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Regulation of transplantation immunity in vivo by monoclonal antibodies recognizing host class II restriction elements. II. Effects of anti-Ia immunotherapy on host T cell responses to graft alloantigens.

Results of the preceding report demonstrated that in vivo treatment with monoclonal anti-I-A antibodies provided an effective means of prolonging the survival of murine tail skin allografts. The mechanism of antibody action was shown to include the activation of alloantigen-specific suppressor T cells (Ts), although the relationship between Ts expression and graft survival was not determined. This issue was addressed in the current studies through a kinetic analysis of suppressor and effector T cell responses in control and treated allograft recipients. Donor-specific delayed-type hypersensitivity (DTH) and cytotoxic T lymphocyte (CTL) responses were detectable in untreated A/J recipients of B10.A allografts 8 days after transplantation, rising to near maximum levels by day 12. Rejection in these animals occurred by day 11. In contrast, the predominant cellular response of anti-I-A treated animals for 12 days after transplantation was that of transferable suppression, DTH and CTL reactivity not being evident until day 15, coincident with the decay of Ts activity. Rejection in these animals was observed approximately 19 days post-transplant. CTL responsiveness in the latter group could not be reconstituted by the addition of antigen-presenting cells to the secondary in vitro culture system, nor was the CTL deficit due to antibody carry-over. It is considered that the altered expression of effector cell responses to graft alloantigens is due at least in part to the in vivo inhibition of helper T cell activity by anti-I-A-induced Ts, and that rejection in the treated host results from an eventual decline in the functional expression of this regulatory T cell subset.

Animals↗

Intraoral reconstruction of mandibular defects after tumor resection.

The intraoral reconstruction of mandibular defects resulting from tumor resection with autogeneic iliac bone is described. Large pieces of pelvis can be harvested and split sagittally for lengthening or altering the direction and shape of the body or angle of the reconstructed mandible. A graft taken from the iliac tubercle region can be used for satisfactory reshaping of the chin area. Delays in reconstruction, if necessary, should be of short duration, and a fabricated Kirschner wire splint with fixation screws, or a Kirschner wire and acrylic condyle may serve to counteract scar retraction prior to grafting. Esthetic and functional results have been good, and postoperative complications have been minimal.

Adult↗

Nonstress delayed-enhancement magnetic resonance imaging of the myocardium predicts improvement of function after revascularization for chronic ischemic heart disease with left ventricular dysfunction.

BACKGROUND: The extent of myocardial scarring of the left ventricle (LV) is important in patients with chronic ischemic heart disease (CIHD). With delayed-enhancement magnetic resonance imaging (DE-MRI), scarred myocardium (hyper-enhanced) is easily distinguishable from viable (dark) myocardium. This investigation assessed the use of DE-MRI for predicting functional improvement after coronary artery bypass grafting (CABG) in patients with CIHD and significant LV dysfunction. METHODS: The patient population (n = 29) with CIHD and LV dysfunction (ejection fraction 28% +/- 10%) underwent both DE-MRI, to delineate scarred regions before revascularization, and echocardiography (Echo), to assess segmental function before and after CABG (interval 188 +/- 57 days). Using a 16-segment model, LV myocardium was semiquantitatively analyzed for scarring based on DE-MRI and for improvements in resting function by pre- and post-CABG Echo. RESULTS: Before CABG, 82% of targeted myocardial segments had abnormal contraction; 78% showed scarring, including 38% with greater than mild amounts (25%-100%). Normal contraction was found in 18% of segments before revascularization; scarred areas were identified in 42%, 84% of which had, at most, minimal amounts (0%-24%). Of segments with pre-CABG dysfunction, 82% with no evidence of scar recovered, compared to only 18% with > or =50% scarring. Amount of hyper-enhancement was a very good indicator of improvement of function, especially at the > or =50%/segment threshold; overall accuracy was 0.74 (95% CI 0.66-0.82, P <.001). CONCLUSIONS: In patients with CIHD and significant LV dysfunction, DE-MRI can predict likelihood of functional improvement after revascularization.

Adult↗

Current status of cardiac surgery in the abciximab-treated patient.

