a United States Army Medical Department continuing education program, perfusion induced immune injury with Jimmy a Light lieutenant colonel, United States Army Medical Corps assistant chief organ transplant Service. Walter Reed, Army Medical Center, Washington, D. C. What I want to talk about specifically is a profusion induced immune injury associated with organ preservation. Now I think every transplant it would take for granted that organ preservation has been one of the really major breakthroughs in kidney transplantation and has allowed the modality of transplantation to be applied to many hundreds or thousands of people who otherwise would have been categorically excluded just because of proximity or for many other reasons. I think, without question, it is valuable as a technique for evaluating the kidney and many of the other things that Dr Alexander's already mentioned. I think, however, there is a possibility, and that we can in fact damage kidneys by preservation, especially when the refuse it is plasma slides, please. I think we take for granted. This is just a slide from the American College of Surgery transplant registry, And all it indicates, is that rejections of primary cause of graft failure, we all know that ImmuLogic mechanisms are involved. We also know that when preformed antibodies to donor antigens are present prior to transplantation, some form of accelerated rejection regularly occurs. You know, however, Dr Alexander has mentioned, and several other transplant surgeons throughout the country have seen cases where hyper acute rejection occurred when the cross matches were negative. They're obviously can be many explanations for those and in insufficiently sensitive cross matched technique or perhaps improperly performed as one explanation. But there is another explanation. That's the possibility of ex vivo immune injury. No, this could obviously take two forms. Uh, this was this is a slide from Dr Phil Oh's paper in surgery of last year, and Dr Philo was at the Naval Medical Research Institute for some time. What he did was to to do dog kidney autographs where the kidney was per fused with specifically sensitized plasma raised in a homologous, um, Alan homologous donor. And what the slide demonstrates is that real change in renal function after auto grafting, Uh, when the plasma was either sensitized homologous in the open bars or and uh, just plain homologous pool plasma in the in the cross hatched bars, the thing that locks this up? Is that the side of toxic antibodies? Progressively as they progressively increase, the severity of the rejection process progressively increased. And these last two with the highest hiders were hyper acutely rejected on the table. The other kidney's exhibited varying degrees of immune injury, which, on serial biopsy were were qualitatively similar to those changes of hyper acute rejection but were able to resolve with time. Now, the other thing he did and I didn't should bring a slide of that along was to, uh to measure the antibody tighter and correlated with the length of time and profusion. And it was clear that, uh, there was a direct correlation between time and profusion and the detriment in, uh, an antibody tighter. So there's no question, and this is these are HLA antibodies in their IgG antibodies, and that's one type of thing. This has been reported in humans by across of Kansas City, uh, where a kidney can, uh, that had a cello and organ. 12, uh, was refused with plasma subsequently identified to have antibodies to that energy. But anyway, what I'm going to tell you about her is experienced with two pairs of Plasma, refused kidneys and 1/5 kidney, which is C1 right here, which was proof used but not transplanted because of a positive cross match with the refusing the N. D. Means that we didn't do it. And the other ones and the other kidney is interesting. See to its mate was refused and transplanted. But the profuse date was not the same as the one we used. It had been, uh, we received only the match kidney. These kidneys were transplanted to eight to A and B kidneys for kidneys were transplanted into recipients who were. I had never had reactive antibody in their blood stream and whose preliminary cross matches were negative by the the techniques that are presently used and so forth. You had all these kidneys exhibited changes of hyper acute rejection. Three of them are lost and one wasn't. And I'll explain that in a minute. By what I mean by this is that these kidneys, uh, function usually immediately and underwent progressive changes. Uh, similar to what you see in this slide here with hemorrhagic appearance and cortical modeling. Particular hemorrhages here and here you can see Evidence of small in functions this is an effect of the specimen. 24 hours post transplant. Another view that's a little closer up that doesn't add very much, but may allow you to see the particular hemorrhages throughout. And this is the microscopic of another kidney. In that set, this kidney was actually removed about six days post transplant. And it demonstrates the findings you would expect to see at that time post transplant with numerous fiber and thrown by frequent policies throughout which I don't think every project very well, but primarily the fiber and change. This is a change that scene later, the early photos of which I didn't bring because they don't show either, uh, so accumulation of polymorphous and the capillary lumens and in the very tubular plexus, uh, at one hour post transfer, this is the same kidney, and what it shows is extensive vasculitis. Uh, and what? I'd like you to keep this in mind because it's very pertinent. All these patients who exhibited hyper acute rejection, uh, before transplanting kidneys had consumption, kogel apathy with fibrinogen consumption and platelet consumption training. As they say, transplanting affected me was needed In all those cases, this is an immuno I don't know if it really shows. This is an immuno with GM, and it's similar in all the kidneys, including the four that were including I'm sorry. The three transplant effectively done is in the kidney that was refused but not transplanted. There's almost no I g m on subsequent study, and they all had extensive deposition of compliment except for the kidney that was refused and not not transplant. And basically what's happened then is that there's been an Injun correction. There's been antibody deposited in the kidney on the energetic, exposed, energetic surfaces. And when these kidneys have been re exposed to the bloodstream with a source of compliment and neutrophils, this system is set for a hyper acute rejection. Now you say, Well, how do you know these are? Well, I'm sorry. Let me make one other point Because these findings they then went on to screen 45 plasma donors for abnormality. I should point out that the plasma donors in all these cases were healthy young males who are basic trainings, perhaps, or at any rate, these are not multiple US. Women are people who have been previously transfused or had known illness. Now in terms of just ignore this for a minute. We know