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Special Articles

HOMOTRANSPLANTATION OF KIDNEYIN PATIENTS TREATED BY PREOPERATIVE

LOCAL IRRADIATION AND POSTOPERATIVE

ADMINISTRATION OF AN ANTIMETABOLITE

(IMURAN)Report of Six Cases

M. F. A. WOODRUFFD.Sc.,M.D.,M.S.Melb.,F.R.C.S.

B. NOLANM.B. Edin., F.R.C.S.

J. S. ROBSONM.D. Edin., F.R.C.P.E.

ANNE T. LAMBIEM.B. Edin., M.R.C.P., M.R.C.P.E.

T. I. WILSONM.B. Edin., F.R.C.S.E.

J. G. CLARKM.B. Edin.

From the Edinburgh Royal Infirmary, the Departments ofSurgical Science and Therapeutics, University of Edinburgh, andthe Medical Research Council Research Group on Clinical and

Experimental Problems of TransplantationTRANSPLANTATION of the kidney has been carried out in

nine patients at the Edinburgh Royal Infirmary. The firstpatient, who received a kidney from his identical twin,remains in good health with normal renal function morethan two and a half years after operation; the second, whoreceived a kidney from her brother after being givenwhole-body irradiation, died from septicxmia 30 daysafter operation with a graft which showed only slighthistological evidence of immunological damage. Boththese cases have already been reported (Woodruff et al.1961, 1962). The eighth patient, like the first, received akidney from an identical twin, and progress so far has beenvery satisfactory.The other six patients (cases 3-7 and 9), who form the

subject of the present report, all received a kidney from aparent (five cases) or non-twin sibling (one case). Their

progress is reviewed up to the end of April, 1963.Selection of Donors

In two patients the possibility of transplantation was sug-gested by us to the parents, while in the other four the patient’srelatives inquired whether this procedure could be carried out.Those who were willing to act as donors were told of the risks

inherent in the operation, the disadvantages of possessing onlyone kidney, and the small chance of a successful outcome for therecipient. The potential recipients were not told at this stagethat transplantation was being considered, and the donors wereable to consider their decision in the knowledge that this was so.If they reaffirmed their offer they were given a general clinicalexamination and the following special investigations wereperformed: (1) blood-grouping (ABO and Rh systems);(2) full haematological examination; (3) examination of urinefor abnormal constituents and culture for organisms; (4) bio-chemical tests of renal function including the determination ofblood-urea-nitrogen (B.U.N.) and creatinine clearance (Cr. Cl.);(5) radiological examination of the chest and abdomen, andintravenous pyelography.

Those whose general health was satisfactory, whose totalrenal function was normal, who had two kidneys of approxi-mately equal size showing no significant abnormality or obviousdifference in function on intravenous pyelography, and whohad the same ABO blood-group as the recipients, were sub-jected to the following additional investigations: (6) blood-grouping in respect of the MN, S, P, Kell, Duffy, Lewis, andLutheran systems; (7) serological investigations to determinewhether they possessed antibodies capable of reacting with thepatient’s erythrocytes; (8) aortography carried out by the

Seldinger technique.In making the final choice of donor we have tried whenever

possible to eliminate those who possessed erythrocyte antigenswhich were lacking in the patient, especially if these includedthe Rh(D) or the Kell (K) antigens. We would certainly

TABLE I-DATA ON SIX NEW CASES

TABLE II-RED-BLOOD-CELL GROUPING

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exclude anyone whose serum contained antibodies active againstthe patient’s erythrocytes, though this situation has not in factarisen.

Management of the RecipientsPreoperative ManagementThe recipients all had severe, irreversible renal failure

(table i) due to acute or subacute glomerulonephritis withprolonged oliguria (cases 4, 7, and 9), chronic pyelonephritiswith severe hypertension (case 5), chronic pyelonephritis withmild hypertension (case 6), or’ congenital renal hypoplasia(case 3). The creatinine clearance, determined on numerousoccasions, was less than 3 ml. per minute in all patients.Haemodialysis was carried out in two patients and peritonealdialysis in four patients, on two or more occasions beforeoperation. All the recipients were anaemic and received blood-transfusion one or two days before operation. Urinary-tractinfection, severe bronchopuhnonary infection, and in two casessepticaemia were treated before operation with appropriateantibiotics after the sensitivities of the causal organisms hadbeen determined.

