Vascular rejection in heart transplantation: clinical correlation, treatment options, and future considerations

Vascular rejection injures the vascular endothelium in cardiac allografts in the absence of significant intramyocardial lymphocytic infiltration. When compared with cellular rejection, vascular rejection occurs earlier after transplantation, is more resistant to immunosuppressive augmentation, causes more allograft dysfunction, and is associated with a higher frequency of allograft loss. Between January 1990 and October 1992, acute hemodynamically significant vascular rejection developed in 13 of 170 patients (8%). Endomyocardial biopsy specimens revealed the typical findings of endothelial cell activation, immune complex deposition, and interstitial fibrin deposition in the absence of significant lymphocytic infiltration. All patients had clinical evidence of allograft dysfunction. In addition to high-dose corticosteroids, all patients received cyclophosphamide as an oral pulse for 4 days and underwent plasmapheresis for 3 consecutive days. Eight patients received OKT3 (n = 6) or antilymphoblast globulin (n = 2), and nine patients underwent systemic anticoagulation. Six patients required inotropic therapy for hemodynamic instability. Although one patient died during the initial episode, rejection resolved and left ventricular function returned to normal in 12 of 13 patients. However, vascular rejection recurred in three patients, two of whom subsequently died. Two other patients died during late follow-up because of noncompliance. Eight patients remain alive with normal allograft function and angiographically normal coronary arteries. Whereas the addition of cyclophosphamide and plasmapheresis may improve the outcome of vascular rejection, the results of treatment with currently available treatment modalities remain unacceptably poor.     

Temporal reduction in acute rejection after heart transplantation is not associated with a reduction in cell-mediated responses to donor-specific vascular endothelium

BACKGROUND: Over the first 6 months after clinical transplantation, the incidence of rejection falls despite typically substantial decreases in maintenance immunosuppression. Despite this, chronic vascular rejection, manifested by an accelerated form of coronary artery disease is usually evident by the first annual angiogram and continues to progress over subsequent years. METHODS: To investigate this phenomenon further, peripheral blood mononuclear cells were prepared from blood samples obtained from 42 cardiac allograft recipients at 1 week, 3 months, and 6 months after transplantation and co-cultured with endothelial cells isolated and cultured from the aortas of their specific cardiac allograft donors. Donor-specific alloreactivity was assessed by (1) peripheral blood mononuclear cell proliferation (3H-thymidine incorporation) and (2) up-regulation of endothelial cell major histocompatibility complex class I and class II antigens and ICAM-1 expression (flow cytometry) at all three time points. RESULTS: Over this 6-month period, rejection incidence fell from 0.68 rejections/patient to 0.12 rejection/patient. Cyclosporine dose was reduced from 5.6 +/- 0.3 mg/kg (mean +/- standard error of the mean) to 4.5 +/- 0.2 mg/kg, prednisone dose was reduced from 0.58 +/- 0.08 mg/kg to 0.17 +/- 0.02 mg/kg, and azathioprine remained constant at approximately 2 mg/kg over the 6-month period. Despite this reduction in rejection and immunosuppression, no measure of in vitro donor-specific cell-mediated response to endothelial cells decreased over the 6-month time period. Peripheral blood mononuclear cell proliferation in response to donor-specific endothelial cells was unchanged between 1 week (916 +/- 139 counts/min [cpm]) and 3 months (896 +/- 135 cpm) and increased at 6 months (1738 +/- 243 cpm, p < 0.01). The increase in endothelial cell major histocompatibility complex class II expression in response to recipient peripheral blood mononuclear cells likewise was unchanged between 1 week (42.5 +/- 7.8 mean channel shift [mcs]) and 3 months (34.7 +/- 6.6 mcs) and increased substantially at 6 months (95.4 +/- 17.2 mcs, p < 0.02). The magnitude of the increase in endothelial cell major histocompatibility complex class I antigen and ICAM-1 expression in response to co-culture with recipient peripheral blood mononuclear cells did not change over the 6-month period. CONCLUSIONS: These data suggest an important dichotomy between cell-mediated responses to allograft parenchyma versus those to allograft vasculature and may provide an explanation for progressive vascular disease despite the absence of acute rejection.     

