No abstract

Although immune responses are generally considered to be systemic, local events such as interaction of complement products with blood vessels and with inflammatory cells play a pivotal role in determining the nature and manifestations of immune responses. This paper will discuss how blood vessel physiology and immunity influence one another to reach homeostasis upon exposure to an infectious agent. We review new insights into the mechanisms by which the microenvironment of tissues protects against microbial invasion yet facilitates migration of leukocytes and ‘decides’ whether immunity or tolerance ensues and whether, in the face of immunity, protective responses or tissue injury ensues. These ‘decisions’ are made based on interaction of components of normal tissues such as proteoglycans and injured tissues such as cell‐associated cytokines with receptors on immune cells and blood vessels.—Saadi, S., Wrenshall, L. E., Platt, J. L. Regional manifestations and control of the immune system. FASEB J. 16, 849–856 (2002)

Abstract. Delayed graft function (DGF) occurs in 15 to 25% (range, 10 to 62%) of cadaveric kidney transplant recipients and up to 9% of living donor recipients. In addition to donor, recipient, and procedural factors, the choice of immunosuppression may influence the development of DGF. The impact of immunosuppression on DGF was studied. The frequency of DGF was evaluated in first cadaveric or living donor kidney allograft recipients (n ϭ 144) transplanted at the University of Washington from November 1999 through September 1, 2001. Donor, recipient, and procedural factors, as well as biopsy results, were compared between patients who developed DGF and those who did not. DGF was more common in patients treated with rapamycin than without (25% versus 8.9%, P ϭ 0.02) and positively correlated with rapamycin dose (P ϭ 0.008). In those developing DGF, the duration of posttransplant dialysis increased with donor age (P ϭ 0.003) but decreased with mycophenolate mofetil use (P ϭ 0.01). All biopsies during episodes of DGF demonstrated changes of acute tubular injury. Of the patients with tubular injury, 12 treated with rapamycin and tacrolimus developed intratubular cast formation indistinguishable from myeloma cast nephropathy. Histologic, immunohistochemical, and ultrastructural studies indicated that these casts were composed at least in part of degenerating renal tubular epithelial cells. These findings suggest that rapamycin therapy exerts increased toxicity on tubular epithelial cells and/or retards healing, leading to an increased incidence of DGF. Additionally, rapamycin treatment combined with a calcineurin inhibitor may lead to extensive tubular cell injury and death and a unique form of cast nephropathy.Delayed graft function in renal allografts occurs most frequently due to peritransplant ischemic injury or toxic medication exposure (1-5). Several donor factors (increased age, hypertension Ͼ10 yr, creatinine clearance Ͻ80 cc/min, vascular sclerosis, weight, female gender, nontraumatic death), recipient factors (pre-sensitization, ethnicity, pretransplant proinflammatory cytokine levels, pretransplant anuria, pretransplant mean arterial pressure Ͻ100 mHg, American Society of Anesthesiology physical status category IV), and transplant procedural factors (cold ischemia times, anastomotic times, selection of preservation solution) are associated with an increased occurrence of DGF. Immunologic factors (rejection) and coagulant mechanisms (thrombosis) also influence the development of DGF. Furthermore, immunosuppressive medications have been shown to affect DGF. The cytokine release syndrome produced by OKT3 or anti-thymocyte globulins and high-dose calcineurin inhibitor use immediately after transplantation are associated with an increased risk for DGF (6,7). Calcineurin inhibitors may contribute to acute injury by promoting renal allograft ischemia (8) and perhaps by enhancing renal tubular epithelial cell apoptosis (9). The use of mycophenolate mofetil has not been shown to influence the development of DGF (10...

Primary immune responses are thought to be induced by dendritic cells. To promote such responses, dendritic cells must be activated by exogenous agonists, such as LPS, or by products of activated leukocytes, such as TNF-α and IL-1. How dendritic cells might be activated in the absence of exogenous stimuli, or without the immediate presence of activated leukocytes, as might occur in immunity to tumor cells or transplants, is unknown. We postulated that heparan sulfate, an acidic, biologically active polysaccharide associated with cell membranes and extracellular matrices, which is rapidly released under conditions of inflammation and tissue damage, might provide such a stimulus. Incubation of immature murine dendritic cells with heparan sulfate induced phenotypic maturation evidenced by up-regulation of I-A, CD40, CD54 (ICAM-1), CD80 (B7-1), and CD86 (B7-2). Dendritic cells exposed to heparan sulfate exhibited a markedly lowered rate of Ag uptake and increased allostimulatory capacity. Stimulation of dendritic cells with heparan sulfate induced release of TNF-α, IL-1β, and IL-6, although the maturation of dendritic cells was independent of these cytokines. These results suggest that soluble heparan sulfate chains, as products of the degradation of heparan sulfate proteoglycan, might induce maturation of dendritic cells without exogenous stimuli, thus contributing to the generation and maintenance of primary immune responses.

The majority of patients are at risk of developing new-onset diabetes within a short time after kidney transplantation. The risk may be due to preexisting risk factors, immunosuppressive agents, or older age. The significance of these findings is not clear, but demands appropriate follow-up studies related to glycemia, end-organ complications, and graft function. It remains to be determined whether the 2003 International Consensus Guidelines are adequate to appropriately diagnose diabetes in the posttransplant time period, with special emphasis on the first 3 months.