PRETRANSPLANT LYMPHOCYTOTOXINS AND BONE-MARROW GRAFT REJECTION

170 tation to ascertain whether the patient responds immunologically to antigens in the transfused blood or to those in the transplanted kidney.6 In addition we should be investigating the possibility that postoperative bloodtransfusions are beneficial, say, in the first 3 months

after transplantation.. This work was supported by the Kidney Foundation of Canada, the Medical Research Council, and the Richard and Jean Ivey Fund. Miss Hilda Bruinsma gave expert secretarial assistance. REFERENCES

Dossetor, J. B., Mackinnon, K. J., Gault, M. H., et al. Transplantation, 1967, 5, suppl. p. 844. 2. Opelz, G. Lancet, 1973, i, 373. 3. Opelz, G., Mickey, M. R., Terasaki, P. I. Transplantation, 1973, 16, 649. 4. Remington, R. D., Schork, M. A. Statistics with Applications to the Biologi1.

Effect of operation-day transfusion

were’either anaemia

on

or some acute

graft survival.

cal and Health Sciences. New Jersey, 1970. 5. Asherson, G. L., Stone, S. H. Immunology, 1965, 9, 205. 6. Stiller, C. R., Sinclair, N. R., Abrahams, S., et al. New

disease--e.g., gastro-

haemorrhage or disseminated intravascular coagulopathy. Although the grafts were seemingly at intestinal

above-average risk, 1-year graft survival in this group 52%, compared with 50% in the 26 patients not transfused postoperatively. A transfusion after surgery did not significantly benefit those transfused on the day of surgery; but in patients who received no blood either on operation day or after the 1-year graft survival was only 20%. In those transfused after operation but not at operation,’ 1-year graft survival was 54%. Among those patients who never received blood, before, during, or after operation, only 1 of 11 grafts was functioning at 1 year (p <0 - 0 1).

PRETRANSPLANT LYMPHOCYTOTOXINS AND BONE-MARROW GRAFT REJECTION

In this

before

Discussion

retrospective study,

the

patients transfused

surgery were more likely than others to be trans-

fused on the day of surgery. The effect of transfusion on the day of operation may account for the variability in reported effect- of preoperative transfusion. Several centres are now investigating prospectively whether preoperative blood-transfusion increases graft survival. But if our results are confirmed the way will be open to routine transfusion of certain patients on the day of operation, thus avoiding the hazards of repeated transfusion during the waiting period on dialysis. Why should blood-transfusion be beneficial in renal transplantation? The’ effect of a transfusion given up to 5 years before ’transplantation has been hard to understand ; and explanations have included presensitisation and thus preselection--separation of responders from rion-responders.2 Our results, however, suggest that transfusion has some direct and active immunological effect. Perhaps the explanation lies in the presentation of a circulating antigen (blood-transfusion) at the same time as a sessile antigen (kidney).s The effect could be related to transplantation antigens or even red-bloodcell antigens. Alternatively, the transfusion might be responsible for immunoregulation, directed against either graft or host. We propose that the effects of transfusion at transplant operation should be assessed in clinical trials, with monitoring of the immune response after transplan-

J. H. FITCHEN

R. P. GALE M. CAHAN

was

-

Engl. J. Med. 1976,

294, 978.

G.OPELZ

M.J.CLINE FOR

THE

U.C.L.A. BONE MARROW TRANSPLANT TEAM

U.C.L.A. School of Medicine, Center for the Health Sciences, Los Angeles, California 90024, U.S.A.

