (20% of group A) to blood group O and B patients expands their potential donor pool and shortens their waiting time for a kidney transplantation.

METHODS

Between May 1991 and June 1998, we transplanted 15 A2 kidneys into 6 blood group O and 9 blood group B patients. Anti-A isoagglutinins were measured before transplantation, and patients with anti-A1 titers > or = 1:8 underwent plasmapheresis (PP).

RESULTS

One patient with high titer anti-A antibodies, who did not receive PP, lost her allograft because of hyperacute rejection. Allograft function was excellent in the remaining 14 patients, with a mean serum creatinine level of 1.7 (+/-0.89) mg/dl at 1 month and 1.3 (+/-0.34) mg/dl at 1 year. The actuarial 1-year graft survival rate was 93.3+/-6.4% and the patient survival rate was 100%.

CONCLUSION

We conclude that the allocation of blood group A2 kidneys for blood group O and B recipients is a practical way to expand the donor pool for these transplant candidates. PP may be important for reducing the levels of anti-A1 and anti-A2 antibodies and for reducing the risk of hyperacute rejection. Splenectomy seems to be unnecessary.

HLA-identical sibling renal transplantation--a 21-yr single-center experience

Human lymphocyte antigen (HLA)-identical sibling organs offer the best long-term outcomes for recipients of a renal transplant apart from an identical twin. Unlike cadaveric transplants, however, factors that affect long-term survival of these immunologically privileged grafts are not well described. We reviewed 108 HLA-identical transplants performed at our institution between January 1977 and February 1993. Variables chosen for graft survival analysis were: gender, age and ABO blood type of donors and recipients, panel reactivity antibodies (PRA), blood transfusions prior to transplant, pregnancies, and the underlying renal disease. Additionally, incidence of acute rejection (AR), timing of AR, serum creatinine levels at 1 wk and at 1 yr, and presence of hypertension were included in the analysis. Mean follow-up was 130.9 +/- 58.2 months (range 38-250 months). Actual 5-yr patient and graft survivals were 92 and 88%, respectively. Thirty-eight grafts were lost, and 22 recipients died during the observation period. Death was the main cause of graft failure. Cardiac events accounted for the majority of deaths. AR occurred in 46% and repeated rejections in 11% of recipients. Actuarial graft survival at 10 yr was poorer for patients with any AR (69%), and significantly worse with repeated AR (33%), compared to patients without AR (86%), p = 0.001). Sixty percent of all rejections and 88% of the first rejections occurred in the first 60 d post-transplantation. The first AR that occurred after 60 d was associated with poor graft survival (49 vs. 70%, p = 0.04). Recipients with renal diseases with potential to recur (membranous glomerulonephritis (MGN), membrano-proliferative glomerulonephritis (MPGN), focal and segmental glomerulonephritis (FSGN), polyarteritis nodosa (PAN), rapid progressive glomerulonephritis (RPGN), Henoch-Schoenlein purpura (HSP), diabetes mellitus (DM), interstitial nephritis, systemic lupus erythematosus (SLE) and chronic glomerulonephritis (CGN)) faired worse as a group than recipients with hypertensive nephrosclerosis (HTN), autosomal dominant polycystic kidney disease (ADPKD), Alport's, reflux or congenital dysplasia (68 vs. 96% at 10 yr, p = 0.0009). Poor patient survival was seen in diabetics (71 vs. 88% at 10 yr, p = 0.01). There was a trend to poorer graft survival in diabetic recipients when compared to non-diabetics (65 vs. 81% at 10 yr, p = 0.054). Elevated creatinine at 1 yr was associated with worse graft survival. Likewise, the magnitude of creatinine increase during the first year directly correlated with the risk of graft loss. Hypertensive patients were more likely to lose their grafts than normotensive recipients (72 vs. 86%, p = 0.04). Pre-transplant blood transfusion, pregnancy, and PRA level were not associated with increased graft failure or AR. Graft survival was not affected by gender, age, or ABO blood type of donors or recipients. In conclusion, better prevention and treatment of AR, hypertension, and cardiac disease should improve graft and patient survival. Close attention to recurrence of disease and subtle changes in the creatinine level during the first year might dictate early diagnostic and, hopefully, therapeutic interventions.

First Report of Ralstonia (Pseudomonas) solanacearum Infecting Pot Anthurium Production in Florida

