Administration Of Antilymphocyte Globulin Research Articles

Acute humoral rejection of kidney allografts in patients with a positive flow cytometry crossmatch (FCXM).

The patients with a positive flow cytometry crossmatch (FCXM) are categorized as a high-risk group causing hyperacute or accelerated acute rejection after kidney transplantation. According to the successful results of ABO-incompatible renal transplantation, we have performed the living related transplant operations in the recipients with positive FCXM for donor T cells, but having a negative complement-dependent lymphocytotoxic reaction test. We have followed the clinical course of 4 FCXM-positive patients, and 2 of them have developed acute humoral rejection. We report the strategies for FCXM-positive living kidney transplantations and the characteristics of pathological findings of acute humoral rejection in FCXM-positive renal transplants. We have had few episodes of acute humoral rejection in ABO-incompatible kidney transplantations under immunosuppressive regimens, including cyclophosphamide, but 2 patients of 4 with FCXM-positive kidney transplantations developed acute humoral rejections. The differences in immunosuppressive regimen between ABO-incompatible and FCXM-positive kidney transplantations concern anti-lymphocyte globulin (ALG) and splenectomy. We have not performed splenectomy and ALG administration in FCXM-positive kidney transplantations. Severe acute rejection episodes have been experienced on post-operative days 7 and 9 in 2 of 4 FCXM-positive recipients. The early acute rejection episodes were clinically and pathologically diagnosed as typical humoral rejections. We have examined an immunofluorescent study to prove the diagnosis of humoral rejection in FCXM-positive kidney transplantations; both immunoglobulin M and C3 were positive for the whole course of humoral rejection. The 2 patients with acute humoral rejection recovered after treatment with double filtration plasmapheresis or plasma exchange to remove their anti-donor antibodies. The gold standard of success in FCXM-positive kidney transplantations is to suppress the production and reduce the level of anti-donor antibodies after transplant operations.

Serum amyloid A protein is a clinically useful indicator of acute renal allograft rejection.

Early diagnosis of acute rejection after renal transplantation is important. There is evidence that measurement of the acute phase proteins, C-reactive protein (CRP) and serum amyloid A protein (SAA) is helpful. In 64 consecutive patients, CRP was measured in a routine clinical system (Technicon RA1000, Bayer) and SAA in a new sensitive automated immunoassay on the Abbott IMx instrument, daily or on alternate days for 30 days after renal transplantation. Patients all received triple immunosuppression with cyclosporin, azathioprine, and prednisolone and all mounted a post-surgical acute phase response of SAA, but the CRP response was reduced or absent. Serum creatinine rose significantly in 36 patients, leading to treatment for first rejection. Thirty of these episodes were confirmed rejection, three were definitely not and three were uncertain. SAA. normally < 10 mg/l, rose to more than 100 mg/l in all episodes except when rejection was definitely absent. In six cases SAA rose above 100 mg/l 1-3 days before the rise in creatinine leading to antirejection therapy, and only twice did creatinine rise 1 day before SAA. In contrast, CRP responses to rejection were modest or absent. In four patients there were SAA and CRP responses unrelated to rejection, three associated with intercurrent infection and one with administration of antilymphocyte globulin. There were also two unexplained isolated spikes of SAA. SAA is a sensitive marker of acute renal allograft rejection. It is not specific, but the differential behaviour of CRP in patients receiving cyclosporin helps to distinguish infection from rejection. Availability of rapid assays for these analytes should facilitate management of renal allograft recipients.

Immunosuppressive therapy in renal transplantation

In 1960, the beneficial effect on allograft survival of 6-mercaptopurine (6-MP) was demonstrated. In 1961, azathioprine, a less toxic derivative of 6-MP, was synthesized and soon became the main form of maintenance therapy. Around the same time, clinical studies of the effects of corticosteroids on the immune system were being conducted and successful reversal of rejection with cortisone was recognized. Subsequently, steroids were added to azathioprine and this regimen constituted maintenance immunosuppressive therapy in most centers for over 20 years. However, these first generation immunosuppressive medications are the cause of the majority of complications following renal transplantation. Both azathioprine and steroids effect nearly all immunologic and inflammatory responses and may predispose to infection and certain malignant diseases. Despite refinement in the use of these agents with improved patient survival, little improvement in graft survival was appreciated. The second generation immunosuppressive agents, antilymphocyte globulin (ALG), emerged in the form of polyclonal antibodies derived from xenotypic antisera and directed against the entire cellular response. Unfortunately, many limitations have been encountered with respect to the administration of ALG. Cyclosporine A is more specific and attacks a subset of the lymphocyte population, the T helper lymphocytes. When cyclosporine A is used in combination with prednisone, the immunologic cycle that causes rejection is interrupted twice by virtue of the fact that prednisone prevents the production of IL-1 by macrophages and cyclosporine A with the production of lymphokines, especially IL-2 (T-cell growth factor). Although cyclosporine A is at present better immunosuppressive drug to azathioprine, it is not without a number of side-effects. Nephrotoxicity, however, is the most worrying complication in patients receiving cyclosporine A. Of most importance to the urologist, however, is the interaction with cyclosporine A by many of the drugs used to treat various urologic infections. The advent of hybridoma technology which has become so important to the urologic oncologist has also impacted upon transplantation and resulted in the development of a new generation of antilymphocyte antibodies. The bulk of clinical experience has been obtained with OKT3, a monoclonal antibody directed against the T3 antigen complex found on all T-lymphocytes. A large multi-center experience has showed the remarkable efficacy of OKT3 in providing rapid depletion of peripheral blood T cell levels and reversal of established rejection not responded to conventional high-dose steroid therapy and in reducing the frequency and delay of the onset of rejection reactions.

