Moshe Shabtai

An Approach To Organ Salvage From Non-heartbeating Cadaver Donors Under Existing Legal And Ethical Requirements For Transplantation

Effective utilization of nonheartbeating cadaver donor organs is limited by the time required to obtain the necessary family consent prior to organ retrieval (a delay of at least 4-6 hr); this exceeds by far the maximum tolerance of kidneys to warm ischemia. Measures that could theoretically permit use of such organs include: (1) rapid in situ flush cooling; (2) continued in situ kidney cooling until permission for donation is secured; and (3) cell-membrane stabilization of vital organs, with only minimal invasion of the donor body. These measures were tested experimentally in dogs. Hemorrhagic shock was produced in mongrel dogs. One hour after cessation of heartbeat, a rapid perfusion tube was placed into the femoral artery; it was advanced, and its balloon was inflated in the aorta above the renal vessels. The kidneys were then flushed in situ with 1000 cc of cold preservation solution containing a calmodulin inhibitor, trifluoperazine. Two other catheters were inserted percutaneously into the peritoneal cavity for continuous intraperitoneal cold perfusion. Core temperatures of 4 degrees C were maintained in situ in the kidneys for 5 hr. Six hours after cardiac arrest, the kidneys were removed and preserved ex vivo at 4 degrees C for 24 hr, and were then transplanted into their respective hosts (n = 11), where they sustained life uneventfully. This method requires a 2-inch incision in the groin of the prospective donor, and two small stab wounds of the abdomen; i.e., semi-invasive procedures which are commonly performed in emergency rooms. The perfused body could then be released to the family if donation is denied. The recently documented increased willingness of the public to donate organs when the termination of life support is not an issue, and court decisions that have authorized the performance of nondeforming diagnostic procedures in cadavers without consent, suggest that the salvage of transplantable semi-invasive procedures described in this study may be useful in helping to alleviate the current shortage of transplantable organs. This technique can provide the time needed for families to consider the option of organ donation from nonheartbeating cadaver donors in an unhurried and unpressured manner, while preserving the viability of vital organs during the decision-making process.

Increased Expression of Activation Markers in Renal Cell Carcinoma Infiltrating Lymphocytes

PURPOSE As manifested by the presence of immune competent cells, failure to control the progression of renal cell carcinoma by a local immune response attests to impaired local cell mediated immunity. To test this hypothesis we compared the expression of T-cell activation markers in renal cell carcinoma infiltrating lymphocytes with the expression of activation markers of peripheral blood lymphocytes in the same patients. MATERIALS AND METHODS Tumor infiltrating lymphocytes were harvested from a patient with renal cell carcinoma undergoing radical nephrectomy. Peripheral blood was obtained before surgery. Tumor infiltrating and peripheral blood lymphocytes were incubated with monoclonal antibodies defining specific differentiation and activation markers on the cell surface, and analyzed by flow cytometry. Cell subsets are expressed as a fraction of the total number of mononuclear cells. RESULTS The T-cell subset level was significantly higher in peripheral blood than in renal cell carcinoma tissue of the same patient. However, the level of activated T-cell subset expressing HLA-DR was significantly higher in renal cell carcinoma tissue than in peripheral blood. The levels of interleukin-2 receptor and transferrin receptors expressing T-cell subsets were also significantly higher in carcinoma tissue than in peripheral blood. Natural killer cells were found in significantly higher proportions in renal cell carcinoma than in peripheral blood. CONCLUSIONS These results point to significant activation of T, B and natural killer tumor infiltrating lymphocytes. The inability of tumor infiltrating lymphocytes to mount an effective immune response to renal cell carcinoma may be secondary to the presence of suppressive factors in the tumor that prevent tumor infiltrating lymphocytes from transforming into effector cells. These factors may be particularly valuable for the further study of renal cell carcinoma-host interactivity.