Xanthomonas campestris pv. dieffenbachiae is a common pathogen of pot anthurium production in Florida. While X. campestris pv. dieffenbachiae was isolated from systematically infected plants with chlorotic, necrotic, and wilted leaves, a fluidal, beige bacteria was occasionally isolated on nutrient agar (Difco, Detroit, MI), as opposed to the common, yellow pigmented Xanthomonas sp. Distinction in the symptomology of plants systematically infected with a Xanthomonas sp. or this new bacterium could not be made. Three isolates were obtained of this unidentified bacterium from leaves and stems of three separate plants. With FAME (fatty acid methyl esters) analysis, using MIDI (Microbial Identification System, software version TSBA 3.90 [Newark, DE]), these isolates were classified as Ralstonia (Pseudomonas) solanacearum (syn. Burkholderia solanacearum) with a mean similarity indice of 0.895. Isolates were found to be gram negative, oxidase negative, catalase positive, motile, strictly aerobic, and metabolically classified as biovar 1; they accumulated poly-β-hydroxybutyrate and produced a hypersensitive response on tobacco within 24 h. A characteristic fluidal, white growth with a distinctive, red, swirling, egg-shaped, pigmentation pattern was observed on triphenyltetrazolium chloride medium. Further confirmation of identity as R. solanacearum was obtained by polymerase chain reaction amplification and electrophoretic analysis with species-specific primers (2), which in all cases produced a 148-bp product along with control strains. The three isolates were inoculated onto three plants of anthurium, tomato, triploid banana, and pothos. Inoculations were done at least twice; plants were inoculated either by stabbing the plant stems with a needle dipped in a suspension of bacteria or by applying 10 ml of a 1 × 10⁸ CFU/ml suspension to the soil of the test plants. Chlorosis, necrosis, and wilt symptoms appeared within 2 weeks on all plant species tested. Recently, pothos (Epipremnum aureum) cuttings imported to Florida from Costa Rica have been implicated as a source of R. solanacearum (1). Imported cuttings of pothos were being grown in hanging baskets over the infected anthuriums. Although no R. solanacearum infections were detected in the pothos, these imported plants are the probable source of the initial inoculum for this disease outbreak on anthuriums. References: (1) D. J. Norman and J. M. F. Yuen. Phytopathology 87:S70, 1997. (2) S. E. Seal et al. Appl. Environ. Microbiol. 58:3751, 1992.

Interaction between tacrolimus and nefazodone in a stable renal transplant recipient

Tacrolimus (FK-506) is an important immunosuppressive agent most often given for maintenance immunosuppression to prevent acute cellular organ rejection. A 57-year-old woman with end-stage renal disease presumed secondary to chronic glomerulonephritis underwent a living related renal allograft transplantation. She tolerated the surgery well and was discharged on postoperative day 5. She was stabilized with prednisone, azathioprine, and tacrolimus. Two years after transplantation, nefazodone 50 mg twice/day orally was prescribed due to depression. After 1 week of nefazodone therapy the patient experienced headache, confusion, and "gray areas" in her vision, without abnormal ophthalmologic findings. Her serum creatinine was elevated to 2.2 mg/dl (baseline 1.5 mg/dl), and trough tacrolimus level was markedly elevated (> 30 ng/ml). Both tacrolimus and nefazodone are metabolized by the cytochrome P450 (CYP) 3A4 system. We suspect that nefazodone inhibits metabolism of tacrolimus. Coadministration of antidepressant agents such as nefazodone, or any other drug that inhibits the CYP3A4 isoenzyme subfamily, should be anticipated to interfere with tacrolimus metabolism. Monitoring blood concentrations of tacrolimus is vital, and appropriate dosage adjustments are required when the two drugs are administered concurrently to avoid serious interactions such as nephrotoxicity and neurotoxicity.

Efficacy and safety of low molecular weight heparin in renal transplantation

BACKGROUND

Deep venous thrombosis (DVT) is a common problem with potentially devastating results in patients undergoing major surgical procedures. Certain renal transplant recipients are particularly at risk for allograft loss as a consequence of renal vein and artery thrombosis. Over the past few years, low molecular weight heparin has been well established as an accepted modality of treatment and prophylaxis of DVT. The efficacy and safety of low molecular weight heparin in the prophylaxis of DVT following renal transplantation in adults has not previously been reported.

METHODS

Dalteparin was administered to 120 adult renal transplant recipients postoperatively at the Oregon Health Sciences University.

RESULTS

No patient developed allograft arterial or venous thrombosis. One patient developed subclavian vein thrombosis. No bleeding complications were encountered, and side effects were very minimal.

CONCLUSION

Prophylaxis with dalteparin is an effective and safe modality for the prevention of thrombosis in adult patients undergoing renal transplantation.

Results of the double-blind, randomized, multicenter, phase III clinical trial of Thymoglobulin versus Atgam in the treatment of acute graft rejection episodes after renal transplantation

BACKGROUND

Thymoglobulin, a rabbit anti-human thymocyte globulin, was compared with Atgam, a horse anti-human thymocyte globulin for the treatment of acute rejection after renal transplantation.

METHODS

A multicenter, double-blind, randomized trial with enrollment stratification based on standardized histology (Banff grading) was conducted. Subjects received 7-14 days of Thymoglobulin (1.5 mg/kg/ day) or Atgam (15 mg/kg/day). The primary end point was rejection reversal (return of serum creatinine level to or below the day 0 baseline value).

