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ELISA IN HEPATITIS A
823 SUSCEPTIBILITY TO DIPHTHERIA
SCREENING FOR ANÆMIA
is
major health problem in developing SiR,—Anaemia in countries, especially preschool children and during pregof the Since 80% population live in rural areas a nancy. screening test for anaemia has to be cheap, acceptable to the community, and simple enough to be used by a village health worker after a short period of training. We have assessed the detection of anaemia by comparison of the colours of tongue, lower lip, and nails with appearance on an anaemia recognition card (produced by the Voluntary Health Association of India and supplied by UNICEF). The card has a picture of an anxmic person on one side and a normal one on the other, both emphasising the colour of tongue, lower lip, and nails. There were 568 children (453 below six years and 115 between six and fourteen years), 207 adults, and 151 pregnant mothers. The identification was done by four field workers to eliminate personal bias and to make the study more broadly based. These health workers were educated and had some training in the basic health care. The identification was done in a room with adequate daylight and also in a room with daylight and a tube light. The results were compared with haemoglobin values determined by cyanmethaemoglobin method. 100% of patients below 6 g Hb/dl and two-thirds of those between 6 and 9 g/dl were correctly identified. The figures for three health workers varied from 66% to 72%; the fourth worker identified almost 80% correctly. About 80% of children with an Hb of more than 11 g/dl were identified correctly as non-anaemic but in the adults there was a wrong assessment in about 25-30% of cases. The difference was probably due to discoloration of tongue and lips with tobacco and betel leaf in adults. Half of the patients with Hb values of 9-11 g/dl were correctly identified. Every screening method hassome drawbacks, but the important finding here is that most patients with Hb values below 9 g/dl were easily identified. The anaemia recognition card can be used as a screening method for detecting moderate to severe anaemia in a population where medical facilities are scarce. In India the village level workers trained for the Integrated Child Development Services as well as the community health workers could do this job. Department of Paediatrics, Safdarjang Hospital,
SHANTI GHOSH MAN MOHAN
New Delhi-110016, India
CAROTID PAIN
SiR,—The syndrome of pain and tenderness of the carotid artery described by Professor Bank (April 1, p. 726) is neither new nor uncommon. It is in the French literature as syndrome doloureux de la fourche carotidiennel and the syndrome is
recognised in Anglo-American journals,2-4 though it is generally ignored in medical textbooks. The syndrome of idiopathic carotid pain is not rare; single authors have described five4 six,2,5 or a dozen cases. The term "carotiditis" is inappropriate because the sedimentation-rate and leucocyte-count are normal. The association with psychoneurosis has often been noted, and the à deux form in both husband and wife was also described.6 The condition is self-limiting, and reassurance is the most important part of treatment. Mater Misericordiæ Dublin, Ireland 1. 2.
SiR,-The report of the Ad-hoc Working Group (Feb. 25,
a
Hospital,
Truffert, P. Mém. Acad. Chir. 1948, 74, 322. Davies, J. V. S. A. Br. med. J. 1961, ii, 1528. 3. Green, G. F. Practitioner, 1966, 196, 562. 4. Hilger, J. A. Laryngoscope St. Louis, 1949, 59, 829. 5. Kern, W. A. Archs intern. Med. 1974, 80, 417. 6. Allison, J. Br. med. J. 1961, ii, 1709.
PETR SKRABANEK
428) indicating the susceptibility of various age-groups to diphtheria prompted me to extract from my records the results
p.