Treatment of humoral rejection after heart transplantation

BACKGROUND: Until a few years ago, the incidence of humoral rejection after heart transplantation was underestimated. These episodes were frequently very aggressive and often fatal, because the maintenance and emergency immunosuppression available at the time only inadequately covered the humoral branch of the immune response. In spite of individual case reports, the effects of blood purification procedures or cyclophosphamide in this situation can only be insufficiently estimated. METHODS: To evaluate this therapy concept, 20 dog-lymphocyte-antigen-matched dogs underwent heterotopic neck-heart transplantation. Fourteen dogs underwent transplantation after having been previously sensitized through multiple skin transplantations, 6 dogs were not sensitized (control). The animals received an induction with 3x 250 mg prednisolone, as well as triple immunosuppression (cyclosporine, azathioprine, and cortisone). Biopsy (light microscopy, immunofluorescence), intramyocardial voltage, electric myocardial impedance (>200 kHz, <10 kHz), and echocardiographic (left ventricular wall thickness, diastolic relaxation velocity) examinations were performed daily to monitor rejection. Rejection therapy was continued for 3 days according to the following regimen: apheresis, cortisone boluses (CB), and cyclophosphamide in group A1 (n = 4), apheresis and CB without cyclophosphamide in group A2 (n = 4), and CB only in group C (n = 6). The subsequent course under triple immunosuppression was then observed. RESULTS: In the sensitized animals the onset of severe humoral rejection on the fifth day deteriorated cardiac function down to 75% (70% to 80%) of the initial values. In groups A1 and A2, apheresis resulted in recovery to near-control values (89% to 94%) within two hours, and indeed to complete recovery (97% to 101%) after the second apheresis, that is, within 1 day. In group C recovery was delayed (2 days) and incomplete (84% to 91 %). After therapy was discontinued, rejection-related functional deterioration recurred immediately in group C, and from 2 to 3 days after apheresis, regardless of whether cyclophosphamide therapy was performed (group A1) or not (group A2). In the control group all animals showed a rejection-free posttransplantation course. CONCLUSIONS: By diluting inflammatory mediators, apheresis leads to a rapid improvement in cardiac function during severe humoral rejection after head transplantation. Neither apheresis nor cyclophosphamide therapy are able to have an immediate positive influence on the activation of the immune cascade and to prevent an ongoing rejection.     

PANAS positive activation is associated with anger.

As a prototypic negative emotion, anger would seem to have little in common with positive activation, as measured by the Positive and Negative Affect Schedule (PANAS; D. Watson, L. A. Clark, & A. Tellegen, 1988). However, growing evidence suggests that both anger and positive affect are associated with approach motivation. This suggests the counterintuitive hypotheses that positive affect should be increased by anger-evoking situations, and that positive affect and anger should be directly correlated in such situations. Four studies tested and supported these hypotheses. Discussion focuses on the implications of these results. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Tumor necrosis factor-beta is associated with thymic apoptosis during acute rejection