RESULTS

A total of 163 patients were enrolled at 25 transplant centers in the United States. No differences in demographics or transplant characteristics were noted. Intent-to-treat analysis demonstrated that Thymoglobulin had a higher rejection reversal rate than Atgam (88% versus 76%, P=0.027, primary end point). Day 30 graft survival rates (Thymoglobulin 94% and Atgam 90%, P=0.17), day 30 serum creatinine levels as a percentage of baseline (Thymoglobulin 72% and Atgam 80%; P=0.43), and improvement in posttreatment biopsy results (Thymoglobulin 65% and Atgam 50%; P=0.15) were not statistically different. T-cell depletion was maintained more effectively with Thymoglobulin than Atgam both at the end of therapy (P=0.001) and at day 30 (P=0.016). Recurrent rejection, at 90 days after therapy, occurred less frequently with Thymoglobulin (17%) versus Atgam (36%) (P=0.011). A similar incidence of adverse events, post-therapy infections, and 1-year patient and graft survival rates were observed with both treatments.

CONCLUSIONS

Thymoglobulin was found to be superior to Atgam in reversing acute rejection and preventing recurrent rejection after therapy in renal transplant recipients.

Squamous and basal cell carcinoma in heart transplant recipients

BACKGROUND

Cutaneous malignancies are frequent in organ transplant recipients. We retrospectively reviewed a large series of heart transplant recipients and report on the prevalence and risk factors for development of cutaneous squamous and basal cell carcinoma.

METHODS

Between Dec. 4, 1985, and Dec. 27, 1996, 299 heart transplantations were performed at the Oregon Health Sciences University. Heart transplant recipients with more than 6 months survival or follow-up were investigated for squamous and basal cell carcinoma (n = 248).

RESULTS

Forty-one patients (17%) were found to have 192 squamous or basal cell carcinomas. Squamous cell carcinoma was the predominate skin malignancy, constituting 172 (90%) of the lesions. The mean number of skin malignancies per patient was 4.7 +/- 0.81 (range 125). Patients with development of a skin malignancy were 8 years older on average, with a male-to-female ratio of 19.5:1. The predominant skin type and eye color were fair (59%) and blue (59%), respectively. Cumulative risk, based on actuarial survival analysis for development of a squamous or basal cell carcinoma at 1 year, was 3% and increased to 21% and 35% at 5 and 10 years, respectively. In addition, cumulative risk increased in patients who received treatment with OKT3.

CONCLUSION

Cumulative risk of development of a skin malignancy increased with time and use of OKT3. Additional patient risk factors included older age, male sex, fair skin, and blue eyes.

Survival of Colletotrichum acutatum in Soil and Plant Debris of Leatherleaf Fern

Leatherleaf fern anthracnose is incited by a new pathotype of Colletotrichum acutatum. Fern anthracnose appeared in Florida in 1993, has spread rapidly, and produces losses that approach 100% in some ferneries. To help develop recommendations for control and management of fern anthracnose, the survival of the pathogen in soil and diseased plant material and on clothing was investigated in laboratory and field experiments. Survival of conidia, sclerotia, and conidia in infected leaf debris was studied in soil maintained at five soil moisture levels. Survival of conidia and sclerotia declined rapidly under moist conditions (≥12% moisture, vol/wt), but under dry conditions, viable conidia could be detected up to 12 months after incorporation into soil. Similar results were obtained in field experiments in which infected leaf debris was buried in soil. Viable conidia were recovered for up to 3 months in leaf debris stored under laboratory conditions. Conidia applied to denim fabric were recovered up to 5 weeks after application. This indicated that contaminated clothing could transport conidia effectively within and between ferneries. Inoculating ferns with dilutions of conidia demonstrated that at least 100 conidia per ml is required to infect and colonize leatherleaf fern leaves. This threshold provides an estimate of levels of conidia populations likely to result in disease and levels that sanitation or cultural practices must exceed to be effective management methods.

Interleukin-12 p40 m-RNA expression in human kidney allograft biopsies

Interleukin-12 (IL-12) is a heterodimeric cytokine implicated in the early differentiation of naive T-lymphocytes into the Th1 subset. IL-12 is important for induction of the cellular immune response against viruses, intracellular parasites and neoplasms. Its role in alloresponsiveness has not been fully elucidated. Preliminary data in the literature point toward the prevalence of Th1 lymphocytes in processes of allograft rejection. In attempt to further investigate the expression of this cytokine during episodes of cellular rejection of renal allografts, we searched for IL-12 message in human kidney allograft biopsies using the reverse transcriptase-polymerase chain reaction technique. Twenty-three allograft core biopsies from 19 patients were obtained percutaneously for clinical indications in 18 cases, and as part of an investigational protocol in five cases. A portion of the tissue was used for RNA extraction using the guanidium-thiocyanide phenol-chloroform method. Histology was performed on the remaining core material. Ten mg of total RNA were used for reverse transcription. PCR of the c-DNAs was done for 40 cycles using primers for the p40 subunit of IL-12 and GAPDH which was used as a control. PCR products were photographed after electrophoresis, transferred to a nylon membrane and hybridized with a radiolabelled cloned human IL-12 p40 1 kb c-DNA fragment. Autoradiographies were developed after 20-min exposure. All samples were run in triplicate. IL-12 p40 m-RNA was expressed in all 17 biopsies showing acute cellular rejection as well as in all three biopsies showing focal interstitial fibrosis. No message was found in the presence of normal allograft histology. This is the first in vivo report of IL-12 p40 subunit m-RNA expression during renal allograft rejection in humans. The role of this Th1 cytokine in the alloresponse deserves further investigation.

