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Antibodies to extractablenuclear antigens (ENA) in antinuclear antibody positive (ANA + ve) autoimmune liver diseases (ALD)
Immunology
Low incidence of chronic rejection in patients experiencing histological acute rejection without simultaneous impairment in liver function tests. O. Farces. A. N. Kalil. M. Sebaeh. M. Revnes. H. Bi,~m01h, Hepato-Biliary Surgery and Liver Transplant Center and Department of Pathology, Hfipital Paul Brousse, University Paris Sud, Villejuif France. Early infiltration of experimental allografts, in some fully incompatible strain combinations, does not always lead to graft rejection and is in fact associated with the spontaneous long term acceptance of the graft. This is in particular so in the rat model of liver transplantation. It has similarly been repeatedly found that human liver allografts may be infiltrated with recipients leucocytes, although liver function tests remain unchanged. These histological signs of rejections resolve spontaneously (in contrast to histological signs of rejection associated with impairment in liver function tests that require bolus steroid therapy and / or OKT3 or ALS). The ,aim of the present study was to assess whether these merely histological signs of rejection are associated, as in the rat model, with a better long term outcome of the graft. Between December 1985 and December 1991, 707 ABO identical or compatible orthotopic liver transplantations were performed. During the first 3 weeks posttransplant, histological signs of rejection not associated with impaired liver function tests (group 1) were identified in 75 patients (usually as part of a protocol liver biopsy) while acute rejection (group 2) was diagnosed in 171 patients. Acute episodes of rejection were treated with 1 - 3 bolus steroid and subsequently, if required, OKT3 or AI_S. Patients with histological signs of rejection were not treated by steroids, OKT3 or ALS. Age (group 1 : 36.8 + 13 versus group 2 : 39.2 _+ 13.4 years) and sex ratio of the recipients, indication for transplantation, number of 11LA mismatch, immunoprophylaxis were comparable between the two groups. During the course of follow-up (median 4.2 versus 3.8 years), incidence of death (17.3 versus 21%) as well as of retransplantation for indications other than acute or chronic rejection (5.3 versus 4.0 %) were comparable. On the contrary, incidence of chronic rejection was c'onsidcrably lower in the group of patients that had undergone histological signs of rejection (I/75 : 1.3 %) than in the group of patients with acute clinical rejection (27/171 : 15.8 %). Conclusion. Patients with histological signs of liver allograft rejection unassociated with impaired liver function tests during the first three weeks after transplantation, not only do not require a specific treatment but ,are in addition at very low risk of chronic rejection.
Prolongation of rat cardiac allograft survival following intraportai injection of donor antigens is inhibited by cyclosporine A. O. Farues. D. Buffello. A. Moufetier. H. Bismuth. Hepato-Biliary SurgeD' and Liver Transplant Center, Htpital Paul Brousse, University Paris South, Villejuif France. Graft rejection is the result of a T cell dependant response against donor antigens, that is efficiently inhibited by Cyclosporine administration. Graft enhancement (such as that observed after administration of donor antigens prior to transplantation) has been shown to be potentiated by the simultaneous administration of cyclosporine. This result is somewhat surprising since graft enhancement is also the result of an active immune response towards donor antigens, that could therefore be similarly inhibited by cyclosporine. To address this issue, we have used a carefully controlled protocol of cyclosporine administration, in a rat model of passive enhancement, using a highly responsive strain combination. Cardiac heterotopic transplantations were performed in the BN to LEW rat strain combination without pretreatment (group I) or 7 days after administration of 107 donor lymph node leucocytes in the portal vein (group 3). Cyclosporine (2.5 mg/kg/IM) was administered daily, starting 24 hours before intraportal administration of donor leucocytes and until 24 hours before cardiac transplantation. This allowed effective cyclosporine blood levels (500 - 1200 ng / ml, monoclonai antibody) to bc rcachcd at the time of and during the 7 days following donor antigens administration with minimal residual blood levels (< 100 n g / ml, monoclou',d antibody) at the time of and following cardiac transplantation (group 3 and 4). Donor cell pretreatment significantly and specifically prolonged cardiac allograft survival (group 1 versus 3, p<0.05)). Cyclosporine pretreatmcnt alone did not significantly prolong cardiac allogruft survival (group 1 versus 2). Prolongation of cardiac allograft survival by prior administration of donor antigens was inhibited by the simultaneous adminisuation of Cyclosporine A (group 4 versus 3). This inhibition was not related to metabolic changes and in particular to uremia. Conclusion. These results show, in contrast to previous studies, that passive enhancement of cardiac allograft survival may be prevented by cyclosporine. This raises the possibility that cyclosporine, used in the clinical setting to prevent rejection, might also, in some cases, prevent the development of graft tolerance or.~llmnccmcllt.