PROGNOSTIC SIGNIFICANCE OF T CELL ASSOCIATED SURFACE ANTIGEN DENSITY CHANGES DURING OKT3 THERAPY OF RENAL ALLOGRAFT REJECTION

We describe 12 acute rejection episodes in 11 cadaver donor renal allograft recipients who required OKT3* rescue treatment for steroid-resistant acute rejection (9) or for severe vascular (antibody-mediated) rejection (3). There were 3 treatment failures with subsequent graft loss. Using 2-color flow cytometry the total T (CD3), B (DR+), activated T (CD3DR), T helper/inducer (CD4), T cytotoxic/suppressor (CD8) and activated T cytotoxic cell (CD8DR) subsets were analyzed before, in mid course (5 to 7 days) and at the end of 12 to 14 days of therapy with 5 mg. OKT3 intravenously daily. In parallel changes in the density of such T cell associated antigens were analyzed. Significant decreases in the mean levels of the CD3 (p less than 0.001), CD3DR (p less than 0.05), CD4 (p less than 0.05), CD8 (p less than 0.05) and CD8DR (p less than 0.05) subsets were observed at mid course. A significant decrease in the density of CD3 was observed (p less than 0.0001). The surface antigen density of CD3DR, CD4 and CD8 had decreased by 160% (p less than 0.002), 383% (p less than 0.001) and 260% (p less than 0.001), respectively. At the end of treatment CD3 and CD4 subset levels increased by 425% and 240% (p less than 0.001 and p less than 0.005), respectively. In contrast, the CD3DR and CD8DR subset levels continued to decrease (p less than 0.05). A higher pre-treatment level of CD3DR and a less sharp decrease in CD3, CD4 and CD8 subsets were associated with a higher risk of treatment failure (p less than 0.05, p less than 0.01, p less than 0.05 and p less than 0.05, respectively). The mean decrease in the density of the CD3 marker in the lost grafts was significantly smaller compared to successful outcomes (p less than 0.001). The results of this preliminary study suggest that OKT3 affects T cell associated antigens other than CD3. Such may provide a sensitive prognostic index for the effectiveness of OKT3 therapy, and permit the identification of those patients who might require higher doses and/or duration of OKT3 therapy to enhance renal allograft salvage rates.

The impact of age on T cell subset profiles in patients on chronic hemodialysis awaiting renal transplantation

Age has been considered a significant risk factor in renal transplation; increasing age is associated with a higher morbidity and mortality, primarily as a consequence of infectious and cardiovascular complications. The increased incidence of potentially lethal infections in this patient population may be due to the impact of immunosuppression on a naturally declining immune system. In search for possible characteristic T cell subsets profile in aging patients, subsets of such cells were analyzed in 270 patients on chronic hemodialysis awaiting renal transplantation. Using two-color flow cytometry and murine monoclonal antibodies recognizing specific T cell subset markers, the following cell subsets were analyzed in patients 55 (n = 41) years of age: total T cells (CD3); activated T cells (CD3DR); B cells (CD3-DR+); T helper/inducer (h/i) cells (CD4); T suppressor/inducer (s/i) cells (CD4+CD45+), T cytotoxic/suppressor (CD8), the activated CD4 and CD8 subsets (CD4DR and CD8DR); T cytotoxic cells (Leu2+7−); cells of the Leu-7 phenotype (Leu7+ and Leu2+7+); interleukin 2 receptor (IL-2-R) expressing CD3 and CD8 subsets (CD3IL-2−R+ and CD81L2-R+); and transferrin receptor (TR+) expressing CD3 (CD3TR+). The ratio CD4: CD8 was derived from the respective subset data. Significantly higher levels of CD3 (P 55) group. In contrast, the CD4 : CD8 ratio, the s/i (CD4+CD45+), the Leu7+2- and Leu2+7+ cell subsets were found to be present at a higher level in the older group (P < 0.001, P < 0.005, P < 0.05 and P < 0.01 respectively). These data demonstrate a significant effect of aging on certain T cell subsets levels in the peripheral blood. Although this study does not provide data regarding the functional status of the immune competent cells, it highlights the actual changes in the distribution of cell subsets in the older potential organ recipients. Such changes may be responsible for the increased risk of infectious complications seen in older renal allograft recipients.