ALG treatment of steroid-resistant rejection in patients receiving cyclosporine.

Thirty-one episodes of biopsy-proved acute rejection (R) in 28 patients maintained on cyclosporine did not respond to high-dose steroids and were treated with antilymphocyte globulin (ALG). Cyclosporine was discontinued in all but three during ALG administration. (A) Twenty-four patients received 26 courses of ALG within 90 days of transplant (11 1st R, 15 2nd or 3rd). Seven treatment courses were cut short due to infection (4), ongoing R (2) and a combination of infection and rejection (1). Only 1 of 7 has a functioning graft. Of the remaining 19 full ALG courses (17 patients) (8 1st R, 11 2nd or 3rd), 13 (11 patients) responded (7 1st R, 6 greater than 1st). The remaining 6 patients lost their grafts to ongoing acute rejection. (B) Five patients were treated after 6 months posttransplant; two responded but no grafts currently function. (C) Overall 7 patients developed systemic infection (7 viruses, 1 Candida) with 1 death, and 2 additional patients developed severe thrombocytopenia and leukopenia. Patients responding to their ALG course were restarted on cyclosporine. We conclude that ALG is not as effective in reversing steroid-resistant rejection in patients maintained on cyclosporine as it has been in patients maintained on azathioprine. However, more than 50% of steroid-resistant rejection episodes are reversed.

Positive direct antiglobulin tests with antilymphocyte globulin.

Patients receiving antilymphocyte globulin (ALG) of equine origin, for prophylactic immunosuppression following renal transplantation or for rejection episodes, develop a positive direct antiglobulin test (DAT), mainly of the IgG type. This finding may be observed as early as the first day following the administration of ALG. The cause for the positive DAT is due to the presence of antihorse globulin in the reagent antiglobulin serum reacting with ALG antigenic material coating the patients' red blood cells. The serum of some of these patients also may result in incompatible cross-matches. These serums and all of the eluates react with donor and reagent red blood cells demonstrating no particular blood group specificity.

Red cell sensitization due to anti-D in anti-lymphocyte globulin.

Four Rh-positive patients with severe aplastic anemia received equine anti-lymphocyte globulin. Each developed a positive direct antiglobulin test. Anti-D was identified in eluates prepared from the patients' sensitized red cells. The administered lot of anti-lymphocyte globulin was found to contain anti-D. Red cell sensitization due to passively acquired Rh antibodies can result from the administration of anti-lymphocyte globulin.

RETICULOENDOTHELIAL FUNCTION IN HUMAN RENAL ALLOGRAFT RECIPIENTS

The phagocytic and metabolic functions of the reticuloendothelial system (RES) were determined, by measuring the plasma clearance rate of 125I-labelled microaggregated human serum albumin and the increase in plasma metabolites of this test substance, in patients with chronic renal failure and in renal transplant recipients at different times after transplantation. All transplant recipients received triple immunosuppressive therapy consisting of azathioprine, corticosteroids, and antilymphocyte globulin. The intravascular clearance of microaggregated albumin was significantly depressed in patients when tested at 1 to 12 days (P less than 0.001), 1 to 4 months (P less than 0.02), and 6 to 9 months (P less than 0.001) after transplantation compared to pretransplantation. The 1- to 3-year transplant survivors had a normal RES phagocytosis. Furthermore, the metabolic RES function in all groups of transplant recipients except the group of patients tested at 1 to 4 months after transplantation was significantly impaired compared to pretransplantation. Administration of antilymphocyte globulin and extremely high daily doses of steroids were probably responsible for the significant depression in the RES functions recorded immediately post-transplantation. The further development of the phagocytic ability of the RES was shown to be correlated to the cumulative dose of steroids given over the last 12 months. The azathioprine regime seemed to have no influence on the RES functions.

