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The presence of preformed cytotoxic antidonor antibodies in the serum of potential allograft recipients leads to the rapid destruction of the graft by the now well known events of hyperacute rejection (10, 21, 24-27). Experimental work in the past several years at our center and in other laboratories has been oriented to the solution of this difficult immunological problem, not only in the presensitized homotransplantation model but also in strongly incompatible xenograft combinations. Antibody and complement depletion (3-5, 7, 8, 13, 16, 19, 21, 23), or treatment by the chelating agents, sodium citrate (12, 14) and ethylenediaminetetraacetate (EDTA) (1), has been shown to delay hyperacute kidney rejection in both experimental models, whereas anticoagulation with heparin (15) or cobra venom (6) has yielded equivocal results. Even the most effective of these therapeutic procedures only delayed the destruction of the graft. More recently, encouraging results were obtained by several workers (11, 20, 22) with pretreatment of the organ with antidonor IgG fragments (F(ab′)2). It was suggested that F(ab′)2 fragments were protective by occupying the donor antigen receptor sites. Unsuccessful attempts to control hyperacute rejection in one of our patients who had preformed circulating cytotoxic antibodies are reported here, using homografts pretreated with sodium citrate or digested IgG.

A 12-year-old girl with homozygous type-II hyperlipoproteinaemia, which was refractory to medical treatment, had significant improvement in her serum lipid abnormalities during a trial of parenteral hyperalimentation. Subsequently, end-to-side portacaval shunt caused striking reduction of the serum-cholesterol and low-density (beta) lipoprotein elevations, regression or disappearance of xanthomatous skin and tendinous lesions during the 61/2 months since operation, and relief of severe cardiac symptoms apparently as resorption occurred of xanthomatous deposits in the aortic valve and around the coronary arteries. Liver biopsy at 51/2 months showed several changes, including depletion of rough endoplasmic reticulum; this finding was consistent with the possibility that the portal diversion caused the desired therapeutic effects by inhibiting synthesis of hepatic cholesterol or low-density lipoprotein.

An electroencephalographic study has been made of both cortical and subcortical activity occurring in the brain of the cat during seizures produced by convulsive doses of metrazol and by auditory stimuli or direct stimulation of thalamic nuclei in the presence of subthreshold doses. The effect upon this activity of various lesions was also observed. The seizure induced by threshold doses of metrazol appeared, by every test, to be primary in the cerebral cortex and to radiate from it to deep structures. Prominent activity in the internal capsule, basis pedunculi, subthalamus and midbrain tegmentum appeared to represent discharge descending to motor outflows. The basal ganglin did not display conspicuous seizure activity. The thalamus was prominently involved, its sensory relay nuclei exhibiting the most marked seizure discharge, paralleling that in related cortical areas. Associational thalamic nuclei were next most affected. The nuclei of the diffuse thalamic projection system were implicated later than their neighbors and manifested a markedly different type of activity, resembling giant spindle bursts. The possibility is suggested that this may be associated with loss of consciousness in seizures. With subconvulsive doses of metrazol, repetitive afferent stimulation led to development of a complex evoked potential in the receiving cortex, to its irradiation to other cortical area and, finally, to seizure induction. This series of events could still be provoked after destruction of the thalamus, except for the relay nucleus of the sensory pathway involved. It could be reproduced by direct stimulation of the thalamic sensory relay nuclei, but not the nuclei of the diffuse thalamic projection system. It was abolished by ablating the sensory receiving area of the cortex. The ascending sensory pathway and the cerebral cortex itself seem to be the only structures essentially involved in such seizure induction.

The survival of 66 patients with retransplanted kidneys, from August 1963 to March 1973, was evaluated. The life expectancy after retransplantation is less than that after primary transplantation but the difference is mainly due to an increased early postoperative mortality. The prognosis after retransplantation is greatly improved if the second kidney is from a related donor. The prognosis is likewise improved if a longer period of time has elapsed between the two transplantations. Surprisingly, previous exposure to specific HL-A antigens does not worsen the prognosis for a subsequent transplanted kidney.