BACKGROUND: Intrathymic events undergoing allograft rejection remain undefined. The present study investigated the role of tumor necrosis factor-beta on acute thymic involution in rat hepatic allograft recipients during rejection. METHODS: Apoptosis and cellular phenotypic changes in the thymus were studied after hepatic transplantation. RESULTS: Thymocytes in both the medulla and cortex were sparse during acute rejection. Phenotypically, CD4+CD8+ T cells decreased significantly, whereas there were relative increases in CD4-CD8-, CD4+CD8-, and CD4-CD8+ T cells in untreated allograft recipients. Additionally, thymic apoptosis was found by in situ DNA end labeling and electron microscopy. Apoptotic cells were predominantly distributed in the cortex. Biologic lymphotoxin (tumor necrosis factor-beta)/tumor necrosis factor-alpha cytotoxic activity in the serum was significantly increased in untreated hepatic allograft recipients. Tumor necrosis factor-beta mRNA was detected in untreated allograft livers, and intraperitoneal administration of recombinant human tumor necrosis factor-beta induced extensive apoptosis of thymocytes in vivo. In contrast, no significant thymic involution was observed in donor-specific blood transfusion-treated allograft and isograft recipients. Intraperitoneal administration of rabbit anti-human tumor necrosis factor-beta polyclonal antibody or recombinant human interleukin-10 inhibited thymic apoptosis in untreated hepatic allograft recipients. CONCLUSIONS: Allograft rejection, but not donor-specific transfusion-induced immunologic unresponsiveness, is associated with thymic involution, a process that may be mediated by tumor necrosis factor-beta.     

Routine surveillance endomyocardial biopsy: late rejection after heart transplantation

BACKGROUND: Transplant programs use routine surveillance endomyocardial biopsies (RSEMB), which are performed at preset intervals to diagnose cardiac rejection. This retrospective study determined the incidence of graft rejection detected by RSEMB. METHODS: The records of 95 patients who underwent heart transplantation between 1987 and 1995 were reviewed. Rejection incidence was recorded for 80 patients who survived at least 30 days, with a mean follow-up of 35 months. RESULTS: One thousand five hundred sixteen total biopsies were performed; 1,170 were RSEMB. Four hundred seventy-five total rejection episodes occurred and 269 (56%) were diagnosed by RSEMB. Two distinct patient groups were identified. The majority (70 patients), had a decline in the incidence of rejection and no rejection episodes were identified by RSEMB after 36 months. In contrast, the high rejection group (10 patients) had a significantly higher ongoing rejection rate (p < or = 0.04 to p < or = 0.001) throughout their postoperative course up to 72 months. CONCLUSIONS: The majority of our transplant patients demonstrate a decrease in rejection with time and do not require RSEMB beyond 30 months. We identified a group of patients who exhibited a higher rate of rejection and need continued RSEMB.     

Detection of acute rejection of heart transplantation by Doppler color imaging

Doppler tissue imaging is a new technique of measuring the velocities of myocardial wall motion. In order to assess its value in the diagnosis of acute rejection, the velocities of the interventricular septum and left ventricular posterior wall were measured in systole and early diastole in 34 cardiac transplant patients at the time of their endomyocardial biopsy, using an M mode left parasternal short axis view. During 40 episodes of acute rejection (26 mild and/or moderate, 10 sub-severe and 4 severe), the wall velocities decreased significantly (p < 0.001) both in the interventricular septum and endocardium of the posterior wall. Myocardial velocities were significantly slower in sub-severe or severe rejection than in mild or moderate rejection. The most sensitive criterion was the measurement of posterior wall endocardial velocity in early diastole, a decrease of 10% having a sensitivity of 92% whereas the sensitivity of usual Doppler echocardiographic parameters is only 73%. Acute rejection, even mild cases, can be diagnosed with excellent sensitivity by measuring myocardial velocities by Doppler tissue imaging. This technique has the advantage of being non-invasive, reproducible and reliable in the follow-up of cardiac transplant patients.     

Daily noninvasive rejection monitoring improves long-term survival in pediatric heart transplantation