of the Schick
tests
which I did
on
the trainee
nurses at
the
Royal Infirmary, Cardiff, during the years 1955-73. With a few exceptions, those tested were in the 18-24 age-group. Of 2148 nurses tested 370 (17.2%) were Schick positive, and all were offered immunisation. The percentage is slightly lower than that noted by the working-group in their 15-24 agegroup. Because of my findings in earlier years I have taught medical students for the past two decades that roughly a fifth of 20-year-olds in the U.K. are, in all probability, susceptible to
diphtheria. In South Glamorgan our immunisation policy is that all Schick positive medical, dental, nursing, laboratory, domestic, and laundry hospital personnel should be offered immunisation against diphtheria. Department of Medical Microbiology, Royal Infirmary, Cardiff CF2 1SZ
R. A. HOLMAN
ELISA IN HEPATITIS A
SIR,-We have developed a sensitive, rapid, and simple enzyme-linked immunosorbent assay’2 (ELISA) for the detection of both hepatitis A virus antigen (H.A.V.) and anti-H.A.V. antibody. The assay is more efficient than immunoelectronmicroscopy and is comparable in sensitivity to radioimmunoassay. H.A.V. is bound to anti-H.A.v. coated wells of polyvinylchloride or polystyrene microtitre plates. Horseradish peroxidase-coupled anti-H.A.v. (conjugate)3 is then allowed to react with the bound H.A.v. A mixture of o-phenylenediamine and urea peroxide is used as enzyme substrate, giving a colour reaction observable by the naked eye or measurable in a spectrophotometer at 492 nm. A human
serum with an anti-H.A.v. titre of 1:400 000 in our used for both coating and conjugate. H.A.V. was detected in 20% faecal extracts prepared by shaking the fmcal sample in 0.01 mol/1 phosphate-buffered saline (pH 7-2) and trichlorotrifluoroethane, and centrifuging at low speed (30 min, 3000 g). Samples with extinctions 0-11 were presumed to be positive and, to confirm this, blocking assays with positive and negative sera from humans or from a chimpanzee (N.I.A.I.D., Bethesda, reference serum no. V811-501-573) were done; samples were regarded as positive if the ratio of the extinctions of the sample incubated with negative serum (no blocking) and positive serum (blocking) was 2. Anti-H.A.v. antibodies in test sera were detected by their blocking of the reaction of antigen and conjugate. Their titre was defined as the dilution giving a 50% colour inhibition compared to the negative control. The assay procedure of both tests was based on a radioimmunoassay for H..v. and anti-H.A.v. described by Purcell et al.,4 and will be described in more detail elsewhere. 20 coded faecal samples were tested for H.A.v. by radioimmunoassay (Dr G. Frosner, Max. von Pettenkofer Institute, Munich) and in our ELISA. 6 samples were positive and 14
test was
negative in both tests. During an outbreak of hepatitis A in an institution for mentally retarded children in Holland, H.A.V. could be detected by ELISA in the faeces of several patients from 2 weeks before until 2 weeks after the onset of jaundice. With the anti-H.A.v. ELISA a number of patients became seropositive some days before jaundice began. These results accord with those of Frösner.5 In 1. Van Weemen, B. K., Schuurs, A. H. W. M. F.E.B.S. Lett. 1971, 15, 232. 2. Engvall, E., Perlman, P. Immunochemistry, 1971, 8, 871. 3. Nakane, P. K., Kawaoi, A. J. Histochem. Cytochem. 1974, 22, 1084. 4. Purcell, R. H., Wong, D. C., Moritsugu, Y., Dienstage, J. L., Routenberg, J. A., Boggs, J. D. J. Immun. 1976,116, 349. 5. Frösner, G. G. Münch. med. Wschr. 1977, 119, 825.
824 INHIBITION OF LYMPHOCYTE-P.P.D. REACTIVITY BY PLASMA