this is a GM for several reasons. First of all, is that immuno fluorescence was negative. That doesn't really exclude it. Still, but with dilution techniques, Uh, where I g is easy to get out of the kidney and where i g m is difficult to get out. The evaluate is pure i g m both by ring precipitation and by immuno diffusion against mono specific rabbit, uh, anti human i g m And the characteristics of this IgM or that when you react. When we reacted this evaluate with a broad panel of lymphocyte donors, uh, it reacted with between 1800% of these donors. And then further proof was that when we took the post transplant and effectively syrah from each of these people who underwent transplant affect me there, Sarah, their own sierra did not react with any of these, uh, did not react with the kidney they received, although there was cross reaction with another kidney in one case, which I think merely points out that the that the screening this investigation technique was adequate. No, I discussed these findings with Dr Terry Sake and Dr Bells are in view of their sort of ongoing controversy about pulse it'll preservation and, uh, cold storage techniques. And Dr Tara sake said, Ha ha! I know that kidneys and as you know, he has published that results at any period of time. From one month onward, after Cold store kidneys transplanted, who have been preserved by only by cold storage. He finds about 15% difference when he compares that series with a series using kidneys that have been perf used. There are other explanations for that difference, but I would point out that the incidents we found of these EGM site of Filic inside of toxic antibodies is about 12%,, Dr Bowser said. That's very interesting, but I never see that and And so that's disturbing here we we say, well, we we think there's 12% incidents in the plasma then we should be seeing more of these cases. I think the answer to the reason we don't see them may lie in fill those dogs in one of our cases, and that's that. I'm pretty sure that this is a reversible injury as long as the source of the antibody is not the recipient if it's a limited amount of antibody stuck on the kidney. And I say that because of our experience here with patient B2, uh, what happened in this patient and this is, uh, never believe it slide, because you won't be able to see any of it, but at any rate, starting at about three days, post transplant we began to see tremendous falls and platelets. 39,000 platelets here on the third post transplant day, along with a hybrid engine which is not terribly low, but in the companion case was very low. Uh, so we then instituted heparin therapy, and lo and behold, the platelets began to come up. The renal function improved. Fibrinogen stayed about the same and subsequently rose. We discontinued heparin therapy after three days. In addition, we've given her low dose aspirin With some trepidation, obviously. But with all those steroids on, she was taking orally. But at any rate, this lady is now over a year post transplant with a creatinine at 1.2 and no rejection episodes. If you remember from pillows paper that in many of his dogs this was a reversible injury. Uh, and I think this data fits together with that. The thing I'd like to further mention in the remaining time is that I think that one way to explain the discrepancy between Bella and Tara sake's reports and one explanation of the importance of these observations is that I think we should consider the weather mild immune injuries such as we're demonstrating right here. Whether this, um mm whether mild immune injury might predispose to subsequent Allah graft rejection or make the kidney less able to tolerate subsequent Allah graft rejection. No, I think it's very difficult to prove that sort of thing, and all we can say is that people who have used other kinds of cross matched techniques and plasma where anti and Ophelia by antibody has looked for Or uh, that's, I think, primarily by Cirelli in Columbus, and the other person who's made comments with regard to the importance of subliminal injury is Dalton Lucas, where he's observed at where anybody preformed antibody was looked for by better techniques. The kidneys, although they had no more hyper acute rejection, had a tremendous fall off with some time. And there's one. There's two or several other explanations obviously involved. And many of those revolved around animal models and come from the scripts Clinical ahoy, UH, primarily notions proposed by Cochran and, uh, Henson. And they've observed that when there's a imagine antibody complexes throughout the vessel wall, the vessel is then much more reactive to subsequent challenge, Let's say with another immune substance. And then another independent observation was that graft rejection could not be produced in another city and using a different kind of model unless vascular permeability was increased. And here I think we have fairly clear cut evidence in this perfumes but not transplanted kidney, that there is increased vascular permeability on the H and E. This goes right on through all layers of the muscle wall. So you might wonder why why GM is the antibody involved? Because it does cast a different complexity on things. Just screening for anti H L. A. Antibodies, then would no longer be, uh, which are basically I G antibodies, or at least in large part, might not be out of. So I think the I G M. We feel is a naturally occurring antibody that's, uh, primarily response to infection with various kinds of things are challenged with different kinds of microbes in assets. It's a called a naturally occurring antibody. Uh, and most of all, these cross reactive active antibodies such as forssmann, uh, colder gluten and so forth are also I g m. So I think these are really the things that make protect us from our environment. And perhaps there's no way to eliminate eliminate them at all As to why do we have a 12% incidents? And that those few units of plasma that we screened I'm not sure I know that other people have screened and terra sake, although I'm not sure it's published data yet has indicated that the incidence of preformed side of toxic or scientific antibody is Only around 5%, or perhaps even less. It may be that what we're seeing is an augmented kind of a big response because of vaccination and the various immunizations that people go through when they come on service. So in summary, I think it's a real observation. I think plasma is an excellent refuse eight. We no longer use it because of our concern with the events that might be produced. That's no question that profusion is of value in my mind. But this is just another area that is emerging where we must be concerned with where there were, in fact, causing damage or causing problems with subsequent organ function. Perfusion induced immune injury with Jimmy a Light Lieutenant colonel, United States Army Medical Corps assistant chief organ transplant Service Walter Reed, Army Medical Center, Washington D. C. Was produced through the mobile facilities of the television division, Academy of Health Sciences, United States Army, Fort Sam, Houston, Texas.