In view of our unhappy experience with whole-bodyirradiation, and encouraging reports of prolonged survival ofexperimental renal homografts in dogs treated with 6-mercapto-purine and related substances (Calne 1961a and b, Calne andMurray 1961, Calne et al. 1962), it was decided to rely mainlyon chemotherapy in the form of long-continued administration

of ’ Imuran ’ (6-[(1-methyl-4-nitro-5-imidazolyl] thio) purine)to modify the homograft reaction. This was started on themorning of the operation. Chemotherapy was combined withpreoperative local irradiation (100-200 rads) of the spleen andthe graft site using either a 4 MeV linear accelerator or a 2 MeVVan der Graaf generator. This was given with the object ofreducing the general lymphoid-cell population and causingdamage to the lymph-nodes in the region of the graft.OperationThe operations on donor and recipient were performed in

adjacent operating-theatres by separate surgical teams. In fourcases the donor’s left kidney, which has the advantage of havinga longer vein than the right kidney, was transplanted extra-peritoneally to the right iliac fossa of the recipient. In the othertwo cases the donor’s right kidney was used-once becauseaccess to the left kidney was difficult on account of scoliosis, andonce because of a double renal artery on the left side-and thesetransplants were placed in the left iliac fossae.

In cases 3-7, as in the two previously reported, the transplantwas cooled with iced saline. In case 9 and in the unreportedcase of transplantation from an identical twin (case 8), thiswas deliberately not done.

In five cases the transplant had a single renal artery, and thiswas anastomosed either end-to-end to the divided internal iliac

artery (four cases) or end-to-side to the external iliac arteryusing two everting stay sutures joined by a continuous over-

Fig. 1-Data on·case 3.Male, aged 12 yr. Wt. 36 kg. Congenital renal hypoplasia. Renal transplant-father to son. Preoperatively there was progressive ill-health

with recurrent serious infections precipitating severe uraemia necessitating haemodialysis on two occasions. The creatinine clearance duringthis period slowly fell to values of between 1 and 3 ml. per minute. The patient’s condition improved rapidly after operation, and thepostoperative course was uncomplicated. Since the 17th postoperative day the blood-urea-nitrogen has been normal, the urine has remainedfree of protein, and the creatinine clearance has remained above 75 ml. per minute. Nine months after operation the patient is leading a normallife, has gained 3 kg. in weight, and has grown 4 in. in height.

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Fig. 2—HEematologicat data on case 3.The immediate postoperative period was attended by sharp

leucocytosis. Thereafter there was a slow fall in the polymorphleucocytes amounting to levels of about 2000 per c.mm. on the 17thpostoperative day with a slight rise to levels of between 3000 and4000 by the 45th postoperative day. The lymphocytes showed asimilar trend. The platelet count has remained within normal limitsthroughout the period of observation.

and-over suture of 4/0 arterial silk. In case the 7 transplant hadtwo renal arteries, and these were anastomosed separatelyend-to-side to the external iliac artery. In each case the renalvein was anastomosed end-to-side to the common or externaliliac vein, using four everting stay sutures joined by a continuoussilk everting suture. The time for which the transplant wasischsmic ranged from 58 to 110 minutes.The ureter was anastomosed to the bladder by the technique

previously described (Woodruff et al. 1961). This anastomosiswas splinted by a piece of’ Neoplex ’ tubing which was broughtout through the anterior wall of the bladder and the anteriorabdominal wall, and connected to a Mayo bottle. The bladderwas drained by a Gibbon catheter which was connected to asecond Mayo bottle.

Postoperative Management .