A correlation bone-marrow

demonstrated between graft rejection and pretransplant lymphocytotoxins. This finding might prove useful as a test for identification of patients at high risk of rejection who might benefit from more intensive

Summary

was

immunosuppression. Introduction GRAFT rejection occurs in 30-40% of bone-marrow transplant recipients with aplastic anaemia despite cornplete HLA matching. 1-4 Bone-marrow dose, transfusions, and/or pretransplant anti-donor immunity have been reported to correlate with graft rejection, but different centres have reported conflicting results* Because of the reported negative association between prior sensitisation to HLA antigens and survival of kidney grafts9.10 we evaluated pretransplant lymphocytotoxins in 25 marrow-graft recipients with aplastic anaemia to determine whether the presence of lymphocytotoxins was predictive of marrow-graft rejection. ,

,

Patients and Methods

Recipients 25 transplant recipients with aplastic anaemia were evaluated. Criteria for entry to the study and clinical details have been reported.’ Median age was 21 years (range 5-56) and two-thirds of the patients were male. Aplasia was related to hepatitis in 6 and to drugs in 2. No cause was identified in 17. Most patients had received multiple transfusions and had failed to respond to androgens and corticosteroids. HLA and mixed-leucocyte-culture (M.L.C.) testing were performed with standard techniques.u.12 All 25 donor-recipient pairs were

171 identical for HLA and M.L.C. 22 pairs were ABO compatible or identical. 3 ABO-incompatible recipients were treated by

TABLE H—CORRELATION BETWEEN GRAFT

REJECTION

AND

LYMPHOCYTOTOXINS

plasma-exchange before transplantation. 13 Immunosuppression conditioned for transplantation with cycloalone (11 patients), total-body irradiation alone phosphamide (2 patients), or both (12 patients). Methotrexate was given after transplantation to prevent or modify graft-versus-host disease (G.V.H.D.). Graft rejection was defined as the decline of neutrophils to 0-03xl0’/l and the disappearance of morphological evidence of engraftment and of spontaneously dividing donor cells in the bone-marrow in recipients with prior evidence of engraftment surviving 28 days.

Recipients

were

TABLE !!!—CORRELATION BETWEEN GRAFT

REJECTION,

LYMPHOCYTOTOXINS, AND MARROW DOSE

In-vitro Tests

Pretransplant sera were assayed for lymphocytotoxins against a panel of 70-120 random lymphocyte donors in a standard complement-dependent microcytotoxicity assay." M.L.c. testing was done with a semi-micro method,12 and relative response indices (R.R.I.) were determined by comparing the recipient’s M.L.c. response to donor cells with his response to 2 unrelated controls. Data Analysis Data were analysed with with Yates’ correction.

a

two-tailed Fisher’s

exact test

Results

Lymphocytotoxins Pretransplant sera of 7 recipients contained lymphocytotoxins against >10% of the panel of unrelated normal peripheral-blood mononuclear cells. The mean cytotoxicity was 42% (range 11-98%). All 7 had a negative cross-match against lymphocytes from the marrow donor. Repeat testing of individual frozen sera and of sequential sera of individual patients gave consistent results.

Graft Rejection Graft rejection was

seen

in 5 of 24

patients

at

risk. 4

TABLE I-PRETRANSPLANT PARAMETERS OF LYMPHOCYTOTOXIN POSITIVE AND NEGATIVE RECIPIENTS

*Mean (range). tincludes one patient who received polymorph transfusions from the marrow

donor.

tSeetext.

of these were conditioned with cyclophosphamide alone and 1 with total-body irradiation alone. The latter received granulocyte transfusions from the donor before transplantation and had no evidence of engraftment despite two infusions of donor marrow. The 4 rejectors conditioned with cyclophosphamide alone showed initial evidence of engraftment with subsequent graft rejection. 3 died of infectious complications after unsuccessful attempts at retransplantation. The 4th patient was retransplanted from a second HLA-idential sibling after a second course of cyclophosphamide. Transient engraftment was again observed, followed by marrow aplasia and then by autologous marrow recovery." Correlation between