Chromosome Studies of Two Transplantable Leukemias of BN Mice&lt;xref ref-type="fn" rid="FN2"&gt;2&lt;/xref&gt;

Karyotypes of two transplantable murine ascites leukemias, LBN/a2 and LBN/b3, were studied with the use of the trypsin-Giemsa technique. The original tumors arose in adult female mice of strains BN/a and BN/b after prolonged antilymphocyte globulin administration. The karyotypes of both leukemias showed similar patterns. Both were hyperdiploid with modal chromosome numbers of 41 and 42 in LBN/a2 and LBN/b3, respectively. The cells consisted of an average of 37 normal chromosomes and 4--5 abnormal chromosomes. The most consistent karyotype deviation was monosomy of the X-chromosome and of several autosomes: no. 9, 14, and 7 in the LBN/a2 line and no. 7, 12, 14, and 9 in the LBN/b3 line. In most LBN/b3 cells and in a lower proportion of LBN/a2 cells, trisomy of chromosome no. 15 was found. With regard to the occurrence of abnormal marker chromosomes, both tumors exhibited great cell-to-cell variation. Two of the markers were common to both leukemia lines.

Mixed IgG-IgA cryoglobulinemia in human serum sickness. Evidence for Equine IgG in the cryoprecipitate.

Serum sickness followed the administration of anti-lymphocyte globulin to a patient with multiple sclerosis. In addition to other characteristic features of this syndrome, there was hypocomplementemia and transient renal dysfunction similar to that observed in the 'one-shot' experimental model of serum sickness. Cryoglobulinemia was transiently demonstrable at the height of the inflammatory response. Analysis of the purified cryoprecipitate revealed the presence of human IgG and IgA, and, in addition, equine IgG. This demonstration of a well-defined exagenous antigen in the cryoprecipitate provides further support for the immune complex nature of mixed cryoglobulins.

Glomerulopathy in recipients of liver transplants after administration of antilymphocyte globulin.

Five of six patients who had undergone liver transplantation were found to have histologic evidence of renal glomerular disease which could be classified into three types: (1) focal proliferative glomerulopathy; (2) diffuse proliferative glomerulopathy; (3) membranoproliferative glomerulopathy. All patients had received antilymphocyte globulin as part of their postoperative treatment. In three of these cases there were immunofluorescent deposits in the glomerular basement membranes. In one case there was electron microscopic evidence of antibody–antigen complexes within the subendothelial portion of the glomerular basement membranes. Absorption, blocking and elution studies indicated that antilymphocyte globulin was the probable offending allergen underlying these glomerular changes.

Kinin liberation during therapy with antilymphocyte globulin

An anaphylactoid reaction occurred during the administration of anti-lymphocyte globulin (A.L.G.) to a patient receiving a bone-marrow transplant and was associated with kinin liberation. The rate of A.L.G. administration was found to determine whether or not kinin liberation occurred. There was no evidence of human antibodies to horse proteins playing a part in this activation of the kininogen-kinin system. In vitro studies demonstrated that incubation of human platelet-free plasma with A.L.G. provoked kinin liberation, and that the presence of cells did not: augment this, Antibodies to human serum-proteins were present in the A.L.G., and may have been responsible. Incubation of A.L.G. and goat plasma did not produce kinin liberation. An anaphylactoid reaction occurred during the administration of anti-lymphocyte globulin (A.L.G.) to a patient receiving a bone-marrow transplant and was associated with kinin liberation. The rate of A.L.G. administration was found to determine whether or not kinin liberation occurred. There was no evidence of human antibodies to horse proteins playing a part in this activation of the kininogen-kinin system. In vitro studies demonstrated that incubation of human platelet-free plasma with A.L.G. provoked kinin liberation, and that the presence of cells did not: augment this, Antibodies to human serum-proteins were present in the A.L.G., and may have been responsible. Incubation of A.L.G. and goat plasma did not produce kinin liberation.