New Disease on Ornamental Asparagus Caused by Xanthomonas campestris in Florida

From dark, water-soaked lesions on stems of asparagus tree fern (Asparagus virgatus) in commercial nurseries in Florida, 33 xanthomonad strains were isolated. Strains formed large, round, butyrus, bright yellow colonies on yeast dextrose calcium carbonate medium, and were gram negative, oxidase negative, catalase positive, motile, strictly aerobic, and did not hydrolyze starch. Strains were further characterized by carbon substrate utilization patterns (Biolog), and by fatty acid methyl esters (FAME) analyses. The metabolic fingerprints of most strains were similar to Xanthomonas campestris pv. vitians, and X. campestris pv. dieffenbachiae from Xanthosoma or Syngonium. Representative strains from A. virgatus were not pathogenic on Dieffenbachia. X. campestris pv. dieffenbachiae strains that did not hydrolyze starch produced scattered lesions on A. virgatus stems. However, starch-hydrolyzing strains of X. campestris pv. dieffenbachiae did not produce symptoms when inoculated onto A. virgatus. FAME analysis indicated the strains were X. campestris pv. vitians or X. campestris pv. translucens; however, low similarity indices ( x = 0.461) indicated that the asparagus strains were not represented in the MIDI library database. FAME analysis profiles were also compared to the University of Florida database, which contains 1,048 X. campestris strains of which 200 are X. campestris pv. dieffenbachiae. Similarity indices were again low with 15 strains matched to X. campestris pv. secalis (x = 0.412), seven strains to X. fragariae (x = 0.224), six strains to X. campestris pv. translucens ( x = 0.437), and five strains matched < 0.20 to other pathovars. Five representative strains were tested on six Asparagus species or cultivars: A. virgatus, A. setaceus, A. macowanii, A. densiflorus 'Sprengeri' , A. densiflorus 'Myers', and A. officinalis. All five strains were pathogenic on A. virgatus but were less virulent on A. setaceus and A. densiflorus 'Sprengeri'.

Allocation of livers for liver transplantation: ethics and politics

The supply of livers for transplantation is not adequate for the number of patients waiting for liver transplantation. The allocation and distribution of the limited supply of livers is hotly debated at the United Network for Organ Sharing. The principles of medical utility and justice must be balanced in an equitable distribution scheme. Excellent local liver transplant centers should be available to all patients.

Cardiac risk stratification in renal transplantation using a form of artificial intelligence

The purpose of this study was to determine if an expert network, a form of artificial intelligence, could effectively stratify cardiac risk in candidates for renal transplant. Input into the expert network consisted of clinical risk factors and thallium-201 stress test data. Clinical risk factor screening alone identified 95 of 189 patients as high risk. These 95 patients underwent thallium-201 stress testing, and 53 had either reversible or fixed defects. The other 42 patients were classified as low risk. This algorithm made up the "expert system," and during the 4-year follow-up period had a sensitivity of 82%, specificity of 77%, and accuracy of 78%. An artificial neural network was added to the expert system, creating an expert network. Input into the neural network consisted of both clinical variables and thallium-201 stress test data. There were 5 hidden nodes and the output (end point) was cardiac death. The expert network increased the specificity of the expert system alone from 77% to 90% (p < 0.001), the accuracy from 78% to 89% (p < 0.005), and maintained the overall sensitivity at 88%. An expert network based on clinical risk factor screening and thallium-201 stress testing had an accuracy of 89% in predicting the 4-year cardiac mortality among 189 renal transplant candidates.

First Report of Colletotrichum gloeosporioides on Cyclamen persicum in Florida

Between March and April of 1996, an estimated 20% of the Cyclamen persicum Mill. grown in Florida were infected with Colletotrichum gloeosporioides (Penz.) Penz. & Sacc. in Penz. Symptoms included extensive lesions on flowers, stems, and leaves. Acervuli containing masses of spores and dark setae were observed within lesions. The most severe damage was observed on the cultivar Red Delight. Infected tissues were dipped into 0.26% sodium hypochlorite for 5 s, blotted dry, embedded in water agar, and incubated at 27 ± 1°C. Hyphal tips that grew from lesions were transferred to potato dextrose agar (PDA) and incubated under cool-white fluorescent lights. Developing colonies were gray and contained masses of orange conidia. Conidia were straight with rounded or bulbous ends and averaged 16.8 (SD 5.2) × 2.25 (SD 0.54) μm. Three isolates were selected to complete Koch's postulates. Conidia of each isolate were obtained from 3-day-old PDA cultures, and suspended in sterile, distilled water (SDW) to 10⁴ conidia/ml. These suspensions were sprayed till runoff with hand sprayers onto C. persicum plants. Plants were incubated in plastic bags for 24 h at 27°C, then placed in a glasshouse. Within 3 days, lesions had developed on flowers; within 7 days, they were visible on stems and leaves. Lesion diameter varied from 2 to 5 mm; however, lesions soon coalesced, causing leaf, stem, and flower death. The fungus was reisolated from acervuli that developed on the flowers, stems, and leaves, following previously outlined procedures. Inoculation tests were repeated once. Symptoms did not appear on controls sprayed with SDW nor was the teleomorph stage of the pathogen observed.

