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RENAL TRANSPLANTATION IN PATIENTS WITH DIABETES MELLITUS
795
discussions of autoimmune disease genetic (germ-line) factors have been postulated in rather indefinite terms. Burnet24 attempted to be more specific in discussing autoimmune hsemolytic ansemia, but we believe that the present findings provide a more direct approach toward an interpretation of the inherited component in autoimmune disease. In
most
We thank Sir Macfarlane Burnet for helpful discussions and Miss J. Lardi and Miss W. Law for their assistance. This work was supported by grants from the National Health and Medical Research Council of Australia, and the Anti-Cancer Council of Victoria, Australia.
Requests for reprints should
be addressed to I. R. M.
REFERENCES
H. O.,
McDevitt, Benaceraff, B. Adv. Immun. 1968, 11, 31. Benaceraff, B., McDevitt, H. O. Science, 1972, 175, 273. Jerne, N. K. Eur.J. Immun. 1971, 1, 1. 4. Lilly, F., Boyse, E. A., Old, L. J. Lancet, 1964, ii, 1207. 5. Tennant, J. R., Snell, G. D. J. natn. Cancer Inst. 1968, 41, 597. 6. Lilly, F. ibid. 1970, 45, 163. 7. Amiel, J. L. Histocompatibility Testing; p. 79. Copenhagen, 1967. 8. Forbes, J. F., Morris, P. J. Lancet, 1970, ii, 849. 9. Grumet, F. C., Coukell, A., Bodmer, J. G., Bodmer, W. F., McDevitt, H. O. New Engl. J. Med. 1971, 285, 193. 10. Waters, H., Conrad, P., Walford, R. L. Tissue Antigens, 1971, 1, 68. 11. Mackay, I. R., Weiden, S., Hasker, J. Ann. N.Y. Acad. Sci. 1965, 124, 767. 12. Whittingham, S., Mackay, I. R., Irwin, J. Lancet, 1966, i, 1333. 13. Mittal, K. R., Mickey, M. R., Singal, D. P., Terasaki, P. I. Transplantation, 1968, 6, 913. 14. Ting, A., Morris, P. J. Vox Sang. 1971, 20, 561. 15. Forbes, J. F., Morris, P. J. J. clin. Invest. 1972, 51, 1156. 16. Walford, R. L., Smith, G. S., Waters, H. Transplantation Rev. 1. 2. 3.
1972, 7, 78.
Thorsby, E., Engeset, A., Lie, S. O. Tissue Antigens, 1971, 1, 147. Engelfriet, P. Personal communication. Stokes, P. J., Asquith, P., Holmes, G. K. T., Mackintosh, P., Cooke, W. T. Lancet, 1972, ii, 162. 20. Mickey, M. R., Kreisler, M., Albert, E. D., Tanaka, N., Terasaki, P. I. Tissue Antigens, 1971, 1, 57. 21. Kissmeyer-Nielsen, F., et al. Transplantation Proc. 1971, 3, 1019. 22. Morris, P. J. PH.D. thesis, University of Melbourne, 1972. 23. Burner, F. M. Aust. J. exp. Biol. med. Sci. 1972, 50, 1. 24. Burnet, F. M. Cellular Immunology; p. 614. London, 1969. 17. 18. 19.
RENAL TRANSPLANTATION IN PATIENTS WITH DIABETES MELLITUS
JOHN E. WOODS WILLIAM J. JOHNSON CARL F. ANDERSON FRANK J. LEARY
PALUMBO PETER P. FROHNERT JAMES V. DONADIO, JR. JAMES H. DEWEERD
PASQUALE J.
Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55901, U.S.A.
Experience with renal transplantation in eight patients with overt diabetes mellitus suggests that renal transplantation from living related donors is not contraindicated as treatment for end-stage nephropathy. Summary
INTRODUCTION
IMPROVED management in renal transplantation has made it feasible to consider for a kidney transplant many patients for whom the procedure might previously have been thought too risky. At this centre a functioning allograft is now obtained in 90 % of patients given a kidney from a living relative, and more than 9500of such patients survive for two years or more.