Quantitative analysis of surface marker densities after exposure of T-cells to concanavalin A (Con A): A sensitive early index of cellular activation

The kinetics of expression of activation-linked T-cell surface markers were analyzed in T-cells obtained from normal donors. The cells were cocultured in triplicate for 0, 1, 24, 48, and 72 hr in the presence of Con A in RPMI 1640. The density of HLA-DR, interleukin 2, and transferrin receptors (IL-2-R and TR, respectively) on the surface of CD3- and CD8-positive cells was computed by a mathematical model based on fluorescence intensity vector analysis, adjusted for cell size, utilizing two-color flow cytometry. The results were compared with controls obtained at the same time with control cells cultured in RPMI 1640 alone. There was a significant increase in the mean density of HLA-DR on the surface of CD3- and CD8-positive cells as early as 1 hr after exposure to Con A when compared with controls (250 and 300%, respectively; P less than 0.0001). The mean density of IL-2-R and TR on CD3+ cells increased by 265 and 208%, respectively; P less than 0.06 and P = n.s., respectively, when compared with control cells. The mean density of Class II MHC products on CD3+ and CD8+ cells treated with RPMI alone increased by 202 and 468%, 234 and 540%, and 1375 and 2442%, respectively, at 24, 48, and 72 hr of culture. In contrast, the mean cell surface density of these markers in cells treated with Con A increased by 614 and 1962%, 3304 and 7231%, and 8665 and 22,619%, respectively (P less than 0.00001) at the corresponding times following exposure to Con A. The density of IL-2-R and TR on CD3+ cells exposed to Con A also increased significantly at 24, 48, and 72 hr (P less than 0.0001). At the same times, the relative percentage of cell subsets bearing these particular markers increased by 78, 138, and 175% at 24, 48, and 72 hr, respectively. The data suggest that objective quantitative evidence of lymphocyte activation after exposure to Con A may be obtained as early as 1 hr after antigen stimulation, and before significant changes in cell numbers occur. Measurement of cell surface marker densities may provide a useful index for the detection and quantitation of cell activation in the early phase of antigenic stimulation.

Homing of CD8CD57 T lymphocytes into acutely rejected renal allografts.

This study compares the cellular events in excised rejected renal allografts (RKT), with concurrent data in the peripheral blood (PB) in the same patients. The kidney transplants were obtained from recipients after rejections crises that were refractory to treatment. Two-color flow cytometry data was used for quantitation of cell subset profiles and quantitation of the density of individual lymphocyte surface antigen(s). The level of CDSDR-positive T cells in RKT was significantly higher than in PB. This difference ranged from 3 to 19-fold increases. There was an even more pronounced increase in CD8CD57 cell subset levels in RKT versus PB. In parallel with these findings, there was a 15-fold greater mean density of the CD8CD57 markers on T cells in RKT, when compared with the same cells in PB. The density of CDS and of DR markers on CDS+ cells was also significantly higher (4-fold in each instance) in RKT. These data point to a homing of CD8CD57 cells with corresponding increases in the density of these markers in acutely rejected renal allografts, with only a relative decrease of this cell subset in peripheral blood. The appearance of a high preponderance of CD8CD57 cells in the renal allograft at the time of a rejection crisis may constitute a particularly severe prognostic sign regarding the reversibility of the response after treatment with steroids and/or monoclonal antibodies.

Rectus Muscle Flap for Repair of Refractory Bladder Fistula Following Renal Transplantation: A Case Report

We report a case of refractory bladder fistula in a diabetic renal allograft recipient that recurred shortly after conventional operative repair without any detectable external cause. After reoperation and use of a vascularized rectus muscle flap the fistula closed and the patient has retained excellent graft function. It is suggested that this technique should be considered as the primary repair modality for bladder fistulas in diabetic recipients, when wound healing is impaired seriously as a consequence of the combined effects of diabetic microangiopathy and steroid therapy.