BACKGROUND: Acute rejection episodes and transplant vasculopathy (TVP) account for most of the late deaths after heart transplantation in both adults and children. Accumulating evidence indicates that fatal acute rejection and TVP are related to unrecognized and untreated early and ongoing acute rejection. Day-by-day surveillance of the heart and prompt treatment of any rejection may yield improved long-term survival. METHODS: In almost all patients having transplantation at our institution (978 patients since 1986), the intramyocardial electrogram (IMEG) was recorded routinely every day through a telemetry pacemaker and transmitted to our center by telephone modem. Earlier studies showed a substantial voltage drop in the IMEG QRS complex is highly indicative of acute rejection, including humoral rejection. In this study, we reviewed the data from 69 pediatric patients up to 16 years old for the incidence of acute rejection, TVP, and long-term outcome. Diagnostic endomyocardial biopsies were performed in only 10 patients, and recent coronary angiograms from 29 children were reviewed. RESULTS: In 50 children discharged after heart transplantation, IMEG surveillance data for a mean of 2.9 years indicated 72 acute rejection episodes. During follow-up of 1 month to 10.5 years (mean follow-up, 4.4 years), 2 patients died late of causes unrelated to either rejection or TVP. Another patient died of rejection during unrecognized underimmunosuppression nearly 8 years after transplantation and nearly 31/2 years after discontinuing IMEG recordings. Two patients without IMEG recording died of acute rejection or late TVP. In 1 patient, moderate TVP was seen on an angiogram after 41/2 years (incidence, 2.0%; 5-year incidence, 5.6%). CONCLUSIONS: Daily recording of the IMEG can reliably detect early stages of acute rejection episodes, and immediate rejection treatment seems to keep the incidence of TVP low. The IMEG appears better than all the other rejection monitoring protocols currently in use.     

C-reactive protein in the monitoring of acute rejection after heart transplantation

OBJECTIVE: To measure short duration sounds (L(PEAK)) in the neonatal intensive care unit and describe their intensity, incidence, and periodicity in relationship to activities within the unit. STUDY DESIGN: We measured 1-minute L(PEAK) at four locations within the intensive care unit, accumulating 48 hours of data for each weekday. RESULTS: Thirty-one percent of the L(PEAK) exceeded 90 dB. For further analysis, the data were transformed to the proportion exceeding 90 dB. These values varied significantly with day, week, location, and time of day. During physician rounds, there was a 16% relative increase in L(PEAK). CONCLUSION: These data demonstrate the intensity, incidence, and periodicity of short duration sounds in the intensive care nursery. Short duration sounds are known to affect the infant's physiological and behavioral states and should be addressed in future recommendations for sound control and reduction strategies.     

Expression of cytokine messenger RNA after heart transplantation: relationship with rejection and serum cytokines

Different groups of cytokines may initiate or inhibit the rejection process. We used the polymerase chain reaction to study the expression of cytokine mRNA for interleukin (IL)-2, -4, -6 and -10, tumor necrosis factor-alpha, and interferon-gamma in 187 biopsy specimens from 24 human cardiac transplant recipients 5-555 days after transplantation. Cytokine levels in the serum were also measured. Cytokine mRNA was detected in 38.5% of biopsy specimens. IL-10 mRNA was detected more frequently with mild or absent rejection (11.6% in grades 0 and 1 - vs. 1.4% in grades 2 and 3, P=0.01). Up to 90 days after transplantation, IL-2 mRNA was detected more frequently with moderate rejection (13% in grades 2 and 3 vs. 0% in grades 0 and 1, P=0.076), and IL-4 mRNA was detected more frequently with mild or absent rejection (16% in grades 0 and 1 - vs. 0% in grades 2 and 3, P=0.061). More than 90 days after transplantation, IL-2 mRNA was detected more frequently with mild or absent rejection (10% in grades 0 and 1 vs. 0% in grades 2 and 3, P=0.078). Serum IL-4 levels corresponding to biopsy specimens positive for IL-4 mRNA were higher than those corresponding to specimens negative for IL-4 mRNA (59 pg/ml vs. 32 pg/ml medians, P=0.028). Our results suggest that IL-10 and possibly IL-4 (T helper 2 cytokines) may suppress graft rejection, whereas IL-2 (T helper 1 cytokine) may promote cellular rejection. In addition, cytokine profiles may change with length of time after transplantation. The association of elevated serum levels of IL-4 with increased expression of intragraft IL-4 mRNA may suggest release of this cytokine from the graft into the circulation.     

Resting respiratory sinus arrhythmia is associated with tonic positive emotionality.