The patients were nursed for 4 to 6 weeks after operation inthe isolation unit described previously (Woodruff et al. 1962),and the same rigorous aseptic precautions were adopted.The urine volume and the total amount of urea nitrogen and

protein in the urine were measured daily. The haemoglobin,total and differential leucocyte-counts, platelet-count, erythro-cyte-sedimentation rate, blood-urea-nitrogen, and serum-

electrolytes were also determined daily for the first week or twoafter operation and thereafter every two or three days while thepatient remained in hospital. The creatinine clearance wasdetermined about once a week for the first few weeks, andthereafter at least once every three or four weeks. Serologicalinvestigations, including estimation of total protein, paperelectrophoresis, determination of the sedimentation pattern,and quantitative estimation of antibodies against both donorand standard erythrocytes, were carried out initially every oneto two weeks, and later at regular intervals.The ureteric splint was removed after three or four days, and

the urethral catheter one day later. Physiotherapy was carriedout daily, and the patient was allowed out of bed after 10 to 12days.

Fluids were given intravenously during the first 24-48 hours,and thereafter all food and fluid were taken by mouth. Supple-ments of sodium and potassium were given when excessiveamount$of these electrolytes were lost in the urine, a proportionof the sodium being given as sodium bicarbonate in order tomaintain the concentration of bicarbonate in the extracellularfluid. The protein intake was limited to 20 g. a day while theblood-urea-nitrogen was above 100 mg. per 100 ml., and thetotal fluid intake was suitably curtailed when the urine outputwas low.

Postoperative hmmodialysis was carried out in case 7.Administration of imuran was begun a few hours before

operation, and all surviving patients are still receiving this drug.During the first week the mean daily dose ranged from 3 to5 mg. per kg. body-weight; thereafter the dosage was adjustedaccording to the leucocyte and platelet counts, the function ofthe transplant, and the clinical state of the patient. When func-tion was satisfactory and there was no sign of deterioration thedose of imuran was reduced to a level which allowed the leuco-

cyte-count to rise to a value between 3000 and 5000 per c.mm.and to remain at this level. If, on the other hand, there wasevidence of commencing graft rejection in the form of a sus-tained fall in urinary output, increasing blood-urea-nitrogen,decreasing creatinine clearance, or increasing urinary excretionof protein, the dose of imuran was increased, or the patient wasgiven supplementary treatment in the form of actinomycin C(4-8 ug. per kg. body-weight given by slow intravenous drip andrepeated if necessary every 10 days) or prednisone in very highdosage (e.g., 700 mg. in 3 days).The prophylactic use of antibiotics was avoided, but two

patients in whom a urinary-tract infection developed weretreated with appropriate antibiotics after the sensitivities of theorganisms had been determined. In the postoperative periodcase 7 developed septicxmia, due to Staphylococcus aureus andEscherichia coli. The patient was treated with cloxacillin andkanamycin, but she died.

Only in case 3 have the patient’s own kidneys been removed.This operation was performed 18 weeks after transplantation,on account of recurrent hypertension.

Results

The salient features of each case are summarised intables i and n, and their clinical course is shown graphicallyin figs 1-7.

It will be seen that the renal function in one of the

recipients (case 3) nine months after transplantation is asgood as that of a healthy child of the same age with twonormal kidneys, and it seems unlikely that this transplantwill now be rejected. Three other patients (cases 4, 5,and 9), whose grafts have been in place for periods rangingfrom 3 to 8 months, are alive with creatinine clearancesranging from 12 to 30 ml. per minute. All have shownsome evidence of an immunological reaction adverselyaffecting the transplant, and in case 9 this took an acuteform. The rapid deterioration in renal function wasreversed by giving large doses of prednisone in combina-tion with imuran, and some stability of renal functionappears now to have been achieved. Renal functionremains adequate in case 4, but in case 5 it has deterioratedslowly over a period of several months.One of the patients who died (case 7) was so desperately

ill at the time of transplantation that the chances of successwould have been small even if an identical twin had beenavailable as donor. The chances were reduced still furtherby the special technical difficulties due to two separaterenal arteries and a stricture of the ureter of the transplant,and to intractable bronchopulmonary and urinary-tract

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infection in the recipient. In the other unsuccessful case