anti-H.A.v. ELISA, titres up to 1 :2x106 were found in a strongly positive serum from a patient a few months after jaundice. Chimpanzee convalescent serum (no. V811-501-573 from N.I.A.I.D.) was used as a control and had a titre in our ELISA of 1:8000. Commercial human immune-serum-globulin preparations had anti-H.A.v. titres of about 1:100 000. In seronegative people given a prophylactic dose of such a preparation, seroconversion was found, with anti-H.A.v. titres ranging our
from 1:20 to 1:40. 500 blood-donor sera obtained from Dr H. Reesink (Central Laboratory of the Blood Transfusion Service, Amsterdam) were tested for anti-H.A.v. in our ELISA and in radioimmunoassay by Dr G. Frosner; 52% were positive in both tests. The anti-H.A.v. incidence was correlated with age, up to 80% for donors aged 40-50 years. WILLEM DUERMEYER Organon Scientific Development Group, JOKE VAN DER VEEN P.O. Box 20, BERNARD KOSTER Oss, Netherlands
BLOOD-TRANSFUSION AND RENAL TRANSPLANTATION
SIR,-A number of reports, including two from this centre, show improved survival of renal grafts in patients given bloodtransfusions before transplantation.-’ Earlier we found that lymphocyte reactivity to purified protein derivation (P.P.D.) of Mycobacterium tuberculosis was diminished in patients who had received multiple blood-transfusions5 and we have now titrated the lymphocyte-depressing factor6in the plasma of patients with chronic renal failure who were in end-stage renal failure. To examine the effect of plasma from transfused patients on lymphocyte-antigen reaction we used the tanned erythrocyte electrophoretic mobility (T.E.E.M.) test’ which has been used successfully in a number of laboratories to assess lymphocyte sensitisation.8-11 The interaction between sensitised lymphocytes and P.P.D. generates a factor which slows the mobility of tanned erythrocytes in an electric field" determined as in the
macrophage electrophoretic mobility test. Lymphocytes were incubated for 30 min with dilutions of test plasma before the addition of P.P.D. and the dilution of plasma producing 50% inhibition of lymphocyte-p.p.D. response was determined by extrapolation from the graphically expressed results. All test plasmas were examined in this way and the mean ±1 S.D. was calculated for each group of patients studied (see table). Normal plasma partially inhibited lymphocyte-p.p.D. reactivity (also described by Field12) but a significantly greater inhibitory activity was found in plasma from multitransfused renal patients (see table). These results suggest that multiple blood transfusions may reduce the lymphocyte response to specific antigen and may generally suppress lymphocyte reactivity.’3 The suppressive factors in plasma have yet to be fully characterised but our initial findings suggest that both macroglobulins and immunoglobins are involved. The beneficial 1.
Murray, S., Dewar, P. J., Uldall, P. R., Wilkinson, R., Kerr, D. N. S., Taylor, R. M. R., Swinney, J. Tissue Antigens, 1974, 4, 548. 2. Opelz, G., Terasaki, P. I. Dialy. Transplant. 1977, 6, 46. 3. Uldall, P. R., Wilkinson, R., Dewar, P. J., Murray, S., Morley, A., Baxby, K., Hall, R. R., Taylor, R. M. R. Lancet, 1977, i, 316. 4. Blarney, R. W., Knapp, M. S., Burden, R. P., Salisbury, M. Br. med. J. 1978, i, 138. K., Uldall, P. R., Swinney, J., Field, E. J. I.R.C.S. Med. Sci.
5. Shenton, B.
1974, 8, 1564. Field, E. J., Caspary, E. A. Br. J. Cancer, 1972,26, 164. Porzsolt, F., Tautz, R., Schmidtberger, R., Ax, W. Z. Immunitatsforsch. 1974, 147, 352. 8. Lampert, F., Nitsche, U., Zwergel, T., Abiodun, P. Lancet, 1977, ii, 141. 9. Douwes, F. R., Hutteman, U., Mross, K. Dt. med. Wschr. 1977, 102, 419. 10. Jenssen, H. L., Shenton, B. K. Acta biol. med. germ. 1975, 34, 29. 11. Shenton, B. K., Jenssen, H. L., Werner, H., Field, E. J. J. immun. Methods, 1977, 14, 123. 12. Field, E. J., Caspary, E. A. Lancet, 1971, i, 95. 13. Sengar, D. P. S., Opelz, G., Terasaki, P. I. Transplant. Proc. 1973, 5, 641. 6. 7.