Ten nondiabetic dogs were submitted to a procedure called splanchnic division which directed the nutrient rich venous return from the intestines into the left lobes of the liver and the hormone rich pancreaticogastroduodenosplenic venous return into the right lobes. Two months later, the right lobes had undergone the expected gross and microscopic hypertrophy. Compared with the abnormal shrunken and glycogen-depleted hepatocytes of the left lobes, the large and otherwise normal hepatocytes of the right lobes had a higher rate of cell division as judged by microscopic examination, measurements of deoxyribonucleic acid synthesis and the results of autoradiography. Both sides had greater cell replication than in the livers of normal unaltered dogs. The dominance of the right lobes following splanchnic division was almost completely eliminated by the prior creation of alloxan-induced diabetes in four dogs and by the performance of total pancreatectomy at the same time as splanchnic division in six dogs. In these ten diabetic dogs, which were treated with subcutaneously administered insulin for the two month period of the post operative study, hepatic lobar and cell size were nearly equal on both sides. By light and electron microscopy, the hepatocytes on both sides had abnormalities, somewhat less pronounced on the right. However, the most active cell division was now transferred to the left lobes. The results with alloxan-induced diabetes were similar to those after total pancreatectomy, except the lipid deposits were less on both liver sides in the alloxan experiments, and the glycogen was selectively reduced in the right lobes. The latter finding presumably was due to the continued action of glucagon in dogs made diabetic with alloxan. Twelve nondiabetic dogs had a procedure called partial portacaval transposition which directed systemic venous blood from the hindquarters, kidneys and adrenal glands into the left lobes of the liver and the total splanchnic venous return into the right lobes. Two months later, the degree of relative hypertrophy and hyperplasia of the glycogen rich right lobes was even greater than after splanchnic division, as was the morphologic damage to the left lobar hepatocytes. The degree of right lobar hypertrophy following partial portacaval transposition was reduced but not eliminated by pre-existing alloxan-induced diabetes in four dogs and by concomitant total pancreatectomy in six more dogs. The dogs were subcutaneously treated with insulin. Structurally, the hepatocytes on the right side after two months were in better condition than were those on the left, although both were abnormal. The dominance of cell division on the right side was reduced, as judged by standard microscopy and by autoradiography, but there was not a shifting of sides. The biochemical analyses reflected the presence or absence of glucagon. These findings are consistent with our earlier multifactorial hypothesis which holds that portal hepatotrophic factors are mainly interreacting hormones generated by splanchnic organs and delivered straight to the liver and that the hormone interrelationships might have augmented significance because of the high concentration of nutritional substrate in the same venous blood. The observations also substantiate by direct testing the suggestion that insulin is the most important hepatotropic factor and that it profoundly affects many aspects of liver cell structure, division and function.

Complete diversion of portal blood in dogs caused sustained falls in serum cholesterol and phospholipid concentrations an declines in hepatic cholesterol and triglyceride synthesis. The hepatocytes in these canine livers were deglycogenated, and they atrophied to about half of their original size within two months. At the same time, there was evidence of increased mitoses. Ultrastructurally, the dominant change in the hepatocytes was in the rough endoplasmic reticulum which decreased in amount, underwent marked dilatation, and became depleted of ribosomes. There was also marked loss of glycogen granules, variable mitochondrial abnormalities, and widespread accumulation in the hepatocyte cytoplasm of lipid vacuoles. Bypass of intestinal venous return around the liver through a mesenteric caval shunt did not influence the serum lipid concentrations in dogs and baboons, although cholesterol synthesis was depressed in the canine livers and significant morphologic changes, including atrophy, were produced. In both species, the addition of a second stage central portacaval shunt which diverted venous return from the pancreaticogastroduosplenic area caused declines in serum cholesterol and phospholipid concentrations. After the second operation, hepatic cholesterol synthesis in the dogs was further reduced, and triglyceride synthesis was markedly depressed. The eventual ultrastructural changes were similar to those after one stage portal diversion. In other experiments on dogs, discrete regions of the liver were provided with portal perfusion from different splanchnic sources during a two month period. When the right lobes received pancreatiogastroduodenosplenic venous blood and the left lobes received intestinal venous effluent, in vivo cholesterol and triglyceride synthesis were higher in the hormone-enriched right lobes. This advantage was eliminated with pre-existing alloxan-induced diabetes or by the concomitant performance of total pancreatectomy in dogs that were treated during the ensuing two months with subcutaneously administered insulin. The nutrient-enriched left lobes had the higher lipid synthesis. In a final series of experiments, the right lobes of dogs were given the total splanchnic flow, and the left lobes were perfused with systemic venous blood by anastomosing the left portal vein to the suprarenal vena cava. The right lobar advantage in lipid synthesis could not be eliminated in this preparation with alloxan-induced diabetes or total pancreatectomy. These results indicate that a reduction of hepatic lipid synthesis is an important, although not necessarily the sole, factor in the antilipidemic influence of portacaval shunt. The effects upon synthesis and blood lipids apparently are due more to the diversion of endogenous hormones than to the bypass of intestinal nutrients. The substances in portal venous blood that subserve hepatic lipid metabolism are presumably largely the same as the hepatotropic factors which have been described before as profoundly affecting hepatic structure, function, and the capacity for regeneration. These portal blood factors are multiple and interrelated, but the single most important one seems to be insulin.