(case 6) the transplant continued to function moderatelywell up to the time of death 2 months after transplantation,and at necropsy no histological evidence of immunologicalrejection was evident. It seems most likely that death wasdue to the toxic effect of long-continued administration ofimuran, probably potentiated by actinomycin C, in a

patient who was extremely debilitated when this treatmentwas begun. The leucocyte and platelet counts suggest thatthe bone-marrow, which had been severely depressed, wasrecovering after suspension of drug treatment; but therewas much loss of weight, atrophy of the tissues, skinpigmentation, loss of hair, and hypotension. Necropsyshowed ulceration of the pharynx and upper oesophagusand general atrophy of the tissues. The vascular supply tothe transplanted kidney was intact. The kidney showed nocellular infiltration but distinct tubular necrosis. Theresults of the serological investigations will be reportedseparately.

DiscussionThe results are encouraging, and -compare favourably

with those published from Boston (Murray et al. 1962) and

Paris (Kiiss et al. 1961, Kiiss 1962, Hamburger et al. 1962;for review see Calne 1963 and Woodruff 1963).

Three aspects of the subject call for discussion:

(1) Donor selection; (2) preoperative and postoperativemanagement; (3) the transplant-host relationship.Donor Selection

The choice of donor may decisively influence the result.In the absence of a proved method of donor selection wehave adhered to the policy of choosing a close relative whowas shown by extensive blood grouping to have few andpreferably none of the red-cell antigens which were lack-ing in the recipient. It is noteworthy, however, that,whereas in one of the two instances in which the blood-

groups of donor and host were identical in respect of allthe systems tested, there appeared to be a very high degreeof donor-host compatibility (case 3), in the other instancethe transplant was threatened by acute rejection on twooccasions, and this was prevented only by the most

vigorous treatment (case 9). The conclusion of Woodruffand Allan (1953) that compatibility in respect of a largenumber of red-cell antigens is not a sufficient condition for

homograft com-patibility is thusreinforced.

It might be ex-

pected on theoreticalgrounds that furtherhelp could beobtained from tests

based on the typingof leucocytes andblood-platelets, be-cause there is evi-dence that the former

carry all, or almost

all, the transplanta-tion antigens and thelatter appear fromthe work of Hageret al. (1962) to carryat least some of them.

Leucocyte typinghas in fact been usedquite extensively byHamburger et al.(1962), but we havebeen deterred by thedifficulty of obtain-

ing consistent results.

Preoperative andPostoperativeManagement

In so far as trans-

plantation antigensare carried on theformed elements ofthe blood, there is adanger that blood-transfusion may, bysensitising the re-

cipient, prejudice thesurvival of a kidneytransplant if the blooddonor and the kidneydonor have one or

Fig. 3-Data on case 4.Female, aged 11 yr. Wt. 43 kg. Acute glomerulonephritis with prolonged oliguria. Renal transplant-father

to daughter. Renal transplantation carried out 3 months after onset of acute glomerulonephritis associatedwith prolonged and severe oliguria. Preoperative course characterised by severe uraemia, oedema, and convulsionswhich necessitated prolonged peritoneal dialysis on two occasions. Apart from mild urinary-tract infection thepostoperative course was uncomplicated. The creatinine clearance rose from a preoperative value of 1 ml. perminute to 22 ml. per minute by the 10th postoperative day. Thereafter it steadily increased to between 30 and 40ml. per minute, showing a slight tendency to decline to values of between 20 and 30 ml. per minute after the150th postoperative day. The urine contains about 1 g. protein per 24 hr. The patient is taking an unrestricteddiet and is clinically well and at school.

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more antigens in common. The danger would seem to beless if the transfusion is given at a time when the patient isreceiving treatment designed to reduce his capacity forimmunological response, or, when imuran and similar

drugs are used, not more than about 48 hours before thestart of treatment. For this reason blood-transfusionshould, we feel, be postponed if possible until 2 daysbefore operation, and peritoneal dialysis is preferable tohsemodialysis unless a dialysing apparatus is availablewhich does not require priming with foreign blood.

