RENAL TRANSPLANTATION AND A POSITIVE SEROLOGICAL CROSS-MATCH

1288 to measure blood-glucose and plasma-insulin levels and social behaviour during the subsequent 5 hours. Genuine mixers were used to dilute the alcohol, since these are generally made up with sucrose (or saccharin) rather than glucose itself. Moreover, they are carbonated, which makes them more palatable and possibly more readily assimilable, and they have a low pH, which accelerates the rate of disposal of an oral glucose load. The total amount of drink consumed was equivalent to roughly three double measures of gin and tonic. This is not inconsistent with normal lunchtime intake, though possibly less common than a mixture of drink and "nibbles". These mostly provide rapidly assimilable carbohydrate and might, therefore, be expected to exaggerate the tendency to reactive hypoglycsemia, which increases with the size of the carbohydrate load. This possibility is now being explored. Our results indicate that a combination of sucrose and alcohol gives a more severe hypoglycaemic "overswing" than does sugar alone and this appears to be due to the greater insulin response to G.T. than to T alone.8.1O-12 The hyperinsulinxmia provoked by alcohol has been attribute’"’" to a direct priming effect of alcohol on the beta-cells, making them more susceptible to the insulinstimulatory effect of glucose and other insulinotropic agents, alcohol having no immediate stimulatory effect in its own right. An alternative, and in our opinion more likely, explanation for the observation made in the present study is that alcohol stimulates the release of one or more of the several intestinal insulin-releasing polypeptides that augment glucose-stimulated insulin secretion but which do not themselves stimulate insulin secretion except in the presence of mild-to-moderate hyperglycaemia. In this context it is interesting that Straus et al.l3 have shown that alcohol, like low pH, can stimulate the release of secretin, a known augmentor of glucose-mediated insulin release. The correlation of mood change with periods of maximum rise and fall of blood-glucose was noteworthy during the G.T. study. A pleasant feeling of inebriation was usually experienced an hour after beginning to drink, when blood-glucose was at its highest value. However, in a few cases in which the alcohol peak occurred after the blood-glucose level had already begun to fall, the subjects became relatively depressed and even experienced grief reactions. There is no completely satisfactory and universally accepted definition of hypoglycsemia. Most investigators have accepted that different criteria may have to be applied to fasting and non-fasting individuals,4 especially since there is evidence14 that in non-fasting subjects the rate of fall in blood-glucose concentration, as well as its absolute level, determines the risk of neuroglycopenic symptoms. These are uncommon when blood-glucose levels exceed 3.0 mmol/1 but become increasingly frequent as blood-glucose levels fall below 2.5mmol/l. Since neuroglycopenia, like alcoholic intoxication, can seriously impair intellectual activity and judgement,15the ability of alcoholic drinks, sweetened with sugar, to produce a reactive hypoglycaemia of 2-55 mmol/1 or less within 3-4 hr in 4 out of 10 normal subjects is clearly of medical, social, and economic importance.

Ingesting

the

same amount

of

alcohol, but without

additional sugar or going without food altogether, is not associated with the same risk of developing hypoglycxmia. Since very few people know the alcohol content of their drinks, let alone their carbohydrate content, our observations are potentially of concern, not least to those involved with motor-car and other aspects of

safety. We should like to thank Dr John Wright and members of the investigation unit and clinical biochemistry department of St. Luke’s Hospital, Guildford, for technical help and the Clinical Biochemistry Fund, University of Surrey, for financial support.

Requests for reprints should be addressed to V. M., Department of Biochemistry, University of Surrey, Guildford, Surrey GU2 5XH. REFERENCES

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Folin, O., Berglund, H. J. biol. Chem. 1922, 51, 213. Jung, Y., Khurana, R. C., Corredor, D. G. et al. Diabetes, 1971, 20, 428. Fariss, B. L. ibid. 1974, 23, 189. Marks, V. Hypoglycemia. Horm. metab. Res. Suppl. Ser. 1976, 6, l. Freinkel, N., Arky, R. A. Psychosom. Med. 1966, 28, 551 Madison, L. Adv. metab. Disorders, 1968, 3, 85. Marks, V., Wright, J. W. Proc. R. Soc. Med. (in the press). Dornhorst, A., Ouyang, A. Lancet, 1971, ii, 957. Phillips, G. B., Safrit, H. F. J. Am. med. Ass. 1971, 217, 1513. Friedenberg, R., Metz, R., Mako, M., Surmaczynska, B. Diabetes, 1971, 20, 397.