* One transfusion comprised one unit of blood or packed cells. In t tests, differences between all groups except between multiply transfused renal
significant (r=0001) patients and haamophiliacs
were
(p=0.165). effects of transfusion may derive from the suppression of developing lymphocyte sensitisation after transplantation. We have found the T.E.E.M. test to be reproducible in blind studies; tanned erythrocytes are homogeneous indicator particles, the investigation is complete in less than 4 h and is therefore suitable for both clinical and experimental investigations. B. K. SHENTON Department of Surgery, Royal Victoria Infirmary, Newcastle upon Tyne NE1
CIMETIDINE
4LP
G. PROUD B. M. SMITH R. M. R. TAYLOR
AND RENAL-ALLOGRAFT REJECTION
SiR,-Cimetidine is effective in the treatment! and prevention2 of stress ulcer. In our experience with forty-six cadaveric renal transplants in children, stress ulcers developed in three with fatal outcome in two, a frequency and mortality similar to those reported in adults.’ The use of cimetidine for treatment of stress ulcers or prophylactically in kidney transplant recipients thus seemed attractive. Our group gave cimetidine to two consecutive children after renal transplantation. Both had severe, irreversible graft rejections 4-5 days after the introduction of this drug. The similarity in timing and severity of these rejection episodes suggest an association with the cimetidine therapy. Perhaps this is the clinical manifestation4.5 of the immunological disturbances caused by histamine Hz receptor antagonists. The first case was a 13-year-old, 32 kg, girl with a stress ulcer 13 days after renal transplantation. Her course had been uncomplicated until this episode. She was receiving prednisone 2 mg/kg daily and had a serum-creatinine of 0.9 mg/dl. Intermittent bleeding persisted despite anatacids and saline lavage. On day 17, when the administration of cimetidine, 150 mg every 6 h intravenously was started, her serum-creatinine was 0-83 mg/dl. On day 21, urine volume dropped precipitously, and creatinine clearance fell from 45.0 to 12.0 ml/min. 2 days later, despite anti-rejection therapy, creatinine clearance was below 2 ml/min and never improved. Bleeding continued, and the child died from complications associated with the stress ulcer. Because of this experience, the next transplant patient, a 5-year-old, 11 kg boy, was put on cimetidine 150 mg every 12 h intravenously as prophylaxis at the time of the transplant. He had good early graft function with a creatinine clearance of 20 ml/min by day 4. During day 5, severe oliguria developed without evidence of obstruction or major vessel thrombosis, and creatinine clearance plummeted to 3 ml/min. The immunological characteristics of allograft rejection are 1. 2. 3. 4. 5.
MacDonald, A. S., Steele, B. J., Bottomley, M. G. Lancet, 1977, i, 68. MacDougall, B. R. D., Bailey, R. J., Williams, R. ibid. p. 617. Moore, T. C., Hume, D. M. Ann. Surg. 1969, 170,1 Malagelada, J. R., Cortot, A. Mayo Clin. Proc. 1978, 53, 184. Moulias, R., Congy, F. Nouv. Presse méd. 1976, 5, 149.
SCREENING FOR ANÆMIA
is
major health problem in developing SiR,—Anaemia in countries, especially preschool children and during pregof the Since 80% population live in rural areas a nancy. screening test for anaemia has to be cheap, acceptable to the community, and simple enough to be used by a village health worker after a short period of training. We have assessed the detection of anaemia by comparison of the colours of tongue, lower lip, and nails with appearance on an anaemia recognition card (produced by the Voluntary Health Association of India and supplied by UNICEF). The card has a picture of an anxmic person on one side and a normal one on the other, both emphasising the colour of tongue, lower lip, and nails. There were 568 children (453 below six years and 115 between six and fourteen years), 207 adults, and 151 pregnant mothers. The identification was done by four field workers to eliminate personal bias and to make the study more broadly based. These health workers were educated and had some training in the basic health care. The identification was done in a room with adequate daylight and also in a room with daylight and a tube light. The results were compared with haemoglobin values determined by cyanmethaemoglobin method. 100% of patients below 6 g Hb/dl and two-thirds of those between 6 and 9 g/dl were correctly identified. The figures for three health workers varied from 66% to 72%; the fourth worker identified almost 80% correctly. About 80% of children with an Hb of more than 11 g/dl were identified correctly as non-anaemic but in the adults there was a wrong assessment in about 25-30% of cases. The difference was probably due to discoloration of tongue and lips with tobacco and betel leaf in adults. Half of the patients with Hb values of 9-11 g/dl were correctly identified. Every screening method hassome drawbacks, but the important finding here is that most patients with Hb values below 9 g/dl were easily identified. The anaemia recognition card can be used as a screening method for detecting moderate to severe anaemia in a population where medical facilities are scarce. In India the village level workers trained for the Integrated Child Development Services as well as the community health workers could do this job. Department of Paediatrics, Safdarjang Hospital,
SHANTI GHOSH MAN MOHAN
New Delhi-110016, India
CAROTID PAIN
SiR,—The syndrome of pain and tenderness of the carotid artery described by Professor Bank (April 1, p. 726) is neither new nor uncommon. It is in the French literature as syndrome doloureux de la fourche carotidiennel and the syndrome is
recognised in Anglo-American journals,2-4 though it is generally ignored in medical textbooks. The syndrome of idiopathic carotid pain is not rare; single authors have described five4 six,2,5 or a dozen cases. The term "carotiditis" is inappropriate because the sedimentation-rate and leucocyte-count are normal. The association with psychoneurosis has often been noted, and the à deux form in both husband and wife was also described.6 The condition is self-limiting, and reassurance is the most important part of treatment. Mater Misericordiæ Dublin, Ireland 1. 2.