If blood has to be given it is, in our view, important toavoid any donor who possesses red-cell antigens which arelacking in the patient, especially if these include some

which are also present in the kidney donor. At one timewe made a point of using relatively old blood on the groundthat it was less likely to contain viable leucocytes or intactplatelets, but this has the disadvantage that the life of thered cells is short and the number of transfusions requiredis correspondingly increased; we therefore prefer as acompromise to use packed red-cells from blood that hasbeen stored in non-siliconised glassware for one or two days.The combination of local irradiation and chemotherapy

which we have used takes advantage of the fact thatirradiation lends itself to direction in space, and chemo-

therapy to control in time. It appears to be safer than whole-body irradiation and makes it possible to obtain significant

suppression or tne

homograft reaction withoutseriously depleting eitherthe patient’s polymorphleucocytes or his blood-

platelets. There is, how-ever, much to be learntabout when to begin treat-ment, what schedule of

dosage to adopt, and when,if ever, treatment may be

stopped.Successful management

depends on accurate day-by-day assessment of theimmunological threat to

the transplant, comparedwith the risk to the patientfrom the treatment givento depress his immuno-

logical responsiveness.Damage to the trans-

plant due to an immuno-logical reaction may beindicated by various signs,including a fall in urinaryoutput or creatinine clear-ance, a rise in blood-urea-

nitrogen, an increase in theamount of protein excretedin the urine, an elevation ofblood-pressure, or swellingof the transplant. Theabsence of these signs,however, does not neces-sarily mean that all is well -,nor does their presencenecessarily imply that thetransplant is being rejected,because they may be pro-duced by other conditionsaffecting the transplantsuch as mechanical inter-ference with its blood-

supply or pyelonephritis.More information could beobtained by biopsy, but wehave been reluctant to

undertake this.

In assessing the threat tothe patient we have reliedlargely on the total anddifferential leucocyte-

Fig. 4-Data on case 5.Female, aged 11 yr. Wt. 24 kg. Chronic pyelonephritis and malignant hypertension. Renal transplant

-mother to daughter. Preoperative course was characterised by slow deterioration in renal functionover a period of several years, progressive uraemia, and the development of malignant hypertension.Following transplantation renal function was good but gradually deteriorated between the 20th and 50thpostoperative days. This deterioration was associated with recurrence of severe hypertension, thediastolic blood-pressure rising to levels of 140 mm. Hg. Thereafter the creatinine clearance improved,and levels of between 30 and 40 ml. per minute were achieved. Somewhat surprisingly this improvementwas accompanied by pyrexia of many weeks’ duration for which there was no demonstrable infectivecause. Bilateral nephrectomy was carried out on the 124th postoperative day because of the persistenceof severe hypertension, but this procedure has had no permanent effect on its severity. Despite admini-stration of imuran, actinomycin C, and prednisone, renal function has slowly deteriorated since the 120thpostoperative day, and the creatinine clearance has fallen to 12 ml. per minute. The patient is living athome and is taking an unrestricted diet but has not been allowed to return to school.

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Fig. 5-Data on case 6.

Female, aged 34 yr. Wt. 53 kg. Chronic pyelonephritis. Renal

transplant-mother to daughter. History of recurrent urinary-tractinfection with progressive renal failure over a period of 15 years.Preoperative course characterised by oliguria, severe uraemia, andoedema and low-grade urinary-tract and bronchopulmonary infectionwith pleural effusion. Life was then sustained only with peritonealdialysis. For technical reasons the donated kidney had to be placed innon-irradiated left iliac fossa of recipient. Postoperatively there wasa prompt massive diuresis, and the creatinine clearance rose to between20 and 30 ml. per minute. Severe pyrexia recurred from the firstpostoperative day for which no satisfactory infective cause was found.As this was thought to be due to an immunological reaction, actino-mycin C was given in combination with imuran from the 20th post-operative day. The patient developed anorexia, diarrhcea, andeventually about the 46th day thrombocytopenia. Imuran was thenwithdrawn, after which the platelet-count increased to normal levels.The total white-blood-cell count then ranged between 1000 and 2000cells per c.mm. The patient died on the 59th postoperative day of anillness believed to be due to drug intoxication. This was characterisedby much weight-loss, pigmentation of the skin, some loss of hair,muscle weakness, tachycardia, and hypotension. Necropsy showedulceration of the pharynx and upper cesophagus and general atrophyof the tissues. The vascular supply to the transplanted kidney wasintact. The kidney showed no cellular infiltration but pronouncedtubular necrosis.