Pituitary lineage determination by the Prophet of Pit-1 homeodomain factor defective in Ames dwarfism

The gene apparently responsible for a heritable form of murine pituitary-dependent dwarfism (Ames dwarf, df) has been positionally cloned, identifying a novel, tissue-specific, paired-like homeodomain transcription factor, termed Prophet of Pit-1 (Prop-1). The df phenotype results from an apparent failure of initial determination of the Pit-1 lineage required for production of growth hormone, prolactin or thyroid-stimulating hormone, resulting in dysmorphogenesis and failure to activate Pit-1 gene expression. These results imply that a cascade of tissue-specific regulators is responsible for the determination and differentiation of specific cell lineages in pituitary organogenesis.

When perfectly HLA-matched kidneys are refused for transplant: implications for a national cooperative sharing system

BACKGROUND

The transplant community attempts to maximize overall renal graft survival rates through nationwide sharing of perfectly-matched cadaveric kidneys. Although the number of such transplants is determined annually, the number available but not transplanted has never been assessed. There has also been no verification of the widespread claim that kidneys transplanted as paybacks for perfect matches are inferior.

STUDY DESIGN

From records of the United Network for Organ Sharing, a complete accounting of six-antigen-matched kidney disposition was obtained, including a frequency distribution of reasons for refusal given when kidneys were refused for matched patients. Actuarial graft survival (GS) rates for matched, payback, and other cadaveric renal transplants were determined.

RESULTS

Of the six-antigen-matched kidneys available, 97 percent were transplanted; 71 percent of those were accepted for matched patients. The two-year GS rate for matched patients was 84 percent, significantly higher than that for kidneys available for matched patients but transplanted into other patients (71.3 percent) and that for all other cadaveric kidneys (75.5 percent). Most reasons for refusal were related to donor quality. Kidneys refused for such reasons showed a 67.7 percent two-year GS rate in nonmatched patients and the highest rates of acute and chronic rejection and primary failure. The two-year GS rate for kidneys accepted as paybacks for matched kidneys (75.7 percent) was equivalent to that for all non-matched cadaveric kidneys (75.5 percent).

CONCLUSIONS

If all normal-quality grafts refused for perfectly matched patients during 1990 through 1992 had been accepted for those patients, the number of transplants with typically superior survival rates could have increased by 25 percent, from 1,365 to 1,704. The payback requirement of the United Network for Organ Sharing does not seem to reduce the overall benefits of sharing perfectly matched kidneys nationwide.

Cadaver kidney transplantation in patients more than 65 years old

Elderly patients with end-stage renal disease often remain on dialytic therapy because they are at increased risk for mortality and morbidity. We placed 24 cadaver kidney transplants into 24 patients aged 65-74 years between September 1, 1985, and August 31, 1995. Rates of patient and graft survival were compared with those of 404 concurrent first cadaver-kidney transplant recipients between the ages of 20 and 44 years. The 5-year rates of patient and graft survival were not significantly different (86% versus 92% and 77% versus 63%, respectively; study group presented first). Primary cadaver kidney transplantation can be successfully performed in patients older than 65 years when a selection algorithm is applied to exclude active infection, active malignancy, unsuitable anatomy for technical success, high probability of operative mortality, and noncompliance. Pelvic arteriosclerosis and lower urinary tract abnormalities can cause intraoperative technical problems.

Identification of high- and low-risk second kidney grafts

The purpose of this study was to identify recipients who are at low or high risk of early cadaveric regraft failure by segregating results of the flow cytometric crossmatch (FCXM) test with previous graft survival time (PGST). Early immunologic kidney regraft failure was analyzed in 103 multicenter recipients by cross-stratifying FCXM negative/positive status with < or =3- and >3-month PGST. T cell and B cell cytotoxicity crossmatches were negative. All were tested retrospectively in the T cell FCXM and 60 of the 103 were also tested in the B cell FCXM. A positive T and B cell FCXM was defined as a mean channel shift of > or = 9 (256 channel log scale) or > or = 40 (1024 channel log scale) for pretransplant crossmatch serum above negative control serum. Recipients received triple immunosuppression therapy and limited-use antilymphocyte induction therapy. Early cadaveric regraft losses were biopsied. Comparably good rates of second kidney graft survival at 3 years were found among three ow risk subsets: 78% for 18 FCXM-positive patients with PGST >3 months, 78% for 49 FCXM-negative patients with PGST >3 months, and 84% for 19 FCXM-negative patients with PGST < or =3 months. in contrast, 53% 3-month and 44% 3-year regraft survival rates occurred in 17 high-risk FCXM-positive recipients with a PGST < or =3 months. The odds ratio for increased relative risk of early second graft loss was 4.5 (confidence interval: 1.32-1.67) for the high-risk versus low-risk subsets (P = 0.009). Within the high-risk subset, 56% (5 of 9) of those who were FCXM T negative B positive experienced early regraft loss. A positive B cell FCXM has an adverse clinical impact only for high-risk regraft recipients. Pretransplant panel reactive antibody levels, pregnancy, number of blood transfusions between grafts, repeat donor HLA mismatches, and regraft recipient HLA mismatches did not correlate with early regraft loss. We conclude that kidney regraft survival rates in low-risk recipients (PGST >3 months/FCXM negative or positive [T and/or B cell] and PGST < or = 3 months/FCXM negative) approach primary graft survival rates and justify retransplantation, but the rate in high-risk regraft candidates (PGST < or =3 months/FCXM positive T and/or B cell) suggests that retransplantation should be performed only with a negative FCXM.