Resting respiratory sinus arrhythmia (RSAREST) indexes important aspects of individual differences in emotionality. In the present investigation, the authors address whether RSAREST is associated with tonic positive or negative emotionality, and whether RSAREST relates to phasic emotional responding to discrete positive emotion-eliciting stimuli. Across an 8-month, multiassessment study of first-year university students (n = 80), individual differences in RSAREST were associated with positive but not negative tonic emotionality, assessed at the level of personality traits, long-term moods, the disposition toward optimism, and baseline reports of current emotional states. RSAREST was not related to increased positive emotion, or stimulus-specific emotion, in response to compassion-, awe-, or pride-inducing stimuli. These findings suggest that resting RSA indexes aspects of a person's tonic positive emotionality. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Heart rate variability as an assessment of acute rejection after heart transplantation

BACKGROUND: Orthotopic heart transplantation is currently a widely accepted treatment for end-stage heart disease. Early detection and adequate therapy of acute rejection increases the survival rate. Currently, the most reliable technique for the detection of acute cardiac rejection (ACR) is endomyocardial biopsy (EMB), which is an invasive procedure with some intrinsic problems. The purpose of this study was to assess heart rate variability (HRV) as a noninvasive procedure for frequent monitoring of ACR. METHODS: Six consecutive orthotopic cardiac transplant recipients were prospectively recruited into this study. The follow-up periods ranged from seven to 359 days (median; 146 days). A precordial electrocardiograph (ECG) of 288 seconds was recorded at 5:00 PM before the patient underwent EMB. The results from the frequency domain analysis of the ECG signals were evaluated to correlate with the findings from EMB. RESULTS: Of 48 EMBs, 42 (87.5%) showed no evidence of rejection, four showed mild focal ACR (EMB grade 1A), one mild diffuse ACR (1B) and one moderate plurifocal ACR (3A). There was no moderate focal ACR (2), severe diffuse ACR (3B) or severe ACR (4). Correlation between ACR (3A) and a significant increase in HRV with a corresponding 'broad-band' or bell-shaped pattern on the power spectrum was noted. CONCLUSIONS: Our study in consecutive cardiac transplant recipients indicates that the changes in HRV provide clinicians with a new concept for heart transplant monitoring. Further study is needed to verify clinical utility.     

Factors contributing to the development of chronic rejection in heterotopic rat heart transplantation

To monitor the low back risk imposed by asymmetric postures at workplaces, a method using angular velocity sensors was studied. According to a simple model analysis, trunk rotation could be calculated from the angular velocities measured at both the waist and shoulder and from the inclination of each angular velocity sensor. We thus developed a new detector consisting of an angular velocity sensor (ENC-05D, Murata, Japan) for detecting angular velocity and an acceleration sensor (ADXL05, Analog Devices, USA) for measuring inclination. The precision of the angular velocity sensor was high as the correlation coefficient between the output of the sensor and the true value was 0.9996. When the detectors were affixed to a subject and compared with data measured by a Vicon System 370 (Oxford Metrics, UK), the correlation coefficients between the two methods were 0.949 and 0.815 during model tasks of box transfer and box lifting, respectively. In a model of lifting boxes at different rates, the mean and standard deviation increased according to the task speed. This method was shown to be of practical use for monitoring trunk rotation.     

Early cardiac allograft rejection is independent of regional myocardial blood flow