This has been despite transplantation of increasingly high-risk patients. Combined pancreatic and renal transplantation in diabetics has been reported, but little has been published on renal transplantation alone in patients with diabetes mellitus. 2,3 We describe here our preliminary experience in eight patients with overt diabetes mellitus who received renal allografts between July, 1970, and June, 1972. PATIENT AND DONOR SELECTION
Patients At first
our criteria for selecting diabetic patients for transplantation were fairly rigid: apart from the standard criteria applicable to any prospective transplant recipient, the patient had to be 45 or less, in good general condition other than end-stage renal failure, have no severe diabetic neuropathy or severe impairment of vision, and there had to be available a living related donor who had no evidence
of latent diabetes. Later we relaxed somewhat these criteria, and our series includes a blind patient and a 67year-old diabetic who had had a myocardial infarct and was a heavy cigarette smoker. No patient is now denied transplantation on the basis of diabetes alone. Donors
Only diabetic patients with living related donors were considered for transplantation. We looked for latent diabetes by standard and cortisone glucose-tolerance tests, and all donors were screened for good bilateral renal function. When both parent and sibling were potential donors, we chose the parent on the basis of decreased likelihood of subsequent onset of diabetic nephropathy. Likewise, older siblings were preferred to younger ones. The ages of donors ranged from 26 to 55 years (average 38-4
years). MANAGEMENT
Recipients All recipients underwent nephrectomy, splenectomy, and appendicectomy approximately 4 weeks before transplantation. Dialysis, if not previously performed, was started just before surgery and continued until transplantation. Management of diabetics on dialysis did not differ significantly from that of nondiabetics, except that special care was required to maintain fluid and electrolyte balance to avoid postural hypotension on the basis of depletion of extracellular fluid volume. The immunosuppressive regimen used was azathioprine 1-3 mg. per kg. per day (after the first 4-5 post-transplant days at 5 mg. per kg.) and intravenous methylprednisolone 1000 mg. on the day of transplantation and for the next 2 days. The dose was subsequently decreased rapidly to a maintenance level of 125 mg. per day intravenously unless rejection occurred. Doses of 1000 mg. were repeated each day until rejection was reversed, as suggested by significant improvement in renal function. On discharge, patients were put on prednisone 20-25 mg. by mouth, and the oral If rejection dose was never subsequently increased. occurred, intravenous methylprednisolone was again used. Antilymphocytic globulin was administered intravenously to three patients in a dose of 15 mg. per kg. per day for 14 days. DIABETES
Insulin requirements were estimated from plasmaglucose levels before and after dialysis. Blood-samples were usually taken 1-2 hours after a meal and after the morning administration of insulin. The dialysate glucose level was kept at approximately 200 mg. per 100 ml., and,
796 TABLE I-RESULTS OF RENAL TRANSPLANTATION IN DIABETICS WHO RECEIVED KIDNEY FROM LIVING RELATED DONOR
__
*
July,
_
1972.
At 6 weeks (time of death). = arteriosclerosis obliterans.
A.S.O.
restrictions the serum-creatinine level stabilised between 3 and 4 mg. per 100 ml. 3 months after transplantation, five of the six survivors had either resumed normal or near-normal occupational and social activities. The sixth (and eldest), though not fully recovered, has resumed part-time activity as a car salesman. Insulin requirements have been greater than before (table n). The increase probably reflects the effect of post-transplant adrenal steroid therapy and the kidney’s role in insulin degradation and excretion.4 We have no reliable data about insulin requirements before renal insufficiency was a factor. Management of the diabetes was sometimes difficult during the early weeks, especially because of repeated large intravenous doses of methylprednisolone. Severe hyperglycæmia, with the accompanying need for extra insulin, almost always ensued. After 6-12 weeks, however, insulin requirements stabilised, and diabetic management posed no special problems. Glycosuria often bore no relation to plasma-glucose (e.g., grade-4 glycosuria with a plasma-glucose of only 54 mg. per 100 ml.), but by 3 months glycosuria could usually be relied on as an indicator of increasing
because theoretically there should be equilibration between blood and dialysate, insulin was not always administered, even when the initial plasma-glucose was high. Generally, however, 10 units of crystalline zinc insulin were given for every 100 mg. per 100 ml. of plasma-glucose beyond the first 300 mg. per 100 ml. In the early post-transplant period, the plasma-glucose was the chief guide to insulin therapy, because urine glucose levels correlated poorly with the plasma-glucose. Ketonuria was also a help: for mild or moderate ketonuria 5 units of regular insulin were given before the meal, and for more severe ketosis 10 units were given. Because intravenous methylprednisolone raises the plasma-glucose, additional insulin was required when methylprednisolone doses greater than 250 mg. were administered. Every effort was made, however, to avoid insulin overdosage, because a moderate hyperglycæmia (less than 300 mg. per 100 ml.) is preferable to hypo-
glycasmia. RESULTS
All eight patients had extrarenal signs of diabetes or other risk factors (table i). The survival-time since transplant has been from 2 months to 25 months in seven patients. One patient died suddenly with a massive pulmonary embolism 6 weeks after transplantation. His diabetes was under control, renal function was good, and he was free of sepsis. Of the remaining seven patients, all but one have had good renal function. Patient 4 has moderate stable renal insufficiency after two severe rejections and pulmonary sepsis. He required dialysis three times during a severe rejection episode, but with moderate dietary TABLE II-INSULIN
plasma-glucose. DISCUSSION
REQUIREMENTS
.