OKT3 prophylaxis in renal grafts with prolonged cold ischemia times: association with improvement in long-term survival

The data on patients participating in two randomized, prospective studies with similar immunosuppressive regimens were updated and combined to evaluate the long-term effects of OKT3 according to cold ischemia time (< or = or > 24 hr). Among 159 patients in the OKT3 and 153 in the cyclosporine A (CsA) group, 8 and 12 deaths occurred, respectively (P = NS). In patients with cold ischemia > 24 hours, OKT3 prophylaxis resulted in a lower mean number of rejection episodes per patient than did CsA prophylaxis within one year (mean +/- SEM: 0.87 +/- 0.11 vs. 1.35 +/- 0.14, respectively; P = 0.008) and within five years (1.07 +/- 0.12 vs. 1.49 +/- 0.15, respectively; P = 0.032). In contrast, rejection incidences in patients with cold ischemia < or = 24 hours was not significantly different in the two groups. In all study patients, there was a trend towards higher graft survival rates in the OKT3 group versus the CsA group (at 5 years, 73% vs. 66%, respectively; P = 0.182). Among recipients of kidneys with cold ischemia times > 24 hours, OKT3 patients had significantly higher graft survival than CsA patients at two years (84% vs. 64%, respectively) and at five years (71% vs. 56%, respectively; P = 0.045). Significant differences were not observed in recipients of kidneys with cold ischemia times < or = 24 hours. In conclusion, patients receiving renal grafts with long cold ischemia times strongly benefit from OKT3 prophylaxis.

Thirty-seven years of renal transplantation in Oregon

What we accomplish today as a matter of routine was only imagined by a few 4 decades ago. The journey from that first successful kidney transplant in the 1950s to the multidisciplinary, multiorgan transplant program of today has been a fascinating one. Although we attribute our current results to careful recipient selection and preparation, improvements in organ procurement and preservation, refinement of surgical techniques, improvement in histocompatibility techniques and organ sharing, improvements in immunosuppression and infection control, and careful monitoring of recipients, we and our patients have benefited from significant contributions from our colleagues in government and the law. The 4 that come to mind are the provision of near-universal insurance coverage for end stage renal disease patients in 1972 under the Medicare program, the passage of brain death laws in the mid 1970s, the passage of the National Transplant Act in 1984, and the passage of the Oregon required request law in 1985.

Reduced human IgG anti-ATGAM antibody formation in renal transplant recipients receiving mycophenolate mofetil

Exposure to the equine-derived polyclonal antithymocyte preparation, ATGAM, frequently elicits human anti-ATGAM antibody formation. The influence of concomitant immunosuppressants on this antiantibody response has not been established. We therefore evaluated IgG antibody formation to ATGAM in 47 patients receiving ATGAM as part of a prospective, randomized, double-blinded study of mycophenolate mofetil versus azathioprine for maintenance immunosuppression after primary cadaveric renal transplantation. All patients received ATGAM for induction of immunosuppression plus methylprednisolone, prednisone, and cyclosporine. In addition, patients were randomized to receive maintenance immunosuppression consisting of either azathioprine (AZA) 1-2 mg/kg/day, mycophenolate mofetil 2 gm/day (MMF2), or mycophenolate mofetil 3 gm/day (MMF3). Patient sequential sera were independently tested for IgG anti-ATGAM antibody by 2 laboratories, which were blinded to treatment arm assignments, using enzyme-linked immunosorbent assays. Both laboratories found significantly greater anti-ATGAM antibody formation in group AZA compared with groups MMF2 and MMF3: laboratory 1 reported sensitization rates in the 3 groups of 94% (AZA), 50% (MMF2) (P < 0.02 vs. AZA), and 60% (MMF3) (P < 0.05 vs. AZA); and laboratory 2 reported rates of 67% (AZA), 17% (MMF2) (P < 0.02 vs. AZA), and 10% (MMF3) (P < 0.02 vs. AZA). In addition, fewer patients formed high titer antibody in the MMF arms compared to the AZA arm: 56% (AZA), 0% (MMF2) (P < 0.02 vs. AZA), and 20% (MMF3) (P < 0.02 vs. AZA) of patients for laboratory 1; and 20% (AZA), 0% (MMF2) (P < 0.05 vs. AZA), and 0% (MMF3) (P < 0.05 vs. AZA) of patients for laboratory 2. Differences in test results between the 2 laboratories were explained by differences in the sensitivity of their respective immunoassays and in the criteria used for assigning a positive result to test specimens. In this protocol, MMF at 2-3 gm/day was associated with a reduced incidence and titer of IgG anti-ATGAM antibody formation compared with standard azathioprine dosing. Although MMF previously has been reported to inhibit T cell responses that mediate acute cellular rejection, this is the first demonstration that MMF significantly inhibits human B cell responses to antigen in vivo.