SiR,-The report of the Ad-hoc Working Group (Feb. 25,
a
Hospital,
Truffert, P. Mém. Acad. Chir. 1948, 74, 322. Davies, J. V. S. A. Br. med. J. 1961, ii, 1528. 3. Green, G. F. Practitioner, 1966, 196, 562. 4. Hilger, J. A. Laryngoscope St. Louis, 1949, 59, 829. 5. Kern, W. A. Archs intern. Med. 1974, 80, 417. 6. Allison, J. Br. med. J. 1961, ii, 1709.
PETR SKRABANEK
428) indicating the susceptibility of various age-groups to diphtheria prompted me to extract from my records the results
p.
of the Schick
tests
which I did
on
the trainee
nurses at
the
Royal Infirmary, Cardiff, during the years 1955-73. With a few exceptions, those tested were in the 18-24 age-group. Of 2148 nurses tested 370 (17.2%) were Schick positive, and all were offered immunisation. The percentage is slightly lower than that noted by the working-group in their 15-24 agegroup. Because of my findings in earlier years I have taught medical students for the past two decades that roughly a fifth of 20-year-olds in the U.K. are, in all probability, susceptible to
diphtheria. In South Glamorgan our immunisation policy is that all Schick positive medical, dental, nursing, laboratory, domestic, and laundry hospital personnel should be offered immunisation against diphtheria. Department of Medical Microbiology, Royal Infirmary, Cardiff CF2 1SZ
R. A. HOLMAN
ELISA IN HEPATITIS A
SIR,-We have developed a sensitive, rapid, and simple enzyme-linked immunosorbent assay’2 (ELISA) for the detection of both hepatitis A virus antigen (H.A.V.) and anti-H.A.V. antibody. The assay is more efficient than immunoelectronmicroscopy and is comparable in sensitivity to radioimmunoassay. H.A.V. is bound to anti-H.A.v. coated wells of polyvinylchloride or polystyrene microtitre plates. Horseradish peroxidase-coupled anti-H.A.v. (conjugate)3 is then allowed to react with the bound H.A.v. A mixture of o-phenylenediamine and urea peroxide is used as enzyme substrate, giving a colour reaction observable by the naked eye or measurable in a spectrophotometer at 492 nm. A human
serum with an anti-H.A.v. titre of 1:400 000 in our used for both coating and conjugate. H.A.V. was detected in 20% faecal extracts prepared by shaking the fmcal sample in 0.01 mol/1 phosphate-buffered saline (pH 7-2) and trichlorotrifluoroethane, and centrifuging at low speed (30 min, 3000 g). Samples with extinctions 0-11 were presumed to be positive and, to confirm this, blocking assays with positive and negative sera from humans or from a chimpanzee (N.I.A.I.D., Bethesda, reference serum no. V811-501-573) were done; samples were regarded as positive if the ratio of the extinctions of the sample incubated with negative serum (no blocking) and positive serum (blocking) was 2. Anti-H.A.v. antibodies in test sera were detected by their blocking of the reaction of antigen and conjugate. Their titre was defined as the dilution giving a 50% colour inhibition compared to the negative control. The assay procedure of both tests was based on a radioimmunoassay for H..v. and anti-H.A.v. described by Purcell et al.,4 and will be described in more detail elsewhere. 20 coded faecal samples were tested for H.A.v. by radioimmunoassay (Dr G. Frosner, Max. von Pettenkofer Institute, Munich) and in our ELISA. 6 samples were positive and 14
test was
negative in both tests. During an outbreak of hepatitis A in an institution for mentally retarded children in Holland, H.A.V. could be detected by ELISA in the faeces of several patients from 2 weeks before until 2 weeks after the onset of jaundice. With the anti-H.A.v. ELISA a number of patients became seropositive some days before jaundice began. These results accord with those of Frösner.5 In 1. Van Weemen, B. K., Schuurs, A. H. W. M. F.E.B.S. Lett. 1971, 15, 232. 2. Engvall, E., Perlman, P. Immunochemistry, 1971, 8, 871. 3. Nakane, P. K., Kawaoi, A. J. Histochem. Cytochem. 1974, 22, 1084. 4. Purcell, R. H., Wong, D. C., Moritsugu, Y., Dienstage, J. L., Routenberg, J. A., Boggs, J. D. J. Immun. 1976,116, 349. 5. Frösner, G. G. Münch. med. Wschr. 1977, 119, 825.