Nikkilä, E. A., Taskinen, M.-R. ibid. 1975, 24, 933. Kühl, C., Andersen, O., Jensen, S. L., Nielsen, O. V. ibid. 1976, 25, 752. 13. Straus, E., Urbach, H.-J., Yalow, R. S. New Engl. J. Med. 1975, 293, 1031. 14. Cole, R. A., Benedict, G. W., Margolis, S., Kowarski, A. Diabetes, 1976, 25, 11. 12.

984. 15.

Marks, V., Rose, F. C. Hypoglycæmia. Oxford, 1965.

RENAL TRANSPLANTATION AND A POSITIVE SEROLOGICAL CROSS-MATCH A. TING M. BISHOP M. S. DUNNILL

P. J. MORRIS D. O. OLIVER K. WILLIAMS

Nuffield Department of Surgery, Department of Pathology, and Transplant Unit, University of Oxford, Radcliffe Infirmary and Churchill Hospital, Oxford A renal

transplant involving a recipient positive serological cross-match against donor lymphocytes generally results in hyperacute rejection of the graft. 13 cadaveric renal transplants were performed in recipients with a known positive serological cross-match against donor B lymphocytes. 12 of these serological cross-matches were positive against donor blood, node, or spleen lymphocytes, but the reactivity was directed against donor B lymphocytes only. 3 transplants failed, 2 because of rejection and 1 because of renal-artery thrombosis. 10 transplants are functioning, 6 to 42 weeks after the operation. Of these 10 successful grafts, 3 had no acute rejection episodes, while 7 had an early acute rejection episode which responded to treatment. Histologically, the grafts showed a cellular rejection, similar to that in enhanced renal allografts in the rat. It is possible to transplant a kidney in a high-risk patient with a positive B lymphocyte cross-match with a low risk of failure. In addition active enhancement of the graft might someSummary

with

times occur.

a

1289

Introduction

transplantation when a serologically positive lymphocyte cytotoxic cross-match exists between donor and recipient will result in hyperacute rejection of the graft in mostinstances,1-3 although exceptions have been reported.4.s Recently a system of antigens with restricted tissue distribution, expressed primarily on B lymphocytes, has been described. This appears to be similar to the la system in the mouse.6’9 This may explain the occasional successful transplant despite a positive crossmatch ; the cytotoxic antibody in the recipient might have been directed only against donor B-cell alloantigens, which we have been unable to demonstrate in renal parenchyma using immunofluorescent labelling with a multispecific anti-B-cell serum. Renal allografts in the rat may be enhanced by the passive administration of a donor specific cytotoxic anti-

Materials and Methods

RENAL

serum.10-12 Davies13 has shown that this enhancement is due to anti-ta activity in the antiserum, and not to antibody directed against the conventional serologically determined antigens of major histocompatibility systems which are expressed on most cells, including B and T lymphocytes. This study has been confirmed in other transplantation systems.14-16 We have also shown in studies on the rat that absorption of an enhancing serum with erythrocytes to produce an la-like antiserum will prevent hyperacute rejection of a renal allograft in the presence of heterologous complement, while maintaining its enhancing properties. 17 For these reasons we began a prospective study, in which selection of recipients for transplantation was based on the presence of a positive cross-match, where the reaction could be shown to be directed only against donor B-cell or la-like alloantigens. After the first transplant,18 Ettenger et al.19 reported 7 successful transplants with a negative cross-match against peripheral blood or spleen lymphocytes, but a positive cross-match against B lymphocytes. This encouraged us to continue this study. 13 transplants have been performed where there was a positive cross-match against peripheral blood lymphocytes (P.B.L.) or spleen lymphocytes, but where the reactivity was shown to be against enriched B target lymphocytes and not against enriched T target

lymphocytes. TABLE I-DETAILS OF PREVIOUS

N.R.=not

Renal

Transplants 13 patients received kidneys from cadaver donors, and the follow-up times were 6 to 42 weeks. 8 patients received first transplants and 5 received a second transplant. In the 5 patients receiving a second transplant, the first kidney had been lost as a result of rejection (4) and secondary haemorrhage (1).