Fifty-five renal transplants in diabetics had been reported to the N.I.H./A.C.S. Organ Transplant Registry by January, 1972.5 Twenty-five of these were from living related donors, with follow-up data on sixteen, four of whom had died at 0, 39, 92, and 167 days. Two patients had non-functioning allografts, giving a kidney-survival rate of 63% and patient survival of 75 %. Although the survival-rates seem less than for nondiabetic transplant patients, the rates are similar or better than those reported for nondiabetic recipients of cadaver organs. Furthermore, dialysis is less satisfactory in diabetics than nondiabetics.6 We cannot predict how long an allografted kidney will withstand the combined insult of diabetes and low-grade chronic rejection; this has been explained to each prospective recipient, but all of them were eager to proceed. If more than 2 years of normal
797 or
near-normal life can be offered as a prospect, we believe that the procedure is worth while. The question of using relatively young donors who have family histories of diabetes is more difficult.
syndrome, in the form of
The cortisone glucose-tolerance test helps to exclude latent diabetes, and the oldest available donor is used. If diabetes develops later in a donor, end-stage nephropathy is less likely and would occur 10-15 years after the onset of overt diabetes,’at which time renal transplantation would be an option. Also, in donors over 45 years of age without evidence of diabetes, diabetic nephropathy is less likely. Coronaryartery disease is the major cause of death in patients with maturity-onset diabetes. The final decision is the donor’s, and no pressure or persuasion is placed on the donor. In our experience, most donors volunteer eagerly, even when they know the risks involved. Although follow-up in our series is as yet very short, we are encouraged to continue renal transplantation as the treatment of choice for end-stage renal disease in many diabetic patients.
pheNHa.
Requests for reprints should be addressed Clinic, Rochester, Minnesota 55901, U.S.A.
to
J. E. W., Mayo
REFERENCES
1.
Lillehei, R. C., Simmons, R. L., Najarian, J. S., Kjellstrand, C. M.,
Goetz, F. C. Transplant. Proc. 1971, 3, 318. 2. Simmons, R. L., Najarian, J. S. Kidney, 1971, 4, 1. 3. Med. Wld News, Feb. 18, 1972, 13, 31. 4. Rabkin, R., Simon, N. M., Steiner, S., Colwell, J. A. New Engl. J. Med. 1970, 282, 182. 5. Bergan, J. J. Personal communication. 6. Comty, C. M., Shapiro, F. L. Abstracts of the American Society of Nephrology, 1971, p. 15. 7. Balodimos, M. C. in Joslin’s Diabetes Mellitus (edited by A. Marble, P. White, R. F. Bradley, and L. P. Krall); p. 526. Philadelphia, 1971.
ISOLATION OF TWO " BIG GASTRINS " FROM ZOLLINGER-ELLISON TUMOUR TISSUE R. A. GREGORY
HILDA
J.
TRACY
Physiological Laboratory, University of Liverpool
pair of larger, less acidic, gastrin peptides additional to the heptadecapeptide amides previously described have been isolated from Zollinger-Ellison tumour tissue. They contain the heptadecapeptide amide as a C-terminal sequence linked to the remainder of the molecule by the peptide bond lysyl-glutaminyl. They differ significantly in charge and are separable by chromatography and electrophoresis. They are both potent stimulants of gastric acid secretion. They correspond in properties to the " big gastrin " identified immunologically in the serum of patients with the ZollingerEllison syndrome. Summary
A
a pair of heptadecapeptide amides of identical aminoacid composition.1 The sequence of the human variety of the hormone is pyroglu. gly. pro, trp.leu.glu5.ala. tyr. gly. trp met. asp.