count, and the blood-platelet count. It is important toconsider the rate of change in the counts as well as theabsolute values and to reduce the dose of drug before thecounts have fallen to dangerous levels, because it may takea week or longer before a change in dosage produces acorresponding change in the leucocyte or platelet count.Moreover, the effect of a given dose of drug may be verymuch greater when the marrow mass has already beenreduced by long-continued treatment.

Despite the importance of marrow aplasia, it is becom-ing apparent that the type of metabolic disturbance which

occurred in case 6,andwhichweattri-bute to widespreadinterference withtissue anabolism,may constitute aneven greater threatto the patient.There is an urgentneed for a reliablemethod of recog-nising this condi-tion before it isirreversible.

It is pertinentto ask whether the

pattern of drugadministrationwhich we have

adopted is themost appropriate.It has been shown

by Berenbaum(1961) that a singledose of 6-mercap-topurine producesmaximal depres-sion of the im-

munological res-

ponse of themouse to a singleinjection of T.A.B.vaccine if the anti-metabolite is given24-48 hours after

injection of the

antigen. In seek-

ing to promotethe survival of a

kidney homograft,Fig. 6-Data on case 7.

Female, aged 14 yr. Wt. 75 kg. Acute glomerulonephritis. Renaltransplant-father to daughter. Severe renal failure developed over aperiod of 4 months following acute glomerulonephritis. Diagnosismade by renal biopsy. The preoperative course was complicated bysevere bronchopulmonary and urinary-tract infection, and peritonealdialysis was required on two occasions over several days. Renaltransplantation was carried out before it was possible to eradicateinfection either in the chest or urinary tract. Postoperatively oliguriapersisted; the blood-urea concentration rose to an extent necessitatinghasmodialysis. The total white-cell count fell to 600 per c.mm. by the10th postoperative day, and the patient died on the 12th postoperativeday with septicaemia due to Staph. aureus and Esch. coli. Necropsyshowed collapse of lower lobe of right lung with bronchopneumoniaand severe cystitis. The transplanted kidney showed no lesion of therenal vessels or site of anastomosis. The renal parenchyma showed nosignificant cellular infiltration, but there was evidence of tubularnecrosis.

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however, we are not restricted to a single dose of anti-metabolite, and it remains an open question whetheror not it would be advantageous to start treatment somedays before the operation. It is equally uncertain howthe doses should be spaced, and whether or not it is

advantageous to give relatively large doses during the firstfew days of treatment.In addition to imuran we have used two other drugs-

actinomycin C and prednisone-which appear to offersome prospect of arresting or even reversing the process ofgraft rejection after signs of damage have appeared.Calne et al. (1962) reported that actinomycin C in

combination with imuran was more effective than imuranalone in preventing the rejection of canine renal homo-grafts, and observed that in some cases it could reverse arejection process after this had become established. Ourexperience suggests that administration of actinomycin Cmay be of value as supplementary treatment when a trans-plant shows deterioration in a patient receiving the maxi-mum amount of imuran he can tolerate, but the evidenceis not sufficient to be decisive.

Administration of steroids in conventional dosageappears to be of little value, but the dramatic effect ofmassive doses of prednisone in case 9 encourages us toadopt the same treatment in future cases showing signs ofacute rejection.Another question of great importance concerns the

indications for removing the patient’s own kidneys. Itwould be generally agreed that grossly infected kidneysshould be removed. Although it might seem reasonable toperform bilateral nephrectomy when, as in case 5, hyper-tension recurs after operation in a patient whose transplantis functioning satisfactorily, the prospect of success isuncertain. In the patient reported here severe hyper-tension reappeared 30 days after bilateral nephrectomy.By this time the function of the transplanted kidney hadbegun to deteriorate, but we have also seen recurrence ofsevere hypertension in a patient whose transplant wasobtained from her identical twin and is functioningnormally, and whose own kidneys remain in situ (case 8).This experience is contrary to that of Murray et al. (1958),who claimed that the introduction of healthy renal tissuereduced the blood-pressure in these circumstances.Unlike Murray and his colleagues (see Murray and