S 1 39
HCV-RELATED CHRONIC CHOLESTASIS: A PBCLIKE SYNDROME DISTINCT FROM AUTOIMMUNE CHOLANGITIS ? A.Floreani, F.Zappal~i, M.Pittoni*, M.Plebani*, F.Marinosci. M.Chiaramonte. Dept. o f Gastroenterology, *Clinical Biochemistry, University o f Padova, Italy. A proportion o f chronic H C V hepatitis pts have clinical, b i o c h e m i c a l and histologic features o f cholestasis. On the other hand, a n e w s y n d r o m e o f antimitochondrial ( A M A ) negative a u t o i m m u n e cholangitis has been d e s c r i b e d (15 % o f these pts were anti-M2 positive) (1). To evaluate a possible link b e t w e e n H C V - r e l a t e d cholestasis and PBC, we tested the m a j o r M2 mitochondrial autoantigens in : a) 10 a n t i - H C V + v e PBC-like chronic cholestasis pts (all A M A - v e by IF); b) 10 A M A + v e / a n t i - H C V - v e classical PBC pts; c) 10 primary sclerosis cholangitis (PSC) pts: d) 24 a n t i - H C V + v e chronic hepatitis pts without b i o c h e m i c a l and histologic signs o f cholestasis. M E T H O D S : anti-M2 were tested by a m o d i f i e d EIA (raised cut-off) (Biorad, Italy) . R E S U L T S : anti-M2 were positive in 90% o f classical PBC pts ( m e a n titre 790 + 321 U/ml) vs 80% o f a n t i - H C V ÷ v e PBC-like chronic cholestasis pts ( m e a n titre 601 + 316 U/ml), p = n.s., while none o f PSC pts was positive. A n t i - M 2 were positive at low titres (189 +112 U/ml) in 3 (14%) pts with a n t i - H C V + v e chronic liver disease without cholestasis. C O N C L U S I O N S : Pts with a n t i - H C V + v e PBC-like chronic cholestasis had similar levels o f anti-M2 c o m p a r e d to pts with classical PBC. A cross reaction b e t w e e n anti-M2 and a n t i - H C V s e e m s to be unlikely. A n t i - H C V + v e / a n t i - M 2 + v e chronic cholestasis may be another subgroup o f the overlap s y n d r o m e o f PBC and chronic active hepatitis. I) Michieletti P. et al Gut .1994: 35:260-265.
ANTIBODIES TO EXTRACTABLE NUCLEAR ANTIGENS (ENA) IN ANTINUCLEAR ANTIBODY POSITIVE (ANA+ve) AUTOIMMUNE LIVER DISEASES (ALD) G. V. Gregorio ~, G. Mieli-Vergani~-, D. Vergani ~. ~Dept of Immunology & :Child Health, King's College School of Medicine and Dentistry, Bessemer Road, London SE5 9PJ, UK. ANA+ve connective tissue disorders (CTD) are subdivided by the presence of specific antibodies to extractable nuclear antigens (antiribonucleoprotein (anti-RNP), anti-Smith (anti-Sm), anti-Ro, anti-La). The significance of ENA in ANA+ve ALD is unknown. To determine if ANA+ve ALD can be further characterised on the basis of the ENA profile, we have tested 15 (median age:12(8-17)yrs;9 girls;median ANA titre:160(10-20480)) with autoimmnne hepatitis (AIH) and 13 (median age:ll(3-16)yrs;8 girls;ANA titre: 320(10-10240)) with sclerosing cholangitis (SC), using both the conventional double dimension immnnodiffusion (DID) and a recently established enzyme linked immunosorbent assay (ELISA). 22 (median age:34 (16-58) yrs;21 girls;ANA titre: 1280 (40-10240)) with systemic lupus erythematosus (SLE) with no liver disease were tested as controls. ENA were detected in 2 of 28 (7%) with AIH (ANA:I/40, 1/10240), -ve by DID, +ve by ELISA: 1 anti-La and 1 anti-Sm/anti-La. Neither patient had evidence of CTD nor associated AI disease and their clinical features were similar to those of ENA-ve. 12 (55%) with SLE were ENA+ve: 9 (ANA titre: 1280 (402560)), -ve by DID, +ve for at least I ENA by ELISA: 7 anti-Ro, 4 antiRNP, 2 anti-La and I anti-Sm; 1 (ANA: 1/2560) anti-RNP+ve by DID, -ve by ELISA; 1 (ANA:I/640) anti-RNP+ve by DID, reacted with an unidentified binding protein (UBP) by ELISA; and 1 (ANA:I/5120) reacted in both techniques with an UBP. As compared with ANA+ve CTD, ENA is less frequently seen in ANA+ve ALD and does not appear to be a useful diagnostic marker in the classification of ANA+ve ALD. Further studies are needed to determine the nature of the nuclear proteins in ANA+ve ALD.