BACKGROUND: Early surgical experience with abciximab and other glycoprotein (GP) IIb/IIIa receptor antagonists suggested a tendency toward excessive bleeding in patients treated with these agents. With increased use of GP IIb/IIIa inhibitors, cardiac surgeons have become aware of their hazards, as well as potential benefits, during and after cardiac surgery. Although published experience with the GP IIb/IIIa inhibitor abciximab is limited in scope, it suggests management guidelines for urgent coronary artery bypass grafting in abciximab-treated patients. As more urgent and elective surgical data are presented, a clearer picture of true bleeding risk will evolve. METHODS: Two large retrospective studies examining reexploration for postoperative bleeding have identified risk factors, including advanced age, preoperative renal dysfunction, and operation/reoperation other than coronary artery bypass grafting. Other risk factors for transfusion requirement and increased morbidity and mortality are emergent operation, postoperative coagulopathy, and prolonged bypass time. RESULTS: To minimize real and perceived bleeding effects, some authors have suggested delaying operation until platelet function has normalized, employing platelet transfusion in patients in whom delay is not possible, and exacting heparin management during cardiopulmonary bypass. Later reports have not noted increased bleeding when incorporating these modifications plus early platelet transfusion, if required. Further experience with abciximab removal and reversal may also ultimately reduce or eliminate excess transfusion requirements. CONCLUSIONS: Surgeons should work closely with perfusionists and anesthesiologists on issues of heparinization in the abciximab-treated patient. The apparent paradox of preserved platelet numbers and depressed platelet function with abciximab use has led to speculation about a role for this agent and other shorter-acting GP IIb/IIIa inhibitors for "platelet anesthesia" during cardiopulmonary bypass. With careful surgical care, GP IIb/IIIa receptor antagonists can maintain and improve beneficial outcomes.

Abciximab↗

Drug-induced acute interstitial nephritis in renal allografts: histopathologic features and clinical course in six patients.

Drug-induced acute interstitial nephritis is a common cause of dysfunction in native kidneys, but is rarely reported in renal allografts. This report describes six renal transplant recipients with acute renal allograft dysfunction or delayed allograft function in whom a renal transplant biopsy showed histopathologic features of drug-induced interstitial nephritis with no diagnostic evidence of acute rejection, cyclosporine or tacrolimus nephrotoxicity, or other lesion that could account for the graft dysfunction. In five of the six patients, interstitial nephritis occurred within 4 weeks of transplantation. All the patients were receiving trimethaprim-sulfamethoxazole and/or other drugs associated with interstitial nephritis. After discontinuation of these drugs and short-term corticosteroid treatment, all patients showed improvement in renal function, although the time course of this improvement varied considerably, with three patients showing a return to baseline serum creatinine level within 2 weeks and two patients showing a gradual improvement over 8 weeks. Four of the five patients followed up for more than 1 year (range, 14 to 33 months) after the episode of interstitial nephritis had good allograft function (serum creatinine level </= 1.6 mg/dL) at most recent follow-up, with one patient who had graft loss because of severe rejection 7.5 months after the development of interstitial nephritis. These findings suggest drug-induced interstitial nephritis may be an infrequent cause of graft dysfunction in kidney transplant recipients. Drug-induced interstitial nephritis is a reversible lesion that should be considered in the differential diagnosis of acute renal allograft dysfunction.

Acute Disease↗

[Ulnar nerve compression and pseudoarthrosis of the medial metacarpal bases].

A case of compression of the deep branch of the ulnar nerve associated with pseudarthrosis of the base of the fifth metacarpal and the upper shaft of the fourth metacarpal is reported. The delayed procedure consisted in volar decompression of the ulnar nerve by dividing the pisi-hamate ligament and plating and grafting of both fractures. The patient achieved marked improvement four weeks post-operatively and had complete functional recovery at follow-up of 16 years after injury without narrowing of the hamato-metacarpal joint despite synostosis of the bases of the medial metacarpals.

Adult↗

Normothermic blood perfusion of isolated rabbit kidneys. II. In vitro evaluation of renal function followed by orthotopic transplantation.