Harrison 1963) we are not convinced of the desirability ofremoving the kidneys of patients with acute or chronicglomerulonephritis. Admittedly, glomerulonephritis hasbeen diagnosed histologically in the transplant in two ofMurray’s patients whose own kidneys were not removed,but it happens also to have supervened in one donor.On theoretical grounds there seems to be a risk in

patients with acute glomerulonephritis of this conditiondeveloping in the transplant, but there is no obvious reasonwhy this should be lessened by removing the affectedkidneys. Indeed, Hamburger et al. (personal communica-tion) have observed changes suggestive of " glomerulo-nephritis " in the transplanted kidney in a patient whoseown kidneys had been removed at a stage when the trans-plant appeared histologically normal; but these changesmay be manifestations of a very slow rejection.

It seems possible that the treatment given to inhibit thehomograft reaction might help to reduce the risk; and, ifthis hypothesis is correct, when the patient has acutenephritis such treatment might suitably be given even ifthe donor were an identical twin.

Fig. 7-Data on case 9.

Male, aged 21 yr. Wt. 55 kg. Subacute glomerulonephritis. Renaltransplant-brother to brother. Patient was known to have chronicrenal disease for 3 years before operation. Developed features ofsevere renal failure in the last 3 months. The diagnosis of subacuteglomerulonephritis was made by renal biopsy. Progressive deteriora-tion in his clinical condition and severe oliguria necessitated hsmo-dialysis on one occasion and peritoneal dialysis on two occasions.After renal transplantation the creatinine clearance and urine volumerose sharply for some days. At the 10th postoperative day there wasa sudden decline in renal function with an increase in blood-urea-nitrogen, severe oliguria, and hsematuria. This was attended by muchswelling of the graft and discomfort. These changes were dramaticallyreversed by large doses of prednisone, and renal function was ulti-mately stabilised with a creatinine clearance of between 20 and 30 ml.per minute. Repeated attempts to withdraw prednisone resulted indeterioration of function and swelling of the graft, and this drug hastherefore been continued. Postoperative course has been characterisedby persistent pyrexia.

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Nature of the Transplant-host relationshipLittle is known of the nature of the symbiotic relation-

ship between a successful renal homotransplant and itshost, but in any given case there would seem to be fivepossibilities:

1. There has been a very high degree of donor-host

compatibility ab initio.2. Survival of the transplant depends on generalised sup-

pression of the host’s immunological responsiveness which ismaintained by continued treatment.

3. There is specific abrogation of the host’s capacity to reactagainst the foreign antigens of the transplant.

4. A process of adaptation has occurred as a result of whichthe transplant has become less vulnerable in the face of

immunological attack.5. Some combination of these factors is responsible.A high degree of donor-host compatibility can be

excluded when, as in three of the four surviving recipientsin the present series, there has been evidence of a moder-ately severe immunological reaction to the transplant atsome stage in its life history.Some generalised impairment of immunological respon-

siveness may be expected with all the procedures currentlyused to diminish the homograft reaction. It seems unlikely,however, that this factor alone could account for prolongedsurvival of a transplant when, as in the present series ofcases, treatment has been maintained after the patient’sdischarge from hospital at a level which allows him areasonable measure of defence against infection.The possible role of specific unresponsiveness is more

difficult to assess.In adult mice unresponsiveness to skin homografts may

be induced by sublethal irradiation followed by the

injection of donor-strain spleen cells (Main and Prehn1955, Michie and Woodruff 1962); and it has been shownthat, while many of the recipient’s cells are replaced bycells of donor origin, some remain and are capable ofreacting against skin from mice of a third strain thoughthey have lost the capacity to react against donor-strainskin. In the light of this fact, and the further observationthat the state of unresponsiveness can be abolished byequipping the recipient with lymphoid cells from a mouseof the same strain which has been immunised againstdonor-strain tissue, Michie and Woodruff (1962) con-cluded that the unresponsiveness was due to a specificcentral failure of the mechanism of immunologicalresponse. They therefore suggested that the term specificimmunological tolerance, which was used originally(Billingham et al. 1956) to denote a similar state induced infoetal or neonatal animals, should be extended to includethe phenomenon under discussion.