Available data concerning the non-hepatic source of plasma factor VIII are conflicting. In the present study, dogs with factor VIII deficiency hemophilia were transplanted with spleen or vascularized lymph node grafts obtained from normal donor dogs. Postoperative immunosuppression was done with azathioprine and heterologous antilymphocyte globulin. Four spleen transplants were successful and the recipients had positive technetium sulfide spleen scans along with adequate plasma factor VIII levels for three to eight weeks. Cessation of graft isotope uptake was accompanied by prompt disappearance of plasma factor in all four dogs. Histologically, the grafts were rejected at this time. In one dog, a second spleen graft immediately restored therapeutic factor VIII levels. Four lymph node transplants were successful and plasma factor VIII was detected for one, one, two, and ten weeks. Three dogs rejected their lymph node grafts with disappearance of factor VIII, while one had a viable transplant removed with loss of factor VIII within two days. The data suggest that factor VIII is produced in the lymphatic tissue of the dog.

Trabecular vertebral bone of renal transplant patients was quantitatively compared with bone from normal individuals and dialyzed and nondialyzed patienets with chronic renal failure reported in detail in an earlier study. Long- and short-term transplant patients have increased bone resorption and mineralization defects similar to renal osteodystrophy in dialyzed and nondialyzed patients. However, in transplant patients the magnitude of resorption is greater, and bone volume tends to decrease rather than increase. Resorptive activity in transplant patients is maximal during the first year after transplantation. Bone volume decreases continuously for at least 96 months after transplantation. Only decreased bone volume correlated with success or failure of the renal transplant. Morphologic findings in this study correlate with other clinical and morphologic data to suggest that reduction in bone volume in transplant patients results from a combination of persistent hyperparathyroidism and suppression of bone formation by steroid therapy.

Cyclophosphamide significantly diminished the canine humoral antibody response to sheep red blood cells and tended to prevent arterial lesions in renal homografts. However, cyclophosphamide failed to prolong renal homograft survival when administered to dogs as the sole immunosuppressive agent, and it did not add to the effectiveness of azathioprine when given as a supplement to the azathioprine and administered simultaneously or sequentially.

Five cases of renal autotransplantation representing five different indications for the procedure are presented and discussed.

A method has been described for establishing shunt patency by determining the difference in postprandial plasma glucose levels between a peripheral vein and the inferior vena cava at or near the site of the portal-systemic anastomosis. This tet was evaluated both in the laboratory with normal dogs before and after Eck fistula formation as well as cirrhotic patients with and without shunts. The results indicate that this test is reliable and has the advantages of safety, specificity, and ease of performance.