This study describes the use of a blood perfusion apparatus to assess the renal function of isolated kidneys. Eight fresh kidneys were obtained from healthy rabbits and perfused with blood at 36 degrees C for 2 hours. Rabbit blood was drawn and diluted to a hematocrit of 25%. The kidneys were evaluated for their capacity to support life in an autograft model. Blood and urine samples were taken at regular time intervals during kidney perfusion. Serum creatinine was measured in surviving rabbits after transplantation. Over the course of the perfusion, arterial pressure was maintained at 87.2 +/- 5.5 mm Hg. The renal blood flow (3.7 +/- 1.0 ml/min per g) and urine output (0.11 +/- 0.04 ml/min per g) were continuously monitored. Glomerular filtration rate (0.29 +/- 0.02 ml/min per g) and fractional reabsorption (FR) of sodium and glucose indicated appreciable tubular function (FR(Na) = 67.9 +/- 8.5%, FR(Glu) = 91.2 +/- 5.8%). Protein was excluded from urine at 99.8% +/- 0.1%. After transplantation, the peak creatinine was 6.8 +/- 3.2 mg/dl at 1.90 +/- 0.92 days for the seven surviving rabbits and was above 16 mg/dl for the only rabbit that died 4 days after operation. The level of free hemoglobin generated at the end of the perfusion (2.6% +/- 2.8%) was correlated with the postoperative peak creatinine (r2 = 0.84). Perfusion of seven additional kidneys by using the roller pump lead to a final hemolysis of only 0.34 +/- 0.14%. Kidneys transplanted after 2 hours of blood perfusion were able to resume normal function and support life. Hemolysis was a measurable stress factor causing delayed function of the kidney after transplantation. Introduction of a roller pump significantly reduced the hemolysis.

Animals↗

Severe carpal and tarsal shearing injuries treated with an immediate arthrodesis in seven dogs.

The medical records of seven dogs with severe, grade 3, open shearing wounds of the carpus or tarsus that were treated with an immediate arthrodesis were reviewed. Six dogs were managed with a transarticular external skeletal fixator (ESF), and one dog was treated with plate fixation. The soft tissues were managed simultaneously along with the definitive joint stabilization in all cases. Minor complications occurred in four dogs: one dog that required a skin graft, one dog in which a skin graft was recommended but not performed, one dog in which a secondary skin closure was performed, and one dog in which a delayed cancellous bone graft was placed. Major complications occurred in three dogs: two dogs that required restabilization of the arthrodesis and one dog that required implant (i.e., plate) removal due to infection. All dogs healed with acceptable functional and cosmetic results. Further long-term evaluation of five dogs revealed that all but one dog had either excellent or good functional outcomes, and the remaining dog had a fair outcome. Similarly, five dogs had either excellent or good cosmetic outcomes, with the remaining dog having a fair outcome. All owners were very satisfied with the overall results. This clinical study demonstrated that an immediate, definitive management technique, in which bone fusion and wound management are undertaken as simultaneous objectives, is a viable technique of managing severe periarticular shearing injuries. Transarticular stabilization with an ESF is the technique recommended.

Animals↗

Respiratory control during independent lung ventilation.

We describe the case of a lung transplant patient with primary graft failure and an emphysematous native lung, who displayed different respiratory rates between the transplanted lung and the native lung. Inflation of the native lung delayed the next inspiratory effort relative to inflation of the denervated transplanted lung. Synchronous inflation of both lungs required more pressure in each lung than when that lung was inflated with the contralateral lung near functional residual capacity, suggesting the two lungs compete for space within the thoracic cavity.

Functional Residual Capacity↗

Cognitive deficits induced by global cerebral ischaemia: prospects for transplant therapy.

Global ischaemia induced by interruption of cerebral blood flow results in damage to vulnerable cells, notably in the CA1 and hilar hippocampal fields, and is frequently associated with memory deficits. This review examines cognitive deficits that occur in animal models of global ischaemia in rats and monkeys, the extent to which these deficits are associated with CA1 cell loss, and the evidence for functional recovery following transplants of foetal CA1 cells and grafts of conditionally immortalised precursor cells. In rats, impairments are seen most consistently in tasks of spatial learning and spatial working memory dependent on use of allocentric environmental cues. In monkeys, ischaemic deficits have been shown to a moderate extent in delayed object recognition tasks, but animals with a selective excitotoxic CA1 lesion show a profound impairment in conditional discrimination tasks, suggesting that these may be a more sensitive measure of ischaemic impairments. Several studies have reported correlational links between the extent of CA1 cell loss following two or four vessel occlusion (2 VO, 4 VO) in rats and behavioural impairments, but recent findings indicate that at intermediate levels of damage these relationships are weak and variable, and emerge clearly only when animals with maximal CA1 cell loss are included, suggesting that the deficits involve more than damage to the CA1 field. Nevertheless, ischaemic rats and CA1-lesioned marmosets with grafts of foetal CA1 cells show substantial improvements; in rats these are not found with grafts from other hippocampal fields. Conditionally immortalised cell lines and trophic grafts are currently being assessed for their functional potential in animal models, because clinical use of foetal cells will not be practicable. Recent findings suggest that an expanded population of neuroepithelial cells derived from the conditionally immortalised H-2Kb-tsA58 transgenic mouse improve spatial learning as effectively as CA1 foetal grafts in rats subjected to 4 VO, and clonal lines from the same source show similar promise. Lines derived from precursor cells have the potential to develop into different types of cell (neuronal or glial) depending on signals from the host brain. These cell lines may therefore have the capacity to repair damaged host circuits more precisely than is possible with foetal grafts, and offer a promising, approach both to functional recovery and to elucidating graft-host interactions.