Total ischsemia times for these kidneys ranged from 7.3to 22.2 hours (mean 14.8). 2 kidneys were maintained in ice slush after flushing with ’Perfudex’ and 11 were maintained on a Gambro preservation machine. Azathioprine (2 mg/kg) and prednisolone (100 mg daily reducing by 5 mg every 5 days to 20 mg) were begun at time of operation. Acute rejection episodes were treated with either 3 intravenous boluses of methyl-

randomised in tion episodes. as

a

Antibody Status and Cross-match of all

patients were screened before transplantation against lymphocyte panel from healthy donors. The sera were screened against P.B.L. and against purified T and B lymphocytes from each donor prepared by rosetting T lymphocytes with papainised sheep red cells.20 A standard TerasakiN.I.H. microcytotoxicity test was used for P.B.L., and the incubation time with complement was extended to 2 hours for B and T lymphocytes. Three patterns of reaction were defined by this pre-transplant screening. Sera reacting with T and B lymphocytes of some donors and only the B lymphocytes of other donors were considered to have antibodies against the A, B, and C series of antigens and B (la) alloantigens. Sera reacting with B lymphocytes only were considered to have antibodies against B (Ia) alloantigens only. No sera were found to have activity against only the A, B, and C series. Before transplantation, cross-matches were performed in duplicate with donor blood, lymph-node, or spleen lymphocytes in all cases, and donor T and B lymphocytes in the 9 The

sera a

cases where both T and B cell alloantibodies were known to be present before transplantation. A cross-match was considered positive if lysis of target cells was more than 5% above background. The proportion of B lymphocytes in the spleen, and in T and B lymphocyte preparations was assessed by a rabbit and anti-human Ia serum (supplied by Dr K. Welsh and Prof. W. F. Bodmer) and a multispecific anti-la pregnancy serum. Thus a weak positive cross-match against T cells could be explained on the basis of B-cell contamination.

TRANSPLANTS, PRE-GRAFT TRANSFUSIONS, PREGNANCIES

relevant, because of failure of first graft.

or increased doses of oral prednisolone, trial of these two therapies for acute rejec-

prednisolone (100 mg)

AND ANTIBODY STATUS BEFORE TRANSPLANT

1290 TABLE II.-DETAILS OF H L A

N.D.=not

MATCHING, CROSSMATCH, IMMEDIATE FUNCTION, AND POST-GRAFT FUNCTION

done

Matching for HLA A, B, and C antigens did not influence the selection of donor-recipient pairs but in the case of second grafts any incompatibility present in the first donor-recipient combination was avoided. Histological Findings All kidneys were examined by biopsy between 30 and 60 minutes after revascularisation of the graft. In addition tissue was taken for biopsy during any acute rejection episode, and after 1 month in 3 patients without acute rejection episodes and in 1 patient with good function following an early histologically confirmed acute rejection episode. Results

antibody status, number of transfusions and pregnancies a first graft, and matching for the A and B series of antigens in these 13 transplants are given in tablesi and n. Only 5 patients shared 2 or more antigens with their donor. All patients but 1 had antibodies detectable against P.B.L., and 6 patients had antibodies against both the conventional HLA A, B, and C antigens and B lymphocyte alloantigens. 2 male patients (6 and 12) who had antibodies before transplantation had not been transfused. Using blood, node, or spleen lymphocytes as targets, all cross-matches were positive except patient 2. In 1 instance (patient 1) where B-cell alloantibodies only had been demonstrated before transplantation, the positive cross-match was judged to be directed against B-cell alloantigens. The remaining definite positive B-cell, cross-matches were demonstrated in the presence of negative or weakly positive T-cell crossThe before

matches. In these latter cases contamination of the T-cell preparation with B cells ranged from 5% to 30%, and in all cases it was assumed that this contamination was sufficient to explain the presence of a weak positive T-cell cross-match. There have been 3 graft failures. 1 immediate failure was considered to be technical because angiography showed renalartery thrombosis and histological examination did not show evidence of hyperacute rejection. 2 kidneys were lost owing to rejection, 1 within the first week (patient 7) and the other on day 40 (patient 2). Patient 7 had rejected an HLA-identical M.L.c.-negative cadaver kidney at 6 weeks, 19 months before this second graft. The antibodies which developed after rejection of the graft were mostly directed against B-cell alloantigens (table i). The allograft perfused normally after revascularisation, and biopsy after one hour showed an abnormal number of polymorphonuclear leucocytes in the glomeruli and intertubular sinusoids. The patient remained on dialysis and on day 5 had a temperature of40°C. Biopsy on day 8 showed

gross oedema and a massive infiltration by polymorphonuclear leucocytes, which in places resembled microabscesses. There were some foci of infiltration by mononuclear cells. On day 21 an infarcted kidney was removed. Patient 2 had non-function of the graft for 21 days due to acute tubular necrosis. Biopsy after 1 hour showed no evidence of hyperacute rejection, but biopsy on day 15 confirmed tubular necrosis and also showed moderate mononuclear infiltration and oedema. The graft