member of the pair of peptides the single residue tyrosine (in position 12) is sulphated, in the other it is not. The N-terminal residue is pyroso the glutamyl, peptides are ninhydrin-negative. The amide group which blocks the C-terminal phenylalanine residue is essential for physiological activity.2 Antibodies raised against human or porcine gastrin are widely used as the basis of a radioimmunoassay for measurement of the gastrin content of body fluids and tissue extracts. Yalow and Berson3 recently reported that in the Zollinger-Ellison syndrome and addisonian pernicious anaemia (where the levels of plasma-gastrin are often very high) radioimmunoassay of gastrin in serum fractions separated on ’Sephadex G50’or by starchgel electrophoresis demonstrated that up to 50% of the immunoreactive material present corresponded in size and charge to the heptadecapeptide (" little gastrin ", L.G.); the remainder, and often the predominant amount, was in a larger and less acidic form which Yalow and Berson termed " big gastrin
In
one
(B.G.). In simple
aqueous extracts of human and porcine antral mucosa, L.G. predominated, only about 20% being in the B.G. form. In one antrum from a case of the Zollinger-Ellison syndrome practically all of the gastrin present was in the L.G. form. When B.G. was digested with trypsin, which attacks those peptide bonds in which the carboxyl group is donated by arginine or lysine, L.G. appeared. This and other evidence led Yalow and Berson to conclude that B.G. consisted of L.G. covalently linked by its N-terminal residue through a lysine or arginine residue to a less acidic peptide. We have isolated from Zollinger-Ellison tumour tissue a pair of peptides which correspond in properties to the " big gastrin " identified immunologically by Yalow and Berson. EXPERIMENTAL
During the past four years active primary and metastatic tumour tissue from cases of the Zollinger-Ellison syndrome has been collected and stored at -70°C. This material was extracted by procedures similar to those previously
INTRODUCTION
WE and our co-workers have isolated the gastric antral hormone gastrin from the pyloric mucosa of man, hog, cow, sheep, dog, and cat, and from tumour tissue obtained from cases of the Zollinger-Ellison
Fig. 1-Fractionation of a partially purified extract of ZollingerEllison tum8ur tissue on a column of sephadex G50 superfine run
in 0.04M ammonium bicarbonate solution.
=salt region. O.D. = optical density.
-
-
-
-
-
discussions of autoimmune disease genetic (germ-line) factors have been postulated in rather indefinite terms. Burnet24 attempted to be more specific in discussing autoimmune hsemolytic ansemia, but we believe that the present findings provide a more direct approach toward an interpretation of the inherited component in autoimmune disease. In
most
We thank Sir Macfarlane Burnet for helpful discussions and Miss J. Lardi and Miss W. Law for their assistance. This work was supported by grants from the National Health and Medical Research Council of Australia, and the Anti-Cancer Council of Victoria, Australia.
Requests for reprints should
be addressed to I. R. M.
REFERENCES
H. O.,
McDevitt, Benaceraff, B. Adv. Immun. 1968, 11, 31. Benaceraff, B., McDevitt, H. O. Science, 1972, 175, 273. Jerne, N. K. Eur.J. Immun. 1971, 1, 1. 4. Lilly, F., Boyse, E. A., Old, L. J. Lancet, 1964, ii, 1207. 5. Tennant, J. R., Snell, G. D. J. natn. Cancer Inst. 1968, 41, 597. 6. Lilly, F. ibid. 1970, 45, 163. 7. Amiel, J. L. Histocompatibility Testing; p. 79. Copenhagen, 1967. 8. Forbes, J. F., Morris, P. J. Lancet, 1970, ii, 849. 9. Grumet, F. C., Coukell, A., Bodmer, J. G., Bodmer, W. F., McDevitt, H. O. New Engl. J. Med. 1971, 285, 193. 10. Waters, H., Conrad, P., Walford, R. L. Tissue Antigens, 1971, 1, 68. 11. Mackay, I. R., Weiden, S., Hasker, J. Ann. N.Y. Acad. Sci. 1965, 124, 767. 12. Whittingham, S., Mackay, I. R., Irwin, J. Lancet, 1966, i, 1333. 13. Mittal, K. R., Mickey, M. R., Singal, D. P., Terasaki, P. I. Transplantation, 1968, 6, 913. 14. Ting, A., Morris, P. J. Vox Sang. 1971, 20, 561. 15. Forbes, J. F., Morris, P. J. J. clin. Invest. 1972, 51, 1156. 16. Walford, R. L., Smith, G. S., Waters, H. Transplantation Rev. 1. 2. 3.