Animals↗

Delayed-type hypersensitivity-like mechanisms dominate late acute rejection episodes in renal allograft recipients.

Episodes of acute rejection (aRx) may occur in functional renal allografts even at a very late stage post-Tx. Histopathology in early and late aRx looks quite similar--however, there is a slower deterioration of graft function in late aRx, suggesting that pathogenetic immune mechanisms are different. In order to investigate this phenomenon we studied the gene expression pattern (IL-1beta, 2, 4, 8, 10, IFNgamma, TNFalpha, GrnA, IL-2R p55/p75) in PBMC and core biopsies from long-term renal allograft recipients with histologically proven late aRx and compared it with transplant and non-transplant controls using a semiquantitative RT-PCR technique. PBMC and graft-infiltrating cells of patients with late aRx showed an upregulation, especially of IFN-gamma, IL-4, IL-10, and TNFalpha transcripts. While IL-2 mRNA was only detected in PBMC of two patients with late aRx who were not on cyclosporine, upregulation of intragraft IL-2 mRNA allowed the best discrimination between aRx and the other groups (sensitivity: 83%, specificity: 93%). In contrast to several reports on early Rx we did not notice an elevation of granzyme A transcripts in comparison with the controls, suggesting that cell-mediated inflammatory processes (CD4+ T cell-mediated DTH) dominate the late aRx, while early aRx is characterized by the additional involvement of cytotoxic T cell response. This may explain the distinct clinical course. Additionally, in a pilot study we successfully treated late aRx in 10/12 patients with the anti-CD 4 mAb, 16H5. Our encouraging therapeutic results underline the pathogenetic role of CD4+ T cells and support our hypothesis on DTH-like mechanisms in late aRx.

Cytokines↗

[Iatrogenic myocardial infarction].

In this paper, iatrogenic myocardial infarction resulting from percutaneous catheter intervention (PCI) and cardiac surgery is described. Among the patients who had experienced iatrogenic myocardial infarction in the past 4 years, 6 had undergone emergent coronary artery bypass grafting (CABG). An emergent operation for myocardial infarction was performed on 3 patients, for problems associated with PCI, and 1 patient had died due to cardiac failure. In the latter case, although the emergent CABG was performed after the failure of percutaneous coronary intervention in another hospital, no improvement in cardiac function was observed. The reason for this was that the myocardial damage became almost irreversible due to the delay in transferring the patient to our hospital. An additional CABG was performed in 2 cases, because they experienced a cardiogenic shock after cessation of the cardio-pulmonary bypass system. In these cases, cardiac function had improved immediately after an additional CABG. Some ST elevation in the electrocardiograms was observed in 8 cases in the intensive care unit after isolated CABG. One patient experienced a cardiogenic shock, and was transferred to the operating room immediately. The radial artery graft connected in sequence to circumflex coronary arteries was spastic, and an additional bypass was performed to the same coronary arteries using a saphenous vein graft. Although conservative medical therapy was administered in the remaining 7 cases, 1 case presented an occlusion of the left descending coronary artery, and an emergent CABG should have been performed. ST elevations in 2 cases were caused by coronary spasm, while in the remaining 4 cases, they were caused by pericardiotomy. Although a postoperative change in the electrocardiogram was considered important, the diagnosis was complicated. In myocardial infarction, cardiogenic shock develops easily, and an emergent CABG is needed in many cases. It is important to decide on an emergent operation promptly after an accurate diagnosis.

Adult↗

Vascular endothelial growth factor receptor-3 mediates induction of corneal alloimmunity.

There are no studies so far linking molecular regulation of lymphangiogenesis and induction of adaptive immunity. Here, we show that blockade of vascular endothelial growth factor receptor-3 (VEGFR-3) signaling significantly suppresses corneal antigen-presenting (dendritic) cell trafficking to draining lymph nodes, induction of delayed-type hypersensitivity and rejection of corneal transplants. Regulating the function of VEGFR-3 may therefore be a mechanism for modulating adaptive immunity in the periphery.