824 INHIBITION OF LYMPHOCYTE-P.P.D. REACTIVITY BY PLASMA
anti-H.A.v. ELISA, titres up to 1 :2x106 were found in a strongly positive serum from a patient a few months after jaundice. Chimpanzee convalescent serum (no. V811-501-573 from N.I.A.I.D.) was used as a control and had a titre in our ELISA of 1:8000. Commercial human immune-serum-globulin preparations had anti-H.A.v. titres of about 1:100 000. In seronegative people given a prophylactic dose of such a preparation, seroconversion was found, with anti-H.A.v. titres ranging our
from 1:20 to 1:40. 500 blood-donor sera obtained from Dr H. Reesink (Central Laboratory of the Blood Transfusion Service, Amsterdam) were tested for anti-H.A.v. in our ELISA and in radioimmunoassay by Dr G. Frosner; 52% were positive in both tests. The anti-H.A.v. incidence was correlated with age, up to 80% for donors aged 40-50 years. WILLEM DUERMEYER Organon Scientific Development Group, JOKE VAN DER VEEN P.O. Box 20, BERNARD KOSTER Oss, Netherlands
BLOOD-TRANSFUSION AND RENAL TRANSPLANTATION
SIR,-A number of reports, including two from this centre, show improved survival of renal grafts in patients given bloodtransfusions before transplantation.-’ Earlier we found that lymphocyte reactivity to purified protein derivation (P.P.D.) of Mycobacterium tuberculosis was diminished in patients who had received multiple blood-transfusions5 and we have now titrated the lymphocyte-depressing factor6in the plasma of patients with chronic renal failure who were in end-stage renal failure. To examine the effect of plasma from transfused patients on lymphocyte-antigen reaction we used the tanned erythrocyte electrophoretic mobility (T.E.E.M.) test’ which has been used successfully in a number of laboratories to assess lymphocyte sensitisation.8-11 The interaction between sensitised lymphocytes and P.P.D. generates a factor which slows the mobility of tanned erythrocytes in an electric field" determined as in the
macrophage electrophoretic mobility test. Lymphocytes were incubated for 30 min with dilutions of test plasma before the addition of P.P.D. and the dilution of plasma producing 50% inhibition of lymphocyte-p.p.D. response was determined by extrapolation from the graphically expressed results. All test plasmas were examined in this way and the mean ±1 S.D. was calculated for each group of patients studied (see table). Normal plasma partially inhibited lymphocyte-p.p.D. reactivity (also described by Field12) but a significantly greater inhibitory activity was found in plasma from multitransfused renal patients (see table). These results suggest that multiple blood transfusions may reduce the lymphocyte response to specific antigen and may generally suppress lymphocyte reactivity.’3 The suppressive factors in plasma have yet to be fully characterised but our initial findings suggest that both macroglobulins and immunoglobins are involved. The beneficial 1.
Murray, S., Dewar, P. J., Uldall, P. R., Wilkinson, R., Kerr, D. N. S., Taylor, R. M. R., Swinney, J. Tissue Antigens, 1974, 4, 548. 2. Opelz, G., Terasaki, P. I. Dialy. Transplant. 1977, 6, 46. 3. Uldall, P. R., Wilkinson, R., Dewar, P. J., Murray, S., Morley, A., Baxby, K., Hall, R. R., Taylor, R. M. R. Lancet, 1977, i, 316. 4. Blarney, R. W., Knapp, M. S., Burden, R. P., Salisbury, M. Br. med. J. 1978, i, 138. K., Uldall, P. R., Swinney, J., Field, E. J. I.R.C.S. Med. Sci.