The immediate renal response to large intravenous doses of prednisolone was studied in 18 kidney homograft recipients and in 6 normal subjects. Clearance rates of inulin (CIN), creatinine (CCR), p-aminohippurate (CPAH), and electrolytes were measured over 3 one-hour periods following intravenous infusion of prednisolone (1 Gm.) and compared with corresponding clearance rates after a placebo infusion. CIN, CCR, and CPAH rates and (CCRCIN) ratios exhibited a substantial decrease during all collection periods following the infusion of prednisolone, both in the normal subjects and in the patients. Fractional excretion of potassium (CKCIN) increased in a progressive fashion reaching peak values after 3 hours. Biphasic variations were observed in the fractional excretion of sodium (CNACIN); an increase during the first hour was followed by a decrease during the third hour. The changes in the fractional excretions of ultrafiltrable calcium (CCaCIN), ultrafiltrable magnesium (CMgCIN), and phosphorus (CPCIN) were minimal. Normal subjects exhibited significant decreases in CCaCIN and CMgCIN following the infusion of prednisolone; there was no significant change in the patients. CPCIN increased significantly both in the normal subjects and in the patients. These results indicate that acute suppression of kidney function is a general renal response to large doses of glucocorticoids. The marked decrease in the creatinine clearance ratio (CCRCIN) observed after the administration of prednisolone is consistent with a depressed tubular secretion of creatinine and emphasizes the inadequacy of CCR as an indication of glomerular filtration rate (GFR) under conditions in which large doses of glucocorticoids are employed.

Renal function was studied in twenty-nine of thirty-four surviving renal allograft recipients from an initial group of sixty-four patients two years after transplantation. Mean clearances of inulin and PAH were, respectively, greater than and equal to half the donors’ initial predicted clearances. Minimum urine osmolality during water diuresis was greater, and maximum urine osmolality during hydropenia was less than normal, an effect attributable partly to enhanced solute load in a single transplanted kidney.

A clinically distinct pneumonitis occurred in six renal transplant recipients receiving azathioprine and prednisone immunosuppressive therapy. The patients ranged in age from 3 to 20 years. The onset was 42 to 102 days postoperatively, coinciding with decrease in prednisone dosage below approximately 1 mg per kilogram of body weight per day. Mild nonproductive cough, fever, and cynanosis were present. Chest x-rays demonstrated extensive hazy to nodular infiltrates usually involving both hila and lower lung fields. Cold agglutinins were present in five patients. Pulmonary function studies demonstrated an alveolar capillary block. The duration of illness was 12 to 34 days and was not influenced by antibiotic therapy. Autopsy of the single case in which death occurred revealed Pneumocystis carinii pneumonia and disseminated cytomegalic inclusion-body disease.

ALG raised against lymphoblasts grown in pure culture for many generations contained antiplatelet activity. The thromboagglutinins could be completely removed by absorption with lymphoblasts, indicating that they had been raised to antigens shared by lymphoblasts and platelets. Anti-spleen ALG possessed levels of such anti-platelet antibodies but in substantially higher titres, because an additional contribution was made by contaminating thrombocytes in the immunizing injectate. By chromatographic separation and immunoelectrophoretic analysis of the eluate from platelet–antibody complexes generated during the absorption of anti-spleen ALG with thrombocytes, the thromboagglutinins were shown to reside almost exclusively (97·7%) in the area of the IgA fraction. The direct Coombs' test, reacting platelets from patients receiving equine anti-spleen ALG with guinea-pig antisera against normal horse serum, showed a highly significant, but not invariable correlation with clinical platelet depression, which was not, however, clearly related to the thromboagglutinin titre of the ALG being administered.

Horse anti-dog and anti-mouse ALS were digested for varying intervals with acid Taka-protease, a proteolytic enzyme. A progressive reduction in antigenicity was demonstrated, as determined by in vitro precipitin reactions with standard antisera and by passive cutaneous and systemic anaphylaxis tests. Leukoagglutinins and lymphocytotoxins were conserved in anti-dog ALS but there was a marked diminution in anti-platelet and anti-erthrocyte activity. Both anti-red cell and anti-white cell antibodies of anti-mouse ALS were reduced. Digestion appeared to completely degrade some protein fractions such as albumin and to alter the immunoglobulin molecule, possibly by cleavage of the terminal portion of the Fc fragment. Digestion of ALS with Taka-protease may prove to be a useful procedure particularly since it was demonstrated that immunosuppressive potency was partially retained. For further evaluation a better standardized Taka-protease will be required.