1972, 7, 78.
Thorsby, E., Engeset, A., Lie, S. O. Tissue Antigens, 1971, 1, 147. Engelfriet, P. Personal communication. Stokes, P. J., Asquith, P., Holmes, G. K. T., Mackintosh, P., Cooke, W. T. Lancet, 1972, ii, 162. 20. Mickey, M. R., Kreisler, M., Albert, E. D., Tanaka, N., Terasaki, P. I. Tissue Antigens, 1971, 1, 57. 21. Kissmeyer-Nielsen, F., et al. Transplantation Proc. 1971, 3, 1019. 22. Morris, P. J. PH.D. thesis, University of Melbourne, 1972. 23. Burner, F. M. Aust. J. exp. Biol. med. Sci. 1972, 50, 1. 24. Burnet, F. M. Cellular Immunology; p. 614. London, 1969. 17. 18. 19.
RENAL TRANSPLANTATION IN PATIENTS WITH DIABETES MELLITUS
JOHN E. WOODS WILLIAM J. JOHNSON CARL F. ANDERSON FRANK J. LEARY
PALUMBO PETER P. FROHNERT JAMES V. DONADIO, JR. JAMES H. DEWEERD
PASQUALE J.
Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55901, U.S.A.
Experience with renal transplantation in eight patients with overt diabetes mellitus suggests that renal transplantation from living related donors is not contraindicated as treatment for end-stage nephropathy. Summary
INTRODUCTION
IMPROVED management in renal transplantation has made it feasible to consider for a kidney transplant many patients for whom the procedure might previously have been thought too risky. At this centre a functioning allograft is now obtained in 90 % of patients given a kidney from a living relative, and more than 9500of such patients survive for two years or more.
This has been despite transplantation of increasingly high-risk patients. Combined pancreatic and renal transplantation in diabetics has been reported, but little has been published on renal transplantation alone in patients with diabetes mellitus. 2,3 We describe here our preliminary experience in eight patients with overt diabetes mellitus who received renal allografts between July, 1970, and June, 1972. PATIENT AND DONOR SELECTION
Patients At first
our criteria for selecting diabetic patients for transplantation were fairly rigid: apart from the standard criteria applicable to any prospective transplant recipient, the patient had to be 45 or less, in good general condition other than end-stage renal failure, have no severe diabetic neuropathy or severe impairment of vision, and there had to be available a living related donor who had no evidence
of latent diabetes. Later we relaxed somewhat these criteria, and our series includes a blind patient and a 67year-old diabetic who had had a myocardial infarct and was a heavy cigarette smoker. No patient is now denied transplantation on the basis of diabetes alone. Donors
Only diabetic patients with living related donors were considered for transplantation. We looked for latent diabetes by standard and cortisone glucose-tolerance tests, and all donors were screened for good bilateral renal function. When both parent and sibling were potential donors, we chose the parent on the basis of decreased likelihood of subsequent onset of diabetic nephropathy. Likewise, older siblings were preferred to younger ones. The ages of donors ranged from 26 to 55 years (average 38-4
years). MANAGEMENT
Recipients All recipients underwent nephrectomy, splenectomy, and appendicectomy approximately 4 weeks before transplantation. Dialysis, if not previously performed, was started just before surgery and continued until transplantation. Management of diabetics on dialysis did not differ significantly from that of nondiabetics, except that special care was required to maintain fluid and electrolyte balance to avoid postural hypotension on the basis of depletion of extracellular fluid volume. The immunosuppressive regimen used was azathioprine 1-3 mg. per kg. per day (after the first 4-5 post-transplant days at 5 mg. per kg.) and intravenous methylprednisolone 1000 mg. on the day of transplantation and for the next 2 days. The dose was subsequently decreased rapidly to a maintenance level of 125 mg. per day intravenously unless rejection occurred. Doses of 1000 mg. were repeated each day until rejection was reversed, as suggested by significant improvement in renal function. On discharge, patients were put on prednisone 20-25 mg. by mouth, and the oral If rejection dose was never subsequently increased. occurred, intravenous methylprednisolone was again used. Antilymphocytic globulin was administered intravenously to three patients in a dose of 15 mg. per kg. per day for 14 days. DIABETES
Insulin requirements were estimated from plasmaglucose levels before and after dialysis. Blood-samples were usually taken 1-2 hours after a meal and after the morning administration of insulin. The dialysate glucose level was kept at approximately 200 mg. per 100 ml., and,
796 TABLE I-RESULTS OF RENAL TRANSPLANTATION IN DIABETICS WHO RECEIVED KIDNEY FROM LIVING RELATED DONOR
__
*
July,
_
1972.