Mechanisms of action and overview of OKT3

OKT3 is a murine monoclonal antibody of the immunoglobulin IgG2a isotype. The target of OKT3, CD3, is a 17-20 kilodalton (kD) molecule that is part of a multimolecular complex found only on mature T cells and medullary thymocytes. This complex is uniquely situated next to the T-cell receptor for antigen. An interaction between T cells, OKT3, and monocytes causes T-cell activation (mitogenesis) in vitro. Because of the unique association between the antigen receptor and CD3, antibodies that react with CD3 block T-cell receptor function and vice versa. Thus, OKT3 blocks both the generation and function of cytotoxic T cells. After an initial dose of OKT3, T cells virtually disappear from the circulation within minutes to hours. During treatment with OKT3, T cells bearing the usual array of surface molecules (CD2, CD4, CD8) reappear in the peripheral blood circulation but these cells are devoid of the OKT3 target molecule, CD3. Within 48 hours of discontinuing OKT3, the normal array of surface molecules including CD3 is found again on all T cells. The selective removal of CD3 by internalization is thought to be the key mechanism of action of OKT3. Comodulation of the antigen receptor with CD3 explains the immunoblocking action of OKT3 in vivo. Experience with a second or third treatment with OKT3 indicates that OKT3 is ineffective clinically if the CD3 target molecule is not modulated. OKT3 has been found to be effective for induction of immunosuppression and for treating initial and steroid-resistant rejections.

Generation of a high-resolution genetic map and a YAC contig of the Lurcher locus on mouse chromosome 6

Lurcher (Lc) is a semidominant mouse mutant that displays progressive neurodegeneration during perinatal development. This genetic lesion results in apoptotic neuronal death in a dosage dependent and cell autonomous manner in specific neurons during their terminal differentiation. To understand the molecular basis of the Lc mutation, we have adopted a positional cloning approach based on its location on mouse chromosome 6. To define the Lc locus, we have extended our previous analysis of an intersubspecific backcross between Mus m. castaneus and B6CBACa-Aw-j/A-Lc consisting of 504 animals (Norman et al. 1991). In addition, 580 animals of a generic backcross between Mus spretus and C57BL/6 (The European Collaborative Interspecific Backcross) were utilized for the fine genetic mapping of the Lc locus. Using three RFLP markers and nine microsatellite markers in the vicinity of the Lc locus, we determined the order and relative genetic distances of these markers at a resolution of 0.1 cM. The Lc mutation was mapped between two flanking markers, D6Mit121 and D6Mit175, separated by a genetic distance of 0.5 cM. We then initiated the cloning of the genomic region surrounding these two markers by screening a YAC library and characterizing YAC end sequences for further screening. This effort has resulted in the construction of a YAC contig consisting of 14 YACs and spanning a 3-Mb region. Markers isolated from these YACs were used to further define the Lc locus, resulting in a physical map that places the Lc gene within an estimated 300-kb interval. This set of YACs and markers will serve as DNA sources for the identification of the Lc gene.

The OKT3 Antibody Response Study: a multicentre study of human anti-mouse antibody (HAMA) production following OKT3 use in solid organ transplantation

Human anti-murine antibody titres following patient exposure to the monoclonal antibody Orthoclone OKT3 (muromonab-CD3) are determined by laboratories using diverse analytical methods which are not standardized and whose concordance is not established. A multicentre study group therefore compared testing for IgG anti-OKT3 antibody among seven laboratories. A set of 270 sera was obtained from 30 heart, 30 kidney and 30 liver transplant recipients with no previous exposure to OKT3 who were receiving OKT3 for induction immunosuppression. Sera were collected from each patient prior to and at 24 +/- 2 days and 31 +/- 2 days following initial OKT3 exposure. Identical aliquots of all 270 sera were tested for IgG anti-OKT3 antibody by each laboratory. In addition, the limit of detection of each laboratory's method was estimated by titration of an affinity-purified IgG anti-OKT3 reference material of known concentration. Anti-OKT3 antibody formation differed greatly among the three organ groups. Cardiac patients demonstrated the least sensitization and almost exclusively lower titres, while kidney recipients had more frequent and higher titre antibody formation. Liver recipients yielded the highest sensitization rate and the most frequent high titre sera. Importantly, the seven laboratories differed widely in the number of pretreatment sera reported as positive (ranging from 0% to 41% among laboratories), the number of post-OKT3 sera reported as positive (17-63%), the number of post-OKT3 samples with titre > or = 1000 (2-31%), and the number of patients sensitized 19-69%). Concordance among laboratories was highly variable, with interlaboratory agreement ranging from 38% to 83% on the sample titres assigned to 180 post-OKT3 sera. Many of the discordant results were consistent with differences in the limit of detection of the analytical methods, which ranged from 0.19 microgram/ml to > or = 15 micrograms/ml, a nearly 100-fold difference among laboratories. This study demonstrated the presence of both good concordance and significant discordance among laboratories in determining human anti-mouse antibody titres, and demonstrated that common titre categories (100, 1000, 10,000) were not equivalent among laboratories. The level of concordance among methods should be considered when comparing anti-OKT3 antibody results from different centres and their correlation with clinical events. Universal comparative testing, patterned after proficiency testing programmes, is needed to assess differences among laboratories and to bring uniformity and a sound interpretative basis to this field of testing.