Low incidence of chronic rejection in patients experiencing histological acute rejection without simultaneous impairment in liver function tests. O. Farces. A. N. Kalil. M. Sebaeh. M. Revnes. H. Bi,~m01h, Hepato-Biliary Surgery and Liver Transplant Center and Department of Pathology, Hfipital Paul Brousse, University Paris Sud, Villejuif France. Early infiltration of experimental allografts, in some fully incompatible strain combinations, does not always lead to graft rejection and is in fact associated with the spontaneous long term acceptance of the graft. This is in particular so in the rat model of liver transplantation. It has similarly been repeatedly found that human liver allografts may be infiltrated with recipients leucocytes, although liver function tests remain unchanged. These histological signs of rejections resolve spontaneously (in contrast to histological signs of rejection associated with impairment in liver function tests that require bolus steroid therapy and / or OKT3 or ALS). The ,aim of the present study was to assess whether these merely histological signs of rejection are associated, as in the rat model, with a better long term outcome of the graft. Between December 1985 and December 1991, 707 ABO identical or compatible orthotopic liver transplantations were performed. During the first 3 weeks posttransplant, histological signs of rejection not associated with impaired liver function tests (group 1) were identified in 75 patients (usually as part of a protocol liver biopsy) while acute rejection (group 2) was diagnosed in 171 patients. Acute episodes of rejection were treated with 1 - 3 bolus steroid and subsequently, if required, OKT3 or AI_S. Patients with histological signs of rejection were not treated by steroids, OKT3 or ALS. Age (group 1 : 36.8 + 13 versus group 2 : 39.2 _+ 13.4 years) and sex ratio of the recipients, indication for transplantation, number of 11LA mismatch, immunoprophylaxis were comparable between the two groups. During the course of follow-up (median 4.2 versus 3.8 years), incidence of death (17.3 versus 21%) as well as of retransplantation for indications other than acute or chronic rejection (5.3 versus 4.0 %) were comparable. On the contrary, incidence of chronic rejection was c'onsidcrably lower in the group of patients that had undergone histological signs of rejection (I/75 : 1.3 %) than in the group of patients with acute clinical rejection (27/171 : 15.8 %). Conclusion. Patients with histological signs of liver allograft rejection unassociated with impaired liver function tests during the first three weeks after transplantation, not only do not require a specific treatment but ,are in addition at very low risk of chronic rejection.
Prolongation of rat cardiac allograft survival following intraportai injection of donor antigens is inhibited by cyclosporine A. O. Farues. D. Buffello. A. Moufetier. H. Bismuth. Hepato-Biliary SurgeD' and Liver Transplant Center, Htpital Paul Brousse, University Paris South, Villejuif France. Graft rejection is the result of a T cell dependant response against donor antigens, that is efficiently inhibited by Cyclosporine administration. Graft enhancement (such as that observed after administration of donor antigens prior to transplantation) has been shown to be potentiated by the simultaneous administration of cyclosporine. This result is somewhat surprising since graft enhancement is also the result of an active immune response towards donor antigens, that could therefore be similarly inhibited by cyclosporine. To address this issue, we have used a carefully controlled protocol of cyclosporine administration, in a rat model of passive enhancement, using a highly responsive strain combination. Cardiac heterotopic transplantations were performed in the BN to LEW rat strain combination without pretreatment (group I) or 7 days after administration of 107 donor lymph node leucocytes in the portal vein (group 3). Cyclosporine (2.5 mg/kg/IM) was administered daily, starting 24 hours before intraportal administration of donor leucocytes and until 24 hours before cardiac transplantation. This allowed effective cyclosporine blood levels (500 - 1200 ng / ml, monoclonai antibody) to bc rcachcd at the time of and during the 7 days following donor antigens administration with minimal residual blood levels (< 100 n g / ml, monoclou',d antibody) at the time of and following cardiac transplantation (group 3 and 4). Donor cell pretreatment significantly and specifically prolonged cardiac allograft survival (group 1 versus 3, p<0.05)). Cyclosporine pretreatmcnt alone did not significantly prolong cardiac allogruft survival (group 1 versus 2). Prolongation of cardiac allograft survival by prior administration of donor antigens was inhibited by the simultaneous adminisuation of Cyclosporine A (group 4 versus 3). This inhibition was not related to metabolic changes and in particular to uremia. Conclusion. These results show, in contrast to previous studies, that passive enhancement of cardiac allograft survival may be prevented by cyclosporine. This raises the possibility that cyclosporine, used in the clinical setting to prevent rejection, might also, in some cases, prevent the development of graft tolerance or.~llmnccmcllt.