At 6 weeks (time of death). = arteriosclerosis obliterans.
A.S.O.
restrictions the serum-creatinine level stabilised between 3 and 4 mg. per 100 ml. 3 months after transplantation, five of the six survivors had either resumed normal or near-normal occupational and social activities. The sixth (and eldest), though not fully recovered, has resumed part-time activity as a car salesman. Insulin requirements have been greater than before (table n). The increase probably reflects the effect of post-transplant adrenal steroid therapy and the kidney’s role in insulin degradation and excretion.4 We have no reliable data about insulin requirements before renal insufficiency was a factor. Management of the diabetes was sometimes difficult during the early weeks, especially because of repeated large intravenous doses of methylprednisolone. Severe hyperglycæmia, with the accompanying need for extra insulin, almost always ensued. After 6-12 weeks, however, insulin requirements stabilised, and diabetic management posed no special problems. Glycosuria often bore no relation to plasma-glucose (e.g., grade-4 glycosuria with a plasma-glucose of only 54 mg. per 100 ml.), but by 3 months glycosuria could usually be relied on as an indicator of increasing
because theoretically there should be equilibration between blood and dialysate, insulin was not always administered, even when the initial plasma-glucose was high. Generally, however, 10 units of crystalline zinc insulin were given for every 100 mg. per 100 ml. of plasma-glucose beyond the first 300 mg. per 100 ml. In the early post-transplant period, the plasma-glucose was the chief guide to insulin therapy, because urine glucose levels correlated poorly with the plasma-glucose. Ketonuria was also a help: for mild or moderate ketonuria 5 units of regular insulin were given before the meal, and for more severe ketosis 10 units were given. Because intravenous methylprednisolone raises the plasma-glucose, additional insulin was required when methylprednisolone doses greater than 250 mg. were administered. Every effort was made, however, to avoid insulin overdosage, because a moderate hyperglycæmia (less than 300 mg. per 100 ml.) is preferable to hypo-
glycasmia. RESULTS
All eight patients had extrarenal signs of diabetes or other risk factors (table i). The survival-time since transplant has been from 2 months to 25 months in seven patients. One patient died suddenly with a massive pulmonary embolism 6 weeks after transplantation. His diabetes was under control, renal function was good, and he was free of sepsis. Of the remaining seven patients, all but one have had good renal function. Patient 4 has moderate stable renal insufficiency after two severe rejections and pulmonary sepsis. He required dialysis three times during a severe rejection episode, but with moderate dietary TABLE II-INSULIN
plasma-glucose. DISCUSSION
REQUIREMENTS
.
Fifty-five renal transplants in diabetics had been reported to the N.I.H./A.C.S. Organ Transplant Registry by January, 1972.5 Twenty-five of these were from living related donors, with follow-up data on sixteen, four of whom had died at 0, 39, 92, and 167 days. Two patients had non-functioning allografts, giving a kidney-survival rate of 63% and patient survival of 75 %. Although the survival-rates seem less than for nondiabetic transplant patients, the rates are similar or better than those reported for nondiabetic recipients of cadaver organs. Furthermore, dialysis is less satisfactory in diabetics than nondiabetics.6 We cannot predict how long an allografted kidney will withstand the combined insult of diabetes and low-grade chronic rejection; this has been explained to each prospective recipient, but all of them were eager to proceed. If more than 2 years of normal
797 or
near-normal life can be offered as a prospect, we believe that the procedure is worth while. The question of using relatively young donors who have family histories of diabetes is more difficult.
syndrome, in the form of
The cortisone glucose-tolerance test helps to exclude latent diabetes, and the oldest available donor is used. If diabetes develops later in a donor, end-stage nephropathy is less likely and would occur 10-15 years after the onset of overt diabetes,’at which time renal transplantation would be an option. Also, in donors over 45 years of age without evidence of diabetes, diabetic nephropathy is less likely. Coronaryartery disease is the major cause of death in patients with maturity-onset diabetes. The final decision is the donor’s, and no pressure or persuasion is placed on the donor. In our experience, most donors volunteer eagerly, even when they know the risks involved. Although follow-up in our series is as yet very short, we are encouraged to continue renal transplantation as the treatment of choice for end-stage renal disease in many diabetic patients.
pheNHa.