Human renal allografts: Glomerular deposits of horse immunoglobulin G and nephritis following administration of antilymphocyte globulin

The administration of horse antilymphocyte globulin (ALG) containing glomerular basement membrane (GBM) cross-reactive antibody has the potential for inducing nephritis of the anti-GBM (linear) type. Similarly, a hostantihorse antibody response to the ALG may result in antigen-antibody complex (granular) nephritis. GBM cross-reactive antibody is more likely to be present in ALG derived from horses immunized with suspensions of lymph modes or thymus than with washed lymphoid cell suspensions, possibly because of the presence of other tissue antigens. However, ALG derived from some of our horses immunized with washed human thoracic duct lymphocytes also contained antibody cross-reactive with human GBM. Such antibody was found to be intermittently present in subsequent bleeds (ALG lots) following its demonstration in initial or early ALG lots. An ALG lot submitted for our evaluation of its possible GBM cross-reactivity was strongly positive but showed a marked reduction in cross-reactivity during extended storage at −20°C. Therefore, each lot of ALG should be tested for the presence of GBM cross-reactive antibody immediately after preparation. Of 58 renal allograft recipients treated intramuscularly with ALG and other immunosuppressants, allograft biopsies were taken for specific indications in 32. Examination of these biopsies for deposits of horse immunoglobulin G (IgG) showed that two contained linear deposits, suggesting that the cross-reactive antibody had not been completely absorbed locally following intramuscular administration. One of the latter two immunosuppressed recipients developed nephritis, probably a result of GBM cross-reactive antibody, from which he subsequently recovered. Although not all patients who received ALG containing GBM cross-reactive antibody develop clinically significant nephritis, until more data are available regarding the nephrotoxic effects of ALG, only lots found not to contain such antibody should be used clinically.

Tissue typing, antilymphocyte globulin, and prophylactic graft irradiation in cadaver kidney transplantation.

In a series of 27 recipients of cadaver kidney grafts, 26 were at the time of writing alive, 3 to 25 months after transplantation, and 25 patients were alive with functioning first grafts. The one-year patient survival in 18 patients was 94% and the one-year graft survival was 89%. There was no beneficial correlation between tissue matching and the frequency of major early rejection episodes or graft function 12 or more months after transplantation. Antilymphocyte globulin administration was associated with a lower incidence of early rejection episodes, but this was not statistically significant. A combination of prophylactic graft irradiation and antilymphocyte globulin administration for at least the first two weeks was associated with a significantly reduced frequency of major early rejection episodes and appreciably better graft function at 12 months. This effect could not be ascribed to better tissue matching.

Liver transplantation in man--3, Studies of liver function, histology, and immunosuppressive therapy.

The experience gained from 13 hepatic transplant operations is described, with particular reference to the findings in nine patients who survived the immediate operative period. A major problem was found to be infection. Fulminant pneumonia caused death in two adults, at a time when liver function was virtually normal. Infection related to bile fistula and sepsis may be overcome by an improved method of biliary drainage by cholecyst-dochostomy, which was carried out in the last two patients. Jaundice in the second week due to rejection was observed in several patients. The striking histological change was centrilobular cholestasis. The jaundice, which was not prevented by administration of antilymphocyte globulin, was rapidly controlled by temporarily increasing die dose of prednisone. One patient who survived for four and a half months and who had a poor tissue match subsequently developed chronic rejection with progressive cholestatic jaundice. Five of the patients were able to go home and at time of publication two are alive and well 14 and 20 weeks after treatment.

Suppression of adjuvant disease in the rat by heterologous antilymphocyte globulin.

The effect of antilymphocyte globulin (ALG) on adjuvant arthritis, an immunologically induced disease in the rat, was studied. ALG was prepared from the serum of rabbits immunized against rat lymphocytes. Adjuvant arthritis was induced in rats by a single intracutaneous injection of Freund's complete adjuvant; after 9 to 12 days, all control rats developed polyarthritis. Administration of antilymphocyte globulin about the time of adjuvant injection produced marked inhibition of clinical disease. Some suppression was apparent even when ALG was started after the onset of arthritis. Rats receiving ALG remained conspicuously healthy compared to controls. Urinary findings and renal histology showed no evidence of nephritis. The results of serum corticosterone determinations made it unlikely that adrenal stimulation contributed to the actions of ALG. Antilymphocyte preparations lowered peripheral lymphocyte counts and suppressed primary antibody responses to sheep erythrocytes, but had little effect on the skin reaction to PPD, even in rats protected from arthritis. All rats given ALG developed antibodies to rabbit globulin; there was no evidence that ALG inhibited the appearance of antibodies to itself, and prior hyperimmunization of rats with rabbit globulin did not interfere with the biological activity of ALG subsequently injected. Antisera produced separately against lymph node and thymus cells had identical properties with regard to agglutination of lymphocytes and thymus cells. Administered to rats, these preparations were equally potent in lowering lymphocyte counts and suppressing both adjuvant arthritis and the primary antibody response to sheep erythrocytes. It is concluded that ALG, as used in these experiments, is a potent immunosuppressive agent without obvious toxic effects.