Immune inhibitory effects of renal cell carcinoma extract on lectin and alloantigen-induced peripheral blood and tumor infiltratinglymphocyte blastogenesis

The presence of tumor infiltrating lymphocytes (TIL) has been attributed to the host cell mediated immune response against the evolving malignancy. However, due to specific evasive and escape mechanisms, the immune competent cells are rendered ineffective. One such mechanism may be the production of immune suppressor substance(s), inhibiting lymphocyte proliferation, and subsequently, their transformation into effector cells. To evaluate a possible impact of RCC extract on lectin and alloantigen-induced proliferation of TIL and peripheral blood lymphocytes (PBL) from renal cell carcinoma (RCC) patients and from healthy control human subjects. Tumor extract and TIL were derived from 13 patients with RCC undergoing radical nephrectomy. Tumor infiltrating lymphocytes and PBL from these patients were activated with Concanavalin A (Con-A), Phytohemoglutinine (PHA) or Pokeweed (PW) and the rate of blastogenesis was measured by (3)H Thymidine incorporation. The same procedure was used in assay with PBL from control healthy blood donors. There was a significant reduction (88.6%) in the proliferative response to ConA of TIL compared to PBL from the same patients (P = 0.007). A similar decrease was seen following stimulation by PHA (85.8%, P = 0.01) and PW mitogen (78.5%, P = 0.001). A 79.5% decrease in response level of TIL to alloantigens compared to PBL from RCC patients (P = 0.021), was observed. Lectin induced proliferative response of RCC patients was significantly lower in the presence of RCC extract (82.9%) compared to normal kidney extract (P = 0.008). Alloantigenic stimulation of healthy individual PBL was also decreased significantly in the presence of RCC extract (92.9%, P = 0.0001) compared to normal kidney extract. Similarly, lectin induced stimulation of healthy control PBL in the presence of RCC extract was significantly lower (83.2%, P = 0.003). Our data suggest that RCC extract contains an immune suppressive substance(s), capable of inhibiting lymphocyte proliferative response of tumor infiltrating lymphocytes as well as of PBL from patients and healthy individuals alike. This may be one of the mechanisms by which the tumor evades the transformation of lymphocytes into effector killer cells, and thus affects the biological inter-relationship between tumor and host. Identification of this substance and its gene may provide an effective anti-tumoral treatment modality.

Current Status of Immunological Monitoring in the Renal Allograft Recipient

With the appropriate combined use of different immune monitoring techniques, it is possible to derive sensitive diagnostic parameters for the transplant surgeon. However, the core biopsy or cytological examination of the graft continues to represent the gold standard for evaluating the specificity and sensitivity of these methods. With the development of newer monoclonal antibodies and a better understanding of the impact of immune processes on the behavior of various activation linked, T cell associated surface antigens, one may be able to secure further valuable information, with enhanced diagnostic and prognostic accuracy.

Multivariate and Boolean Factor Analysis of Immune Complex/Complement Deposits and their Effects on Renal Blood Flow During Allograft Rejection

The role of humoral immune factors in graft destruction is not fully understood. With immunofluorescence techniques the possibility of a specific pattern and/or clustering of immune complex or complement deposits was analyzed in 140 percutaneous kidney needle biopsies performed in 73 patients with renal allograft dysfunction. The results were correlated with concomitant alterations in renal blood flow as measured by cortical and global perfusion indexes and graft survival. The deposition of IgG, IgM, C3 and C4 correlated significantly with acute rejection confirmed by biopsy (p less than 0.05, less than 0.001, less than 0.02 and less than 0.001, respectively). Subsequent graft survival was compromised when IgA, IgG, IgM, C3, C4 and properdin were present together in biopsy specimens (p less than 0.05). There was a significant clustering of IgA with C3, of IgG with C3 and C4, and of IgM with C1, C3 and C4 (p less than 0.001). There also was a significant association among alterations in renal blood flow, deposition of IgA (p less than 0.05) and C4 (p less than 0.02), and graft outcome. Higher perfusion indexes, indicative of decreased blood flow, showed significant associations (p less than 0.007 and less than 0.04 for the cortical and global perfusion indexes, respectively) with a greater risk of graft loss. Although it primarily is a cellular event, the data suggest that acute rejection is associated with a deposition of various humoral factors that may mediate alterations in renal blood flow. The latter may affect graft function and structural integrity, and, thus, may show a direct correlation with the outcome of a graft.