began to function on day 21, achieving creatinine clearances of 25 ml/min, but a further irreversible rejection episode began on day 35, resulting in return to haemodialysis on day 40. Biopsy at this time showed severe rejection changes with interstitial haemorrhage, fibrinoid necrosis of arteries, and focal of infarction. Of the other kidneys that did not function immediately, none showed evidence in the 1-hour biopsy specimen of antibody mediated damage to the graft, and acute tubular necrosis was thought an adequate explanation for the initial non-function. All functioned well subsequently. 10 kidneys are still functioning, 6 weeks to 42 weeks after transplant, with excellent function in all but 1 (patient 3, table n). 3 patients had no rejection episodes at all during the first month, while the others had a rejection episode between 1 and 3 weeks after transplantation which responded promptly to treatment (e.g., patients 5 and 6). The first biopsies were normal in all these grafts. The histological picture during these rejection episodes showed a moderate mononuclear cellular infiltration with interstitial oedema but without vascular or glomerular changes. For example, patient 5 had a normal biopsy after one hour with immediate good function of the graft; there was an acute rejection episode, with the histological picture described, on day 6. This responded to treatment with methylprednisolone and a biopsy done 2 weeks later showed an almost normal kidney. Biopsies after 1 month on 3 patients without a definite acute rejection episode during the first month (patients 10-12) showed slight mononuclear infiltration, with a little interstitial oedema in 1, and no glomerular or vascular changes.

areas

Discussion 12 of the 13 patients had not only a positive B-cell cross-match but also a positive conventional cross-match

against blood, node, or spleen lymphocytes. The fact that 10 grafts have been successful, with only 2 failures due to rejection, suggests that it may be safe in many instances to perform a renal transplant despite a positive cross-match, where it is known that the recipient’s serum is reacting only with donor B lympho-

1291

cytes. Only 1 of the 3 failures

was

due to

an

accelerated

rejection and this occurred in patient 7, who had rejected his first graft in a similar way. Cross-matches between recipient and donor for cell-mediated immunity were performed in most of these transplants; some were positive but the result bore no relationship to the fate of the graft. In general the 10 successful transplants had a relatively benign course in terms of acute rejection episodes and response to rejection therapy. This is quite impressive when it is remembered that this was a potentially high-risk group of patients. Several inferences

be drawn from these results. a high-risk group, in which considerable difficulty was experienced in finding a graft. Indeed 12 of these 13 patients would not have been given these grafts because of a positive cross-match with the donor. These findings greatly increase the chances of a renal transplant for many sensitised patients, and taken together with those of Ettenger et al.19 suggest that B and T lymphocyte cross-matching will have to be part of the immunological assessment of possible donor-recipient combinations. Second, and this is far more speculative, it is possible that some of these grafts may have been actively enhanced. Even in the kidneys which had an early acute rejection episode, microscopic examination showed a cellular type of rejection, very similar to the results in our enhanced renal allografts in the rat. This is circumstantial evidence indeed that active enhancement of some grafts may have occurred; only a much larger number of such grafts will show whether a positive B-cell cross-match improves the chances of the graft taking. It does seem that such transplants may be performed in most instances without immediate rejection of the kidney. can

First, these patients constituted

This work was supported by a grant from the Medical Research Council. We thank Dr A. Daar, Dr H. Shepherd, Dr D. Gray, Mr J. Smith, and Mr G. Fellows, who helped with the management of many of these and Mr P. Trotter who helped with the serological cross-matches Requests for reprints should be addressed to P.J.M., Nuffield Department of Surgery, University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE.

patients,

REFERENCES

F., Olsen, S., Petersen, V. P., Fjeldborg, O. Lancet, 1966, ii, 662. 2. Williams, G. M., Hume, D. M., Hudson, R. P., Morris, P. J., Kano K., Mil1. Kissmeyer-Nielsen,

grom, F. New Engl. J. Med. 1968, 279, 611. 3. Patel, R., Terasaki, P. I. ibid. 1969, 280, 735. 4. Heale, W. F., Morris, P. J., Bennett, R. C., Mortensen, P. J., Ting, A. Med. J. Aust. 1969, ii, 382. 5. Beleil, O. M., Mickey, M. R., Terasaki, P. I. Transplantation, 1972, 13, 493. 493. 6. Lancet, 1976, ii, 240. 7. Walford, R. L., Gossett, T., Smith, G. S., Zeller, E., Wilkinson, J. Tissue