It has been suggested that the occasional prolongedsurvival of renal homografts in dogs after treatment withantimetabolites has been discontinued is due to a similartype of unresponsiveness (Pierce and Varco 1962, Zukoskiand Callaway 1962). There is, however, no experimentalproof of this; and the observation of Alexandre et al.

(1963) that Imuran-treated dogs bearing renal homo-transplants rejected a subsequent skin graft from thekidney donor is prima facie evidence against the existenceof specific immunological tolerance. This finding is,however, not quite decisive because of the possibility thatskin may carry some antigens which are not present in thekidney. -

Another form of specific impairment of the immuno-logical response to homografts, known as enhancement,appears somewhat paradoxically to depend on the presence

of haemagglutinating antibodies active against the erythro-cytes of the tissue donor, and may be transferred passivelyby means of serum (see Kaliss 1957). The degree ofimpairment of immunological responsiveness may besufficient to permit a tumour transplanted from oneanimal to another of different genetic constitution, whichwould otherwise be destroyed, to grow and kill the host;but so far only slight prolongation of the survival of

homografts of normal tissues has been achieved in this way(see Woodruff 1960 for review). There is no evidence thatenhancement plays, or can be made to play, a major role inpromoting the survival of kidney homotransplants, but itwould be unwise to dismiss this possibility.

There is evidence that homografts of various kindsbecome progressively less vulnerable as a result of adapta-tion (Woodruff 1959), though the mechanisms involvedhave not been elucidated. It seems likely that adaptationcan occur in renal homotransplants, and it is sometimesdifficult, as in the experiments of Alexandre et al. (1963),to account for prolonged survival in any other way; butfurther experimental investigation is needed to settle thematter.

We are indebted to many colleagues for referring cases to us andfor their helpful collaboration. In particular we should like to thankDr. J. H. Bowie and Dr. R. W. Tonkin for the bacteriologicalinvestigations, Dr. K. L. G. Goldsmith and Dr. R. A. Cumming forblood-grouping the patients and donors, Dr. S. H. Davies for under-taking the hxmatological investigations, Prof. R. McWhirter andDr. J. Newall for carrying out the irradiation, Dr. J. D. Robertsonand his colleagues who have been responsible for the anaesthetics inthe donors and recipients, Dr. Mary MacDonald for pathologicalinvestigations, and our nurses for their skilful and devoted work.We are grateful also to the Nuffleld Foundation for generous financialsupport, and to Dr. D. A. Long and Burroughs Wellcome & Co. fora plentiful supply of ’ Imuran ’.

REFERENCES

Alexandre, G. P. J., Nolan, B., Murray, J. E. (1963). Transplantation (inthe press).

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Hager, E. B., Burns, R. O., Carter, R. D., Merrill, J. P. (1962) Fed. Proc.21, 37.

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Kaliss, N. (1957) Ann. N.Y. Acad. Sci. 64, 977.Küss, R., Legrain, M., Camey, M., Désarmenien, J., Mathé, G., Nedey, R.,

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Pierce, J. C., Varco, R. L. (1962) Lancet, i, 781.Woodruff, M. F. A. (1959) in Biological Problems of Grafting. Les Congrès

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Public Health

Death of Pets in South WalesIN the weekend of Sept. 20-22, about 100 cats and dogs

died in Merthyr Tydfil, in South Wales. They had all beenfed on meat from a horse taken to the slaughterhouse earlierin the week, after it had been found dead on a road. Up tolast Tuesday, it had not been established whether chemical

poisoning or bacterial toxins were responsible for the deaths.Local farmers denied allegations that poison, laid down to