S 1 39
HCV-RELATED CHRONIC CHOLESTASIS: A PBCLIKE SYNDROME DISTINCT FROM AUTOIMMUNE CHOLANGITIS ? A.Floreani, F.Zappal~i, M.Pittoni*, M.Plebani*, F.Marinosci. M.Chiaramonte. Dept. o f Gastroenterology, *Clinical Biochemistry, University o f Padova, Italy. A proportion o f chronic H C V hepatitis pts have clinical, b i o c h e m i c a l and histologic features o f cholestasis. On the other hand, a n e w s y n d r o m e o f antimitochondrial ( A M A ) negative a u t o i m m u n e cholangitis has been d e s c r i b e d (15 % o f these pts were anti-M2 positive) (1). To evaluate a possible link b e t w e e n H C V - r e l a t e d cholestasis and PBC, we tested the m a j o r M2 mitochondrial autoantigens in : a) 10 a n t i - H C V + v e PBC-like chronic cholestasis pts (all A M A - v e by IF); b) 10 A M A + v e / a n t i - H C V - v e classical PBC pts; c) 10 primary sclerosis cholangitis (PSC) pts: d) 24 a n t i - H C V + v e chronic hepatitis pts without b i o c h e m i c a l and histologic signs o f cholestasis. M E T H O D S : anti-M2 were tested by a m o d i f i e d EIA (raised cut-off) (Biorad, Italy) . R E S U L T S : anti-M2 were positive in 90% o f classical PBC pts ( m e a n titre 790 + 321 U/ml) vs 80% o f a n t i - H C V ÷ v e PBC-like chronic cholestasis pts ( m e a n titre 601 + 316 U/ml), p = n.s., while none o f PSC pts was positive. A n t i - M 2 were positive at low titres (189 +112 U/ml) in 3 (14%) pts with a n t i - H C V + v e chronic liver disease without cholestasis. C O N C L U S I O N S : Pts with a n t i - H C V + v e PBC-like chronic cholestasis had similar levels o f anti-M2 c o m p a r e d to pts with classical PBC. A cross reaction b e t w e e n anti-M2 and a n t i - H C V s e e m s to be unlikely. A n t i - H C V + v e / a n t i - M 2 + v e chronic cholestasis may be another subgroup o f the overlap s y n d r o m e o f PBC and chronic active hepatitis. I) Michieletti P. et al Gut .1994: 35:260-265.
ANTIBODIES TO EXTRACTABLE NUCLEAR ANTIGENS (ENA) IN ANTINUCLEAR ANTIBODY POSITIVE (ANA+ve) AUTOIMMUNE LIVER DISEASES (ALD) G. V. Gregorio ~, G. Mieli-Vergani~-, D. Vergani ~. ~Dept of Immunology & :Child Health, King's College School of Medicine and Dentistry, Bessemer Road, London SE5 9PJ, UK. ANA+ve connective tissue disorders (CTD) are subdivided by the presence of specific antibodies to extractable nuclear antigens (antiribonucleoprotein (anti-RNP), anti-Smith (anti-Sm), anti-Ro, anti-La). The significance of ENA in ANA+ve ALD is unknown. To determine if ANA+ve ALD can be further characterised on the basis of the ENA profile, we have tested 15 (median age:12(8-17)yrs;9 girls;median ANA titre:160(10-20480)) with autoimmnne hepatitis (AIH) and 13 (median age:ll(3-16)yrs;8 girls;ANA titre: 320(10-10240)) with sclerosing cholangitis (SC), using both the conventional double dimension immnnodiffusion (DID) and a recently established enzyme linked immunosorbent assay (ELISA). 22 (median age:34 (16-58) yrs;21 girls;ANA titre: 1280 (40-10240)) with systemic lupus erythematosus (SLE) with no liver disease were tested as controls. ENA were detected in 2 of 28 (7%) with AIH (ANA:I/40, 1/10240), -ve by DID, +ve by ELISA: 1 anti-La and 1 anti-Sm/anti-La. Neither patient had evidence of CTD nor associated AI disease and their clinical features were similar to those of ENA-ve. 12 (55%) with SLE were ENA+ve: 9 (ANA titre: 1280 (402560)), -ve by DID, +ve for at least I ENA by ELISA: 7 anti-Ro, 4 antiRNP, 2 anti-La and I anti-Sm; 1 (ANA: 1/2560) anti-RNP+ve by DID, -ve by ELISA; 1 (ANA:I/640) anti-RNP+ve by DID, reacted with an unidentified binding protein (UBP) by ELISA; and 1 (ANA:I/5120) reacted in both techniques with an UBP. As compared with ANA+ve CTD, ENA is less frequently seen in ANA+ve ALD and does not appear to be a useful diagnostic marker in the classification of ANA+ve ALD. Further studies are needed to determine the nature of the nuclear proteins in ANA+ve ALD.