Requests for reprints should be addressed Clinic, Rochester, Minnesota 55901, U.S.A.
to
J. E. W., Mayo
REFERENCES
1.
Lillehei, R. C., Simmons, R. L., Najarian, J. S., Kjellstrand, C. M.,
Goetz, F. C. Transplant. Proc. 1971, 3, 318. 2. Simmons, R. L., Najarian, J. S. Kidney, 1971, 4, 1. 3. Med. Wld News, Feb. 18, 1972, 13, 31. 4. Rabkin, R., Simon, N. M., Steiner, S., Colwell, J. A. New Engl. J. Med. 1970, 282, 182. 5. Bergan, J. J. Personal communication. 6. Comty, C. M., Shapiro, F. L. Abstracts of the American Society of Nephrology, 1971, p. 15. 7. Balodimos, M. C. in Joslin’s Diabetes Mellitus (edited by A. Marble, P. White, R. F. Bradley, and L. P. Krall); p. 526. Philadelphia, 1971.
ISOLATION OF TWO " BIG GASTRINS " FROM ZOLLINGER-ELLISON TUMOUR TISSUE R. A. GREGORY
HILDA
J.
TRACY
Physiological Laboratory, University of Liverpool
pair of larger, less acidic, gastrin peptides additional to the heptadecapeptide amides previously described have been isolated from Zollinger-Ellison tumour tissue. They contain the heptadecapeptide amide as a C-terminal sequence linked to the remainder of the molecule by the peptide bond lysyl-glutaminyl. They differ significantly in charge and are separable by chromatography and electrophoresis. They are both potent stimulants of gastric acid secretion. They correspond in properties to the " big gastrin " identified immunologically in the serum of patients with the ZollingerEllison syndrome. Summary
A
a pair of heptadecapeptide amides of identical aminoacid composition.1 The sequence of the human variety of the hormone is pyroglu. gly. pro, trp.leu.glu5.ala. tyr. gly. trp met. asp.
member of the pair of peptides the single residue tyrosine (in position 12) is sulphated, in the other it is not. The N-terminal residue is pyroso the glutamyl, peptides are ninhydrin-negative. The amide group which blocks the C-terminal phenylalanine residue is essential for physiological activity.2 Antibodies raised against human or porcine gastrin are widely used as the basis of a radioimmunoassay for measurement of the gastrin content of body fluids and tissue extracts. Yalow and Berson3 recently reported that in the Zollinger-Ellison syndrome and addisonian pernicious anaemia (where the levels of plasma-gastrin are often very high) radioimmunoassay of gastrin in serum fractions separated on ’Sephadex G50’or by starchgel electrophoresis demonstrated that up to 50% of the immunoreactive material present corresponded in size and charge to the heptadecapeptide (" little gastrin ", L.G.); the remainder, and often the predominant amount, was in a larger and less acidic form which Yalow and Berson termed " big gastrin
In
one
(B.G.). In simple
aqueous extracts of human and porcine antral mucosa, L.G. predominated, only about 20% being in the B.G. form. In one antrum from a case of the Zollinger-Ellison syndrome practically all of the gastrin present was in the L.G. form. When B.G. was digested with trypsin, which attacks those peptide bonds in which the carboxyl group is donated by arginine or lysine, L.G. appeared. This and other evidence led Yalow and Berson to conclude that B.G. consisted of L.G. covalently linked by its N-terminal residue through a lysine or arginine residue to a less acidic peptide. We have isolated from Zollinger-Ellison tumour tissue a pair of peptides which correspond in properties to the " big gastrin " identified immunologically by Yalow and Berson. EXPERIMENTAL
During the past four years active primary and metastatic tumour tissue from cases of the Zollinger-Ellison syndrome has been collected and stored at -70°C. This material was extracted by procedures similar to those previously
INTRODUCTION
WE and our co-workers have isolated the gastric antral hormone gastrin from the pyloric mucosa of man, hog, cow, sheep, dog, and cat, and from tumour tissue obtained from cases of the Zollinger-Ellison
Fig. 1-Fractionation of a partially purified extract of ZollingerEllison tum8ur tissue on a column of sephadex G50 superfine run
in 0.04M ammonium bicarbonate solution.
=salt region. O.D. = optical density.
-
-
-
-
-