Prognostic Parameters

and

Graft

Rejection Characteristics of the lymphocytotoxin positive and negative groups are shown in table i. The median age of the two groups was comparable. 6 of the 7 lymphocytotoxin-positive recipients were male, whereas the male/female ratio in the lymphocytotoxin-negative group was 12/5. Most recipients in both groups had aplasia of undetermined origin, but all 5 patients with hepatitis-associated aplasia were in the lymphocytotoxin-negative group. Transfusions, sex matching, R.R.L, and marrowdose were comparable in the two groups. The relationship between the lymphocytotoxin test and graft rejection is indicated in table it. 5 of 7 recipients with positive lymphocytotoxins rejected their grafts. 4 were conditioned with cyclophosphamide and 1 with total-body irradiation. 2 patients with positive lymphocytotoxins did not reject their grafts (1 conditioned with total-body irradiation and 1 with both cyclophosphamide and total-body irradiation). Graft rejection was not observed in the 17 lymphocytotoxin-negative recipients. The correlation between lymphocytotoxins and graft rejection is highly significant (r< 0-001). Since the intensity of the immunosuppressive-conditioning regimen may influence the incidence of graft failure in-

172

dependently of lymphocytotoxins, a similar analysis was performed in 10 recipients conditioned with cyclophosphamide alone. All 4 patients with positive lymphocytotoxins rejected their grafts. Graft rejection was not observed in the 6 lymphocytotoxin-negative recipients (p=0.005). Because others have reported a correlation between marrow dose and graft rejection, a multifactorial analysis correlating lymphocytotoxins, marrow dose, and graft rejection was done (table in). These data indicate that the significant correlation between graft rejection and lymphocytotoxins could not be explained by an effect of marrow dose. In fact, no significant correlation between marrow dose and graft rejection was observed in this small series.

Discussion Our results indicate a significant correlation between graft rejection and pretransplant sensitisation to histocompatibility antigens as measured by lymphocytotoxins. The adverse effect of lymphocytotoxins was demonstrable despite complete HLA identity between donor and recipient and a negative antibody crossmatch. There was no significant correlation between transfusions and the development of lymphocytotoxins. None of the 4 minimally transfused recipients had a positive test. In our previous studies of kidney transplantation we also noted that many patients remained lym-

phocytotoxin-negative despite multiple transfusions.9-10 The most plausible explanation is that some patients are poor immunological responders. The relation between marrow dose, transfusions, and/or anti-donor immunity and graft rejection is controversial. In our series we observed no significant correlation between these factors and graft rejection. In the cohort conditioned with cyclophosphamide alone there were too few patients to determine whether the combination of positive lymphocytotoxins and a low marrow dose have an additive adverse effect. In the overall series, however, marrow dose had no significant effect on rejection. Nevertheless, since no adverse effect of high marrow doses has been reported, it is our practice to give high doses of marrow when technically feasible. Although transfusion might be expected to influence both lymphocytotoxins and graft rejection, the Seattle seriesthe U.C.L.A. series,3 and the International Bone Marrow Transplant Registry8 fail to indicate a correlation between transfusions and graft rejection. This may relate to the small number of minimally transfused

patients reported. The pathogenetic relation between lymphocytotoxins and -graft failure is unknown. Whereas the cross-match of recipient serum against donor lymphocytes was uniformly negative, cytotoxicity to donor haematopoietic stem-cells cannot be excluded. Alternatively, lymphocytotoxins may indirectly measure the inherent immune reactivity of the recipients. This relationship has been postulated in kidney transplantation, where a correlation between graft survivial and absence of lymphocytotoxins has been reported.lO Immune-reactivity (Ir) genes have been identified in rodents,16 and similar genes are believed to exist in man. The correlations between HLA and disease susceptibility, 17 malignancy,’8 response to immunisation,19 and platelet refractoriness,20 and between lymphoctotoxins and kidney-graft survival9·lo have been interpreted as indirected evidence for human

Ir genes. might be survival.

Clearly, the differences in immune reactivity expected to have a significant effect on graft

This work was supported by grants CA-12800, CA-15688, and RR00865 from the National Institutes of Health and U.S. Public Health Service. R.P.G. is a Scholar of the Leukemia Society of America.