Animals↗

Re-establishment of erythropoietin responsiveness in end-stage renal failure following renal transplantation.

Re-establishment of erythropoietin (EPO) secretion following renal transplantation is poorly understood. The development of sensitive EPO radioimmunoassay has enabled further study of this phenomenon. Forty-one adult patients were studied during the first 16 weeks following renal transplantation. Twenty six received cyclosporin monotherapy and 15 also received prednisolone and azathioprine. Serum creatinine, haemoglobin (Hb), ferritin and EPO were assayed pre-operatively, daily for 1 week, weekly for 1 month, and fortnightly to 16 weeks. An expected EPO value, for any Hb level, was derived by linear regression analysis in 144 patients with iron deficiency anemia. An observed to expected ratio (O/E) was calculated, a value of 1.0 implying appropriate responsiveness. Hb increased from 8.6 +/- 2.0 (SD) to 12.3 +/- 2.1 g/dl (p < 0.001) over 16 weeks, an increase unaffected by ferritin status. Mean EPO concentration increased during the first week with a peak at day 4 (22.1 +/- 13.3 to 44.6 +/- 40.0 mu/ml, p < 0.05), a change apparent only in patients with immediate graft function (24 cases). There was no correlation between EPO and Hb pre-operatively; however a significant inverse relationship was established by week 16 (r = -0.404, p < 0.02). The median O/E ratio (0.22) at baseline increased progressively to 1.0 at 16 weeks (p < 0.001); ratios were significantly greater in the immediate versus delayed function group throughout (p < 0.05). In the former group an O/E ratio of 1.0 was reached at 10 weeks when mean serum creatinine was 142 +/- 48 mumol/l. Patients with poor ongoing renal function (9 cases, serum creatinine > 250 mumol/l at 16 weeks) had impaired Hb recovery (10.1 +/- 1.6 vs 12.7 +/- 2.0 g/dl at 16 weeks, p < 0.05). EPO values were not different in those patients but median O/E ratios were significantly depressed (p < 0.05) throughout, the maximum O/E ratio being 0.75. Recovery of renal function is accompanied by a beneficial Hb response driven by EPO synthesis in the transplant. The O/E ratio provides a useful index to assess EPO responsiveness. Appropriate secretion was achieved during the first 4 months and optimized by immediate and satisfactory graft function.

Adult↗

Lymphocyte dysfunction in chronic graft-versus-host disease.

Three recipients of HLA-identical bone marrow transplants developed chronic graft-versus-host disease (cGVHD) and hypergammaglobulinemia. All three had evidence of abnormal B-lymphocyte function, including a polyclonal increase in immunoglobulins (Ig), antinuclear antibodies, rheumatoid factor, lymphocytotoxins, and increased immune complexes. T-lymphocyte function was also abnormal, including decreased mitogen reactivity and delayed cutaneous hypersensitivity. The cellular basis of these immune abnormalities was studied in an in vitro system in which we analyzed spontaneous pokeweed mitogen (PWM) driven Ig synthesis. Multiple defects in both T- and B-lymphocyte function were detected. In contrast to normal B cells, circulating B cells from all three patients with cGVHD spontaneously synthesized in vitro greater than 200 ng of IgG and in two of the three greater than 175 ng of IgM. This increase in spontaneous Ig synthesis was not due to a deficiency of regulatory cells, since T cells from the three patients suppressed spontaneous Ig synthesis in a normal fashion. In contrast to this increased spontaneous Ig synthesis, the response of the patients' B cells to PWM-driven Ig synthesis was normal. Using the PWM system we demonstrated several defects in these patients' T cells, including increased suppressor activity and decreased helper cell activity. These data indicate that some patients with cGVHD have multiple defects in both T- and B-cell function that may contribute to their profound immune deficiency.

Adolescent↗

Patterns of allosensitization in allograft recipients: long-term cardiac allograft acceptance is associated with active alloantibody production in conjunction with active inhibition of alloreactive delayed-type hypersensitivity.