Antigens, 1975, 5, 196. 8. Ting, A., Mickey, M. R., Terasaki, P. I. J. exp. Med. 1976, 143, 981. 9 Winchester, R. J., Fu, S. M., Wernet, P., Kunkel, H., Dupont, B., Jersild, C. ibid. 1975, 141, 924. 10. Stuart, F. P., Saitoh, T., Fitch, F. W. Science, 1968, 160, 1463. 11. French, M. E., Batchelor, J. R. Lancet, 1969, ii, 1103. 12. Fabre, J. W., Morris, P. J. Transplantation, 1973, 15, 397. 13. Davies, D. A. L., Alkins, B. J. Nature, 1974, 247, 295. 14. Staines, N. A., Guy, K., Davies, D. A. L. Eur. J. Immunol. 1975, 5, 782. 15. Soulillou, J. P., Carpenter, C. B., d’Apice, A. J., Strom, T. B. J. exp. Med.

1976, 143, 405. 16. McKenzie, I. F. C. Personal communication, 1976. 17. Winearls, C., Millard, P., Morris, P. J. Unpublished. 18. Morris, P. J., Ting, A., Daar, A. S., Oliver, D. Lancet, 1976, ii, 312. 19. Ettenger, R. B., Terasaki, P. I., Opelz, G., Malekzadeh, M., Pennisi, A. J., Uitenbogaart, C., Fine R. ibid. 1976, ii, 56. 20. Wilson, A. B., Haegart, D. G., Coombs, R. R. A. Clin. exp. Immunol. 1975,

22, 177.

Reviews of Books

Cardiovascular Pharmacology Edited

by

MICHAEL

J. ANTONACCIO,

PH.D.

New York: Raven.

1977. Pp. 534.$27. THIS book is aimed at graduate students in biological at "new and established investigators in the field of cardiovascular pharmacology, who wish to broaden their general knowledge", and at practising and teaching clinicians. It seeks to provide a summary of the important areas of cardiovascular pharmacology. There is a need for a book on a subject in which there have been so many new and interesting developments. The title perhaps fails to convey the scope of this excellent book. It is not just a summary of animal pharmacology or clinical pharmacology alone. It should certainly meet the needs of all the groups of workers it claims to be serving. The most satisfied may well be the clinician. The book is very much therapeutically oriented, with chapters on antiarrhythmic drugs, inotropic agents, shock,’antianginal agents, and platelet-aggregation inhibitors. Chapters contain adequate pathophysiological background while the longest chapter in the book, on hypertension, summarises all aspects of this subject. Diuretics are covered in a chapter on renal physiology and pharmacology, and there is a very full chapter on the renin-angiotensin system. The book opens with a fine survey of the regulation of circulatory functions, and there is a chapter on central neurochemical mechanisms. If the book is accepted as a summary of the pathophysiological basis of cardiovascular therapeutics it is excellent. If, however, the title is taken literally then the book gives scant coverage to certain aspects; antihypertensive drugs receive only 22 out of a total of 534 pages. This book is highly recommended; all interested in cardiovascular disease should read it and most will want to own a copy.

sciences,

Biomedical Computing Edited by W. J. PERKINS, computer science laboratory, National Institute for Medical Research. London: Pitman Medical. 1977. Pp. 362. /;20.

OvER the years, Mr Perkins has acquired a reputation as a good organiser of biomedical engineering conferences, and it is interesting to see his technique applied to a multiauthor, multidiscipline volume. The book is divided into six main sections: processing and analysis of biological signals; image processing and analysis; control systems engineering; modelling; clinical monitoring; and clinical decision making. Each of these has an introduction by an expert who must have advised on the choice of authors for his section. For example, Prof. B. M. Sayers of Imperial College introduces the first section, which is subdivided into neurology, clinical applications, and general applications. The range of subjects is broad and topical e.g., automatic analysis of the E.E.G. during the random eye-movement period, arrhythmia monitoring and on-line analysis by a bedside computer, a clinical assessment for digitised diagnostic ultrasound images, computer transaxial tomography of the entire body, a terminal-oriented clinical record system, decision making in intensive care, computer-aided fluid therapy. The standard of the text and diagrams is good and references are provided. To whom is the book addressed? 4 pages on laboratory data processing with micro-computers can do no more than whet a reader’s appetite, so the book can only show scientists, engineers, and clinicians what might be achieved on the basis of their working together. This is the theme of the editor’s preface, for the clinical advances highlighted in the volume have not come about overnight. As an international account

of computer progress in biomedicine this book is

worthy of a prominent location in medical libraries and in hospital computer centres.