5. Shenton, B.
1974, 8, 1564. Field, E. J., Caspary, E. A. Br. J. Cancer, 1972,26, 164. Porzsolt, F., Tautz, R., Schmidtberger, R., Ax, W. Z. Immunitatsforsch. 1974, 147, 352. 8. Lampert, F., Nitsche, U., Zwergel, T., Abiodun, P. Lancet, 1977, ii, 141. 9. Douwes, F. R., Hutteman, U., Mross, K. Dt. med. Wschr. 1977, 102, 419. 10. Jenssen, H. L., Shenton, B. K. Acta biol. med. germ. 1975, 34, 29. 11. Shenton, B. K., Jenssen, H. L., Werner, H., Field, E. J. J. immun. Methods, 1977, 14, 123. 12. Field, E. J., Caspary, E. A. Lancet, 1971, i, 95. 13. Sengar, D. P. S., Opelz, G., Terasaki, P. I. Transplant. Proc. 1973, 5, 641. 6. 7.
* One transfusion comprised one unit of blood or packed cells. In t tests, differences between all groups except between multiply transfused renal
significant (r=0001) patients and haamophiliacs
were
(p=0.165). effects of transfusion may derive from the suppression of developing lymphocyte sensitisation after transplantation. We have found the T.E.E.M. test to be reproducible in blind studies; tanned erythrocytes are homogeneous indicator particles, the investigation is complete in less than 4 h and is therefore suitable for both clinical and experimental investigations. B. K. SHENTON Department of Surgery, Royal Victoria Infirmary, Newcastle upon Tyne NE1
CIMETIDINE
4LP
G. PROUD B. M. SMITH R. M. R. TAYLOR
AND RENAL-ALLOGRAFT REJECTION
SiR,-Cimetidine is effective in the treatment! and prevention2 of stress ulcer. In our experience with forty-six cadaveric renal transplants in children, stress ulcers developed in three with fatal outcome in two, a frequency and mortality similar to those reported in adults.’ The use of cimetidine for treatment of stress ulcers or prophylactically in kidney transplant recipients thus seemed attractive. Our group gave cimetidine to two consecutive children after renal transplantation. Both had severe, irreversible graft rejections 4-5 days after the introduction of this drug. The similarity in timing and severity of these rejection episodes suggest an association with the cimetidine therapy. Perhaps this is the clinical manifestation4.5 of the immunological disturbances caused by histamine Hz receptor antagonists. The first case was a 13-year-old, 32 kg, girl with a stress ulcer 13 days after renal transplantation. Her course had been uncomplicated until this episode. She was receiving prednisone 2 mg/kg daily and had a serum-creatinine of 0.9 mg/dl. Intermittent bleeding persisted despite anatacids and saline lavage. On day 17, when the administration of cimetidine, 150 mg every 6 h intravenously was started, her serum-creatinine was 0-83 mg/dl. On day 21, urine volume dropped precipitously, and creatinine clearance fell from 45.0 to 12.0 ml/min. 2 days later, despite anti-rejection therapy, creatinine clearance was below 2 ml/min and never improved. Bleeding continued, and the child died from complications associated with the stress ulcer. Because of this experience, the next transplant patient, a 5-year-old, 11 kg boy, was put on cimetidine 150 mg every 12 h intravenously as prophylaxis at the time of the transplant. He had good early graft function with a creatinine clearance of 20 ml/min by day 4. During day 5, severe oliguria developed without evidence of obstruction or major vessel thrombosis, and creatinine clearance plummeted to 3 ml/min. The immunological characteristics of allograft rejection are 1. 2. 3. 4. 5.
MacDonald, A. S., Steele, B. J., Bottomley, M. G. Lancet, 1977, i, 68. MacDougall, B. R. D., Bailey, R. J., Williams, R. ibid. p. 617. Moore, T. C., Hume, D. M. Ann. Surg. 1969, 170,1 Malagelada, J. R., Cortot, A. Mayo Clin. Proc. 1978, 53, 184. Moulias, R., Congy, F. Nouv. Presse méd. 1976, 5, 149.