The lurcher gene induces apoptotic death in cerebellar Purkinje cells

In the neurologically mutant mouse strain lurcher (Lc), heterozygous animals display cell autonomous degeneration of cerebellar Purkinje cells beginning in the second postnatal week. During the course of our studies to identify the genetic lesion responsible for this disease (Norman et al., 1991), we have formulated an hypothesis suggesting that in Lc Purkinje cells homeostasis is sufficiently perturbed to lead to the activation of programmed cell death, thus resulting in neuronal loss and the consequent neurologic disease (Heintz, 1993). To address this possibility, we have examined the properties of Lc Purkinje cells as they die during the second postnatal week. Our light and electron microscopic studies demonstrate that dying Lc Purkinje cells exhibit the characteristic morphologic features of apoptosis, including nuclear condensation, axon beading and membrane blebbing. Using an in situ end-labeling method, we have also detected nicked nuclear DNA in these cells. Furthermore, we have examined the expression of the sulfated glycoprotein 2 (SGP2), whose mRNA is induced in both T-cells and prostate epithelial cells undergoing apoptotic death. We show by in situ hybridization that SGP2 is not expressed at detectable levels in normal Purkinje cells, but that its mRNA is present in Lc Purkinje cells prior to their death. Also expression of the Kv3.3b potassium channel, which marks the terminal phase of Purkinje cell differentiation, is evident in Lc Purkinje cells prior to their death. These data demonstrate that the Lc mutation induces apoptosis in cerebellar Purkinje cells following their maturation in postnatal cerebellum. Isolation of the Lc mutation and further analysis of its action in eliciting apoptosis can provide an important opportunity for understanding the etiology of neurodegenerative disease.

Screening and confirmatory testing of cadaver organ donors for hepatitis C virus infection: a U.S. National Collaborative Study

Hepatitis C virus (HCV) can be transmitted by organ transplantation. Cadaver organ donors are screened for HCV infection by testing for antibodies to HCV (anti-HCV). The prevalence of HCV infection and performance of anti-HCV tests in detecting HCV infection in organ donors are unknown. Sera from 3078 cadaver organ donors were tested for anti-HCV by a first generation enzyme-linked immunosorbent assay (ELISA1). Sera from all 137 ELISA1 positive donors and a random sample of 92 ELISA1 negative donors were tested for anti-HCV by a second generation ELISA (ELISA2) and for HCV RNA by the polymerase chain reaction. Organ bank records were reviewed for risk factors associated with HCV infection. Follow-up was available on 70 recipients of organs from 42 ELISA2 positive donors. The prevalence of HCV RNA, extrapolated to all 3078 donors, was 2.4%. Liver disease, anti-HCV and HCV RNA were detected more frequently among recipients of organs from ELISA2 positive donors with HCV RNA than from ELISA2 positive donors without HCV RNA. Among donors, the sensitivity and negative predictive value of the ELISA2 for HCV RNA were 100%. However, despite a specificity of 98.1%, the positive predictive value was only 55.1%. Clinical and laboratory characteristics did not distinguish ELISA2 positive donors with and without HCV RNA. The presence of serum HCV RNA in organ donors predicts the risk of transmission of HCV infection. Discarding organs from ELISA2 positive donors would eliminate transmission, but organs from 1.88 percent of donors would be wasted.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective, double-blind, randomized study of high-versus low-dose OKT3 induction immunosuppression in cadaveric renal transplantation

We undertook a prospective, double-blind study of high-(5-mg) versus low-(2-mg) dose OKT3 for induction immunosuppression (12 days) in cadaveric renal allograft transplantation. Maintenance immunosuppression was identical in both groups and consisted of azathioprine and prednisone initially, with cyclosporine beginning on the 5th postoperative day. Twenty-six patients were randomized. The groups were similar in terms of age, kidney ischemia time, peak PRA, and latest PRA. There were more diabetics and women in the high-dose group. Patient survival at 12 months was 100% in both groups. Graft survival at 12 months was 92% and 100% in the high- and low-dose groups, respectively. Infections were mostly minor and equal in frequency in the two groups. All patients receiving high- or low-dose OKT3 had manifestations of the cytokine release syndrome; these were delayed in onset in the low-dose group. Eleven patients (85%) in each group produced anti-OKT3 antibodies. Lymphocyte depletion after 1 day was major (> 98%) and identical in both groups. CD3 antigens were removed more slowly in the low-dose group but eventually at equal rates in both groups. Cost was significantly lower in the low-dose group. We conclude that while both doses of OKT3 were effective and safe for induction immunosuppression, it may be prudent to use a lower dose of OKT3 for induction immunosuppression because of its potential to reduce cytokine-mediated effects and to avoid the complications of overimmunosuppression and because of the lower costs associated with it.