478 COLD AND WARM B-CELL ANTIBODIES IN RENAL TRANSPLANTATION

SiR,—Iwaki

et

antibodies which

al.demonstrated that

patients with B-cell

reactedonly at 5C (B-cold) in a lymphocytosignificantly better kidney-graft survival-rate

toxic test had a than either patients with B-cell antibodies which reacted at both 5°C and 37°C (B-warm) or patients with no antibodies. They suggested that B-cold antibodies may be enhancing antibodies. However, our results disagree with these observations. We have examined the sera of 23 recipients of a B-cell-positive-crossmatch transplant for cold and warm antibodies against a panel of T and B lymphocytes. In addition the sera of 7 patients were tested under the same conditions against their donor’s B lymphocytes. The cytotoxicity method and the criteria used for the definition of B-cold, B-warm, and T-warm antibodies were those described by Iwaki et al.1Failure of a graft was defined as nephrectomy or return to chronic haemo-

dialysis.

3-MONTH

Department of Surgery, University of Oxford, Radcliffe Infirmary, Nuffield

Oxford OX2 6HE

*Type of antibody assigned according t Includes one technical failure.

Although

the number of

to

patients

the method of Iwaki

et

al.’

in each group is small

those with B-warm and T-warm antibodies certainly do

not

have success-rate at 3 months inferior to that in the groups with either B-cold antibodies or no antibodies (see table). Although we have classified the sera as having only B-cold, B-warm, or T-warm antibodies using Iwaki’s criteria, we feel that this classification is incomplete. We found, as Iwaki noted, that a serum which reacts at 37°C with some panel B cells will in most instances react with the same cells at 5C but that the reverse is not necessarily true-i.e., sera which react with B cells at 5C will not always react with the same cells at 37°C. In addition some sera react with certain B cells at both 5C and 37°C and other B cells at 5C only. These antibodies have been called B-warm by Iwaki, but we feel that they should be defined as B-cold+B-warm. "B-warm" should be reserved only for sera which react with the same cells at both 50C and 37°C. We found, in our 23 patients, 14 (61%) with B-cold+B-warm antibodies (3 had a failed transplant), 8 (35%) with B-cold antibodies (2 had a failed transplant), and 1 with only B-warm antibodies who had a successful transplant. The division of Iwaki’s B-warm antibodies into either B-cold+B-warm or B-warm is particularly relevant in the interpretation of B cell crossmatch results. The crossmatch sera of 7 of the 23 recipients were reacted against their respective donors’ B cells at both 3°C and 37°C. 6 patients had B-cold+B-warm antibodies against panel B cells and 1 had only B-cold antibodies. The 5 successfully transplanted patients with B-cold+B-warm antibodies reacted with their donors’ B cells at both 5C and 37°C. The patient with the failed graft and B-cold+B-warm antibodies also reacted with the donor at 5C and 37°C. As expected the patient with B-cold antibodies reacted only at 5C with the donor’s B cells. Y., Terasaki, P. I., Park, M. S., Billing, R.Lancet, 1977, i, 1228.

ALAN TING PETER J. MORRIS

ENDOSCOPIC DILATATION OF PYLORIC SPHINCTER

GRAFT OUTCOME IN PATIENTS WITH DIFFERENT TYPES

OF ANTIBODIES

1. Iwaki,

Iwaki tested only 1 serum from each recipient, but we have found that the type of antibody can change over time. For example, 1 patient who rejected her first transplant developed B-cold+B-warm antibodies immediately after removal of the graft. 3 months later her serum also reacted with T cells at both 5C and 37°C, but 15 months later had only B-cold antibodies. Therefore for a full picture of the antibodies serial serum-samples from each patients should be tested. When sera from potential transplant recipients are tested for lymphocyte cytotoxic antibodies at both 5C and 37°C there is no doubt that some antibodies react at both temperatures while others react only at 5°C. However, in contrast to Iwaki et al. we feel that transplantation can be carried out with the same degree of success whether a B-cell crossmatch is positive at 50C and 370C or just at 5°C.

SIR,-Instrumental dilatation of stricturing oesophageal lesions is standard practice. There is no reason why it should not be applied to comparable lesions of the pyloric sphincter. Pyloric stenosis is a well-known complication of chronic or recurrent duodenal-ulcer disease, and sometimes it becomes the main indication for surgery. During endoscopic examination of these patients, the passage of the instrument through the pyloric sphincter stretches it. After two patients reported relief of their vomiting following endoscopy, we realised that dilatation of the sphincter could be a deliberate therapeutic objective. We now have a further three patients in whom this has been carried out with success. If this is a major goal of the endoscopic procedure, the instrument should be passed in and out of the sphincter zone several times. Endoscopic dilatation of the pyloric sphincter is feasible in some patients and it works. It may have to be repeated, but this is no different from the management of many oesophageal lesions. In certain patients it can stave off surgery. The endoscope would seem to be the best instrument for the technique, though there will be degrees of stenosis it cannot deal with. Department of Medicine and Gastrointestinal Unit, Victoria Hospital, London, Ontario N6A 4G5, Canada

W. C. WATSON

SUCCESS OR FAILURE OF DIPYRIDAMOLE IN MIGRAINE

SIR,-Dr Hawkes (July 15, p. 153) described a trial of dipyridamole in migraine which had to be stopped because of increased migraine attacks in all patients. Dipyridamole was given because platelet aggregation in migraine patients has been reported to be abnormal.1However, the author did not indicate in how many of his patients platelet aggregation was abnormal. In my experience only a subgroup of migraine patients have abnormal platelet aggregation. Masel et al.noted that only patients with abnormal aggregation improved on dipyridamole (indeed, two of their non-responders had normal platelet aggregation). It thus seems possible that Hawkes’ patients had normal platelet aggregation, which may explain their lack of response.

Migraine may have worsened, on the other hand, because of dosage used by Hawkes (400 mg/day). I have used dipyri-

the

1. Deshmukh, S. V., Meyer, J. S. Neurology, 1976, 26, 347. 2. Couch, J. R., Hassanein, R. S. ibid. p. 348. 3. Masel, B. E., Chesson, A. L., Alpenin, J. B., Levin, H. S., Peters, B. H. ibid.

1978, 28, 371.

Cold and warm B-cell antibodies in renal transplantation.

478 COLD AND WARM B-CELL ANTIBODIES IN RENAL TRANSPLANTATION SiR,—Iwaki et antibodies which al.demonstrated that patients with B-cell reac...
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