Thomas Fehr

Immunodeficiency and Chronic Myelogenous Leukemia-like Syndrome in Mice with a Targeted Mutation of the ICSBP Gene

Interferon consensus sequence binding protein (ICSBP) is a transcription factor of the interferon (IFN) regulatory factor (IRF) family. Mice with a null mutation of ICSBP exhibit two prominent phenotypes related to previously described activities of the IRF family. The first is enhanced susceptibility to virus infections associated with impaired production of IFN(gamma). The second is deregulated hematopoiesis in both ICSBP-/- and ICSBP+/- mice that manifests as a syndrome similar to human chronic myelogenous leukemia. The chronic period of the disease progresses to a fatal blast crisis characterized by a clonal expansion of undifferentiated cells. Normal mice injected with cells from mice in blast crisis developed acute leukemia within 6 weeks of transfer. These results suggest a novel role for ICSBP in regulating the proliferation and differentiation of hematopoietic progenitor cells.

Troponin as a risk factor for mortality in critically ill patients without acute coronary syndromes

OBJECTIVES We sought to assess the mechanism and prognostic value of elevated troponins in patients without acute coronary syndromes (ACS). BACKGROUND Cardiac troponins are used as specific markers for the diagnosis of ACS. Recent studies reported a considerable number of critically ill patients without ACS as being troponin-positive, especially patients with sepsis, pulmonary embolism, renal failure, and stroke. METHODS We analyzed 58 consecutive, critically ill patients admitted for reasons other than ACS, according to their troponin status. Thirty-day mortality, left ventricular ejection fraction (LVEF), and a panel of inflammatory cytokines were compared between troponin-positive and troponin-negative patients. Relevant coronary artery disease was excluded either by stress echocardiography or autopsy. RESULTS Of the 58 critically ill patients, 32 (55%) without evidence of ACS were troponin-positive. Positive troponin levels were associated with higher mortality (22.4% vs. 5.2%, p < 0.018) and a lower LVEF (p = 0.0006). Troponin-positive patients had significantly higher median levels of tumor necrosis factor (TNF)-alpha, its soluble receptor, and interleukin (IL)-6. A subgroup of 10 aplastic patients was troponin-negative at study entry. Three became troponin-positive during leukocyte recovery and subsequently died, whereas all the others stayed troponin-negative and survived. Flow-limiting coronary artery disease was not demonstrable at autopsy or stress echocardiography in 72% of troponin-positive patients. CONCLUSIONS Elevated troponin is a mortality risk factor for medical intensive care patients admitted for reasons other than ACS. It is associated with decreased left ventricular function and higher levels of TNF-alpha and IL-6.

Myeloma Responses and Tolerance Following Combined Kidney and Nonmyeloablative Marrow Transplantation: In Vivo and In Vitro Analyses

Six patients with renal failure due to multiple myeloma (MM) received simultaneous kidney and bone marrow transplantation (BMT) from HLA‐identical sibling donors following nonmyeloablative conditioning, including cyclophosphamide (CP), peritransplant antithymocyte globulin and thymic irradiation. Cyclosporine (CyA) was given for approximately 2 months posttransplant, followed by donor leukocyte infusions. All six patients accepted their kidney grafts long‐term. Three patients lost detectable chimerism but accepted their kidney grafts off immunosuppression for 1.3 to >7 years. One such patient had strong antidonor cytotoxic T lymphocyte (CTL) responses in association with marrow rejection. Two patients achieved full donor chimerism, but resumed immunosuppression to treat graft‐versus‐host disease. Only one patient experienced rejection following CyA withdrawal. He responded to immunosuppression, which was later successfully withdrawn. The rejection episode was associated with antidonor Th reactivity. Patients showed CTL unresponsiveness to cultured donor renal tubular epithelial cells. Initially recovering T cells were memory cells and were enriched for CD4+CD25+ cells. Three patients are in sustained complete remissions of MM, despite loss of chimerism in two. Combined kidney/BMT with nonmyeloablative conditioning can achieve renal allograft tolerance and excellent myeloma responses, even in the presence of donor marrow rejection and antidonor alloresponses in vitro.

Selection of a Broad Repertoire of CD4+ T Cells in H-2Ma0/0 Mice

According to past reports, H-2Ma0/0 mice express a single major histocompatiblity complex class II molecule, A(b), heavily loaded with a single peptide derived from the invariant chain, CLIP. Despite the highly restricted diversity of the class II:peptide complexes expressed on thymic stromal cells in the mutant animals, a large and diverse population of CD4+ T cells is positively selected. However, two important issues remained unresolved and are addressed here: Just how preponderant is CLIP occupancy of the class II molecules from H-2M0/0 mice? How extensive and functionally competent is the CD4+ population selected in the mutant animals? Our results argue that a single class II:peptide complex can select a very broad, though not complete, repertoire of CD4+ T cells.

Chronic Norovirus Infection after Kidney Transplantation: Molecular Evidence for Immune-Driven Viral Evolution

BACKGROUND Norovirus infection is the most common cause of acute self-limiting gastroenteritis. Only 3 cases of chronic norovirus infection in adult solid organ transplant recipients have been reported thus far. METHODS This case series describes 9 consecutive kidney allograft recipients with chronic norovirus infection with persistent virus shedding and intermittent diarrhea for a duration of 97-898 days. The follow-up includes clinical course, type of immunosuppression, and polymerase chain reaction for norovirus. Detailed molecular analyses of virus isolates from stool specimens over time were performed. RESULTS The intensity of immunosuppression correlated with the diarrheal symptoms but not with viral shedding. Molecular analysis of virus strains from each patient revealed infection with different variants of GII.4 strains in 7 of 9 patients. Another 2 patients were infected with either the GII.7 or GII.17 strain. No molecular evidence for nosocomial transmission in our outpatient clinic was found. Capsid sequence alignments from follow-up specimens of 4 patients showed accumulation of mutations over time, resulting in amino acid changes predominantly in the P2 and P1-2 region. Up to 25 amino acids mutations were accumulated over a 683-day period in the patient with an 898-day shedding history. CONCLUSION Norovirus infection may persist in adult renal allograft recipients with or without clinical symptoms. No evidence for nosocomial transmission in adult renal allograft recipients was found in our study. Molecular analysis suggests continuous viral evolution in immunocompromised patients who are unable to clear this infection.