BACKGROUND: The immunologic characteristics of experimental allograft acceptance remain ill-defined. This study evaluates humoral and cell-mediated immunity in transiently immunosuppressed mice that have accepted cardiac allografts. METHODS: DBA/2-->C57BL/6 heterotopic cardiac allograft recipients were immunosuppressed with either GK1.5 monoclonal antibody or gallium nitrate and monitored for donor-reactive delayed-type hypersensitivity (DTH) assessed by ear challenge and for alloantibody production detected by flow cytometry. RESULTS: Cardiac allograft function continued for >90 days in approximately 50% of GK1.5-treated and 97% of gallium nitrate-treated transplant recipients. All nonsuppressed recipients lost graft function within 7 to 10 days. Among mice that accepted allografts, donor-reactive IgG was produced by about 50% of GK1.5 monoclonal antibody-treated mice and 80% of gallium nitrate-treated mice. None of the these mice exhibited donor-reactive DTH responses, and all could down-regulate third-party DTH responses in a donor alloantigen-dependent manner. This down-regulation is not found in nonsuppressed allograft recipients or in naive mice. Importantly, transfer into SCID mice of splenocytes from mice that accepted allografts, but not naive splenocytes, provided them with a similar ability to accept cardiac allografts, even if the grafts co-expressed third-party alloantigens. CONCLUSIONS: IgG alloantibody production by murine cardiac allograft recipients is not a precise indicator of allosensitization leading to either cardiac allograft rejection or acceptance. However, expression of alloreactive DTH is a reliable indicator of allosensitization leading to acute rejection, and the absence of DTH in association with active DTH down-regulatory mechanisms is a reliable indicator of allograft acceptance in this experimental model. Thus, DTH analysis may hold more promise than alloantibody detection for clinical assessment of posttransplant immune status.

Animals↗

Prevention of oral tolerance induction to ovalbumin and enhanced antigen presentation during a graft-versus-host reaction in mice.

Systemic hyporesponsiveness after ingestion of a protein antigen (oral tolerance) depends on antigen processing by the gut and the actions of immunoregulatory T cells. We have examined the effects of a graft-versus-host reaction (GvHR) on oral tolerance, since both immune status and intestinal function are altered in GvHR. The GvHR was induced in unirradiated (CBA X BALB/c)F1 mice by intraperitoneal injection of CBA spleen cells. The tolerance of systemic humoral immunity and of delayed-type hypersensitivity normally found in mice fed 25 mg ovalbumin (OVA) was partially abrogated from 1 to 3 weeks after induction of the GvHR. In addition, mice with GvHR had a persistent enhancement of systemic immunity to OVA, and this was associated with an augmented ability of spleen cells to present OVA to primed T cells. The phagocytic activity of the reticuloendothelial system, as established by carbon clearance tests, was not altered by the GvHR. These findings suggest that enhanced antigen-presenting cell activity interferes with the induction of oral tolerance, and may be another pathogenetic mechanism of intestinal hypersensitivity disease.

Administration, Oral↗

Longitudinal monitoring of immune reconstitution by CDR3 size spectratyping after T-cell-depleted allogeneic bone marrow transplant and the effect of donor lymphocyte infusions on T-cell repertoire.

Delayed immune reconstitution after allogeneic bone marrow transplantation (BMT) with associated infection is a major cause of morbidity and mortality. We used third complementarity region (CDR3) size spectratyping as a tool for monitoring T-cell repertoire reconstitution in 19 patients over a median time of 40 months after T-cell-depleted allogeneic BMT for chronic myeloid leukemia (CML). Furthermore, the effect of donor lymphocyte infusions (DLI) for the treatment of relapse in 18 of the 19 patients was analyzed. All BMT recipients had irregular spectratypes in the first 3- to -6 months after transplant. These evolved to more normal patterns by 12 months after transplant and continued to improve thereafter. In approximately a third of the patients, it took 2 to 3 years for all spectratypes to normalize, whereas in the other two thirds, some abnormal spectratypes persisted even after several years. In 9 patients, there was no immediate change in the CDR3 size profiles after DLI. In 3 patients, spectratypes improved slightly after DLI, whereas in 6 patients, spectratypes became more restricted and irregular. Overall, T-cell spectratypes in BMT patients were characterized by instability over time and in patients with graft-versus-host disease (GVHD), this was even more exaggerated. Several factors, such as pre-BMT conditioning, T-cell depletion of the donor marrow, loss of thymic function in adults, exposure to infectious agents, GVHD, and immunosuppressive treatment, are likely contributors to the delay in T-cell-repertoire reconstitution. (Blood. 2000;95:3990-3995)

Adolescent↗