Requests for reprints should be addressed to R. P. G., U.C.L.A. Bone-Marrow Transplant Unit, School of Medicine, Center for the Health Sciences, Los Angeles, California 90024, U.S.A. REFERENCES 1. Storb, R., Thomas, E. D., Buckner, C. D., et al. Blood, 1975, 43, 157. 2. Storb, R., Thomas, E. D., Weiden, P. L., et al. Blood, 1976, 48, 817. 3. U.C.L.A. Bone Marrow Transplant Team, Lancet, 1976, ii, 921. 4. Camitta, B. M., Thomas, E. D., Nathan, D. G., Santos, G., Gordon-Smith, E. C., Gale, R. P., Rappeport, J. M., Storb, R. Blood, 1976, 48, 63. 5. Mickelson, E. M., Fefer, A., Storb, R., Thomas, E. D. Transplantation,

6.

1976, 22, 294. Warren, R. P., Storb, R., Weiden, P. L., Mickelson, E. M., Thomas, E. D.

ibid. p. 631.

7. Storb, R., Prentice, R. L., Thomas, E. D. New Engl. J. Med. 1977, 296, 61. 8. Report for the A.C.S./N.I.H. Bone Marrow Transplant Registry, J. Am. med. Ass. 1976, 236, 1131. 9. Patel, R., Terasaki, P. I. New Engl. J. Med. 1969, 280, 735. 10. Opelz, G., Mickev, M. R., Terasaki, P. I. Lancet, 1972, i, 868. 11. Mittal, K. K., Mickey, M. R., Singal, D. P., Terasaki, P. I. Transplantation,

1968, 6, 913.

Sengar, D. P. S., Terasaki, P. I. ibid. 1971, 11, 260. Gale, R. P., Feig, S. A., Ho, W., Falk, P., Rippee, C., Sparkes, R. S. Blood, 1977, 50, 185. 14. Mittal, K. K., Mickey, M. R., Singal, D. P., Terasaki, P. I. Transplantation, 1968, 6, 913. 15. Territo, M. C., for the U.C.L.A. Bone Marrow Transplant Team, Br. J. Hœmat. 1977, 36, 305. 16. Benacerraf, B., McDevitt, H. O. Science, 1972, 195, 273. 17. Dausset, J., Svejgaard, A. (editors) First International Symposium on HLA 12. 13.

and Diseases. INSERM, Paris, 1976. 18. Murphy, G. P. (editor) HLA and Malignancy. New York, 1977. 19. De Vries, P. J., Kreeftenberg, C. E., Loggen, H. G., van Rood, Engl. J. Med. 1977, 297, 692. 20. Duguesnoy, R., Filip, D. J., Aster, R. H. Blood, 1977, 50, 407.

J. J.

New

PRESSOR AMINES AND MONOAMINE-OXIDASE INHIBITORS FOR TREATMENT OF POSTURAL HYPOTENSION IN AUTONOMIC FAILURE Limitations and Hazards BLEDDYN DAVIES ROGER BANNISTER PETER SEVER

Department of Neurology and Medical Unit, St. Mary’s

Hospital, London

W2

The short-term effects of pressor amines were investigated in four patients with postural hypotension caused by autonomic failure. In supine patients p-tyramine alone or with a monoamineoxidase inhibitor produced pronounced supine hypertension without abolishing the symptoms associated with a postural fall in blood-pressure. Phenylephrine or ephedrine maintained a normal blood-pressure on standing but caused supine hypertension. Thus the effects of p-tyramine with or without a monoamine-oxidase inhibitor were unpredictable and did not include relief of postural hypotension. Phenylephrine or ephedrine had some beneficial effect, but since all these drugs influence standing pressure only at the expense of pronounced supine hypertension, alternative therapy must be

Summary

sought.