Raised cardiac troponins

Causes extend beyond acute coronary syndromes Cardiac troponins are regulatory proteins of the thin actin filaments of the cardiac muscle. Troponin T and troponin I are highly sensitive and specific markers of myocardial injury. Serial measurement of troponin I or troponin T has become an important tool for risk stratification of patients presenting with acute coronary syndromes. The joint committee of the European Society of Cardiology, the American College of Cardiology, and the American Heart Association has recently accepted their measurement in serum as the standard biomarker for the diagnosis of acute myocardial infarction and for diagnosis and management of acute coronary syndromes.1 2 Cardiac troponins, however, are raised in many patients presenting with conditions other than acute coronary syndromes (box). To ignore this fact will lead to unjustified, potentially harmful investigations and increases medical costs. In sepsis, for example, cardiac troponins are raised in up to 85% of patients in the absence of any acute coronary syndromes.3 Doctors need to be aware that troponins are biochemical markers that replace neither electrocardiograms nor clinical investigation. In the …

Rituximab and intravenous immunoglobulin treatment of chronic antibody-mediated kidney allograft rejection.

Kidney transplant rejections are classified into T-cell-mediated and antibody-mediated rejections (AMR). C4d staining on allograft biopsies and solid-phase assays to measure donor-specific alloantibodies have helped to precisely define the latter. Although for acute AMRs, therapy mainly relies on plasmapheresis or immunoadsorption, no studies for treatment of chronic AMR are available. Here, we report on four kidney allograft recipients suffering from chronic AMR 1 to 27 years posttransplant, who were treated with a combination of rituximab and intravenous immunoglobulin (IVIG). Rituximab/IVIG improved kidney allograft function in all four patients, whereas donor-specific antibodies were reduced in 2 of 4 patients. However, in one patient an acute rejection episode occurred 12 months after this treatment, and another patient had severe, possibly rituximab-associated lung toxicity. Thus, rituximab/IVIG may be a useful strategy for the treatment of chronic AMR, but further randomized multicenter studies are necessary to establish its efficacy and safety profile.

Disseminated varicella infection in adult renal allograft recipients: four cases and a review of the literature.

Disseminated varicella-zoster (VZV) infection is a rare complication after renal allotransplantation in adults. We report four patients, among them one with combined VZV and cytomegalovirus infection. The main complications were hepatitis, pneumonitis, and disseminated intravascular coagulation. A review of the literature from 1981 to 2000 revealed 34 additional cases of disseminated varicella infection in adult renal allograft recipients with an overall mortality of 34%. Among these patients 82% suffered from primary varicella, 18% had a reactivation. High-dose acyclovir therapy combined with reduction of immunosuppression lead to reduction of mortality from 53% before 1990 to 22% after 1990. No immunosuppressive drug is significantly associated with a higher risk of disseminated VZV infection. Immunization against VZV in adults is still a matter of controversy. Whereas passive immunization is performed only for prophylactic but not therapeutic purpose, active immunization is routinely performed in children and may also be recommended for adults before renal transplantation.

Molecular evidence of interhuman transmission in an outbreak of Pneumocystis jirovecii pneumonia among renal transplant recipients.

S. Gianella, L. Haeberli, B. Joos, B. Ledergerber, R.P.  Wüthrich, R. Weber, H. Kuster, P.M. Hauser, T. Fehr, N.J. Mueller. Molecular evidence of interhuman transmission in an outbreak of Pneumocystis jirovecii pneumonia among renal transplant recipients.
Transpl Infect Dis 2010: 12: 1–10. All rights reserved

Donor-specific antibody levels and three generations of crossmatches to predict antibody-mediated rejection in kidney transplantation.

Background. This study evaluated the prognostic impact of pretransplant donor-specific anti-human leukocyte antigen antibodies (DSA) detected by single-antigen beads and compared the three generations of crossmatch (XM) tests in kidney transplantation. Methods. Thirty-seven T-cell complement-dependent cytotoxicity crossmatch (CXM) negative living donor kidney recipients with a retrospectively positive antihuman leukocyte antigen antibody screening assay were included. A single-antigen bead test, a flow cytometry XM, and a Luminex XM (LXM) were retrospectively performed, and the results were correlated with the occurrence of antibody-mediated rejections (AMRs) and graft function. Results. We found that (1) pretransplant DSA against class I (DSA-I), but not against class II, are predictive for AMR, resulting in a sensitivity of 75% and a specificity of 90% at a level of 900 mean fluorescence intensity (MFI); (2) with increasing strength of DSA-I, the sensitivity for AMR is decreasing to 50% and the specificity is increasing to 100% at 5200 MFI; (3) the LXM for class I, but not for class II, provides a higher accuracy than the flow cytometry XM and the B-cell CXM. The specificity of all XMs is increased greatly in combination with DSA-I values more than or equal to 900 MFI. Conclusions. In sensitized recipients, the best prediction of AMR and consecutively reduced graft function is delivered by DSA-I alone at high strength or by DSA-I at low strength in combination with the LXM or CXM.