Noninvasive telemetric monitoring of canine heterotopic cardiac allograft unipolar peak-to-peak amplitude (UPPA) has permitted prospective surveillance for rejection; moreover, this technique is able to reliably detect rejection before the development of histologic evidence of myocyte necrosis. This study was performed to determine whether early cardiac allograft rejection and the accompanying decline in allograft UPPA were associated with alterations in regional myocardial blood flow (RMBF). Seven heterotopic, intrathoracic canine cardiac transplantations were performed using triple-drug immunosuppression. Native hearts and allografts were instrumented with right ventricular and left ventricular epicardial screw-in electrodes connected to subcutaneous telemeters. Daily measurement of native and graft UPPA was performed; using radioactive microspheres, native and graft RMBF were determined during the control period and when UPPA had declined by 15%, 30%, and 45%. Graft histologic status was determined by endomyocardial biopsy at the time of RMBF determination. Mean duration of the study was 19.7 +/- 3.9 days. Rejection was documented in all animals. The UPPA was stable in native hearts; UPPA declined in the allografts after the onset of rejection. A biphasic change in allograft blood flow was seen. Initially RMBF increased as UPPA declined; a 30% to 45% reduction in UPPA was associated with a 41% increase in RMBF (p = 0.028 versus allograft control). Subsequently, a significant decline in blood flow was observed for reductions in UPPA greater than 45% (0.68 +/- 0.44 versus 1.07 +/- 0.47 mL.g-1 x min-1 for a 30% to 45% decline in UPPA; p = 0.007).(ABSTRACT TRUNCATED AT 250 WORDS)     

The clinical significance of flow cytometry crossmatching in heart transplantation

BACKGROUND: Flow cytometry crossmatching is more sensitive than cytotoxic methods in identifying preformed antibodies to donor alloantigens. However, the significance of a positive flow crossmatch remains unknown for a recipient of a heart transplant who has a negative anti-human globulin crossmatch. METHODS: Flow crossmatching was performed retrospectively for 92 recipients of a primary cardiac allograft who underwent transplantation with a negative AHG crossmatch. RESULTS: Forty-six patients were flow crossmatch-positive for alloantibody: 20 were positive on both T and B lymphocytes, 12 were positive only on B lymphocytes, and 13 were positive only on T lymphocytes. Eleven had autoantibody invalidating the flow crossmatch with donor cells. Thirty-six patients had negative flow crossmatch. A significantly higher incidence of graft dysfunction with vascular rejection by 6 months was found for patients who had a positive flow crossmatch on B lymphocytes. This group also had an increased incidence of mortality within this same period. Patients who were flow crossmatch-positive on T and B lymphocytes were more likely to experience greater than two episodes of treated cellular rejection within the first 6 months. Flow crossmatch-positive patients stayed longer in the hospital in comparison to the other two groups, although the increases were not statistically significant. There were no differences between groups with regard to time to first rejection, absence of rejection episodes, episodes of decreased cardiac index (<2.3 L/m2), depressed left and right ventricular ejection fraction, or development of transplant atherosclerosis. CONCLUSION: A positive flow crossmatch identified a subset of patients who are predisposed to development of vascular rejection or are more likely to have frequent cellular rejection.     

Thrombocytopenia following liver transplantation is associated with platelet consumption and thrombin generation

PSA-based screening substantially increases the prostate cancer detection rate and the percentage of organ-confined tumors. It appears that there is some benefit from screening for prostate cancer because of the increased amount of potentially curable disease discovered and the fact that 96% of the pathologically staged tumors detected have histologic features associated with aggressive cancer. Additional evidence that nearly all tumors detected on the basis of initial PSA screening are apt to be clinically significant may be derived from the information that PSA-based screening decreases the incidence of incidental A1 grade III and A2 tumors but does not increase the detection of clinically insignificant A1 grade I and II tumors. At this time, PSA represents the most effective and valuable tool to detect early prostate cancer; therefore, PSA should be used to improve early diagnosis of prostate cancer. Some advances have been made with the introduction of age-specific reference ranges and the ability to measure free to total PSA ratios. The data presented support the clinical usefulness of age-specific reference ranges for serum PSA. Calculation of the free to total PSA ratio is valuable in deciding which screening volunteers require further evaluation, increases the specificity of PSA screening, and as demonstrated may be useful in deciding which patients with isolated PIN should undergo repeat biopsies. Based on these facts, PSA truly can be described as the most important and useful marker for adenocarcinoma of the prostate. Based on these encouraging results and the obligingness of the social insurances, we will be able to continue PSA screening for early detection of prostate cancer for all concerned Tyrolean men in the future.