Diagnosing acute liver graft rejection: experimental application of an implantable telemetric impedance device in native and transplanted porcine livers

BACKGROUND AND AIMS: Diagnosis of acute rejection is a complex and persistent problem in liver transplantation. Focused on the use of proprietary impedance technology a porcine liver model was designed to provide immediate information for differentiation of normal and acute rejecting tissue by an implantable telemetric device. METHODS: Electrical impedance was analyzed by electrodes implanted in vitro and in vivo in the liver of pigs, where impedance is derived from measurements of voltage transients produced in response to programmed current pulses. Consequent electric recordings in porcine livers after transplantation and after mere laparotomy were evaluated in relation to biochemical parameters and histological results of liver biopsies. RESULTS: Acute rejection was correctly predicted in all cases and correctly excluded in the remaining 32 biopsy related impedance recordings (P<0.004). Impedance measurements not only correlated with the diagnosis from liver biopsy specimen (r=0.84, P<0.0001) but also exemplified the severity of histological acute rejection. CONCLUSION: Impedance analysis reveals evident physiologic relation of acute liver graft rejection and electrical organ properties. Electrodes implanted in transplanted porcine livers allow running less invasive monitoring and thus early detection of rejection. The technology may have broad value in providing an immediate diagnosis of acute rejection, reducing unnecessary patient anxiety and eliminating the significant expenses associated with multiple referrals, expensive sample handling and tissue analysis.     

Correlation of endothelin-1 concentration and angiotensin-converting enzyme activity with the staging of liver fibrosis

Increased serum angiotensin-converting enzyme (SACE) activity and serum concentration of endothelin-1 (ET-1) were found in liver cirrhosis. We investigated a correlation between the different stages of liver fibrosis and SACE activity and serum ET-1 concentration. Seventy patients with pathohistologically established chronic liver disease were divided in three groups according to Ishak criteria for liver fibrosis: minimal fibrosis (Ishak score 0-1, n =20), medium fibrosis (Ishak score 2-5, n=20) and cirrhosis (Ishak score 6, n=30). SACE activity and ET-1 concentration were determined using commercial ELISA kits. SACE activity and ET-1 concentrations were proportional to the severity of disease, the highest being in patients with liver cirrhosis. Maximal increase in SACE activity was found between minimal and medium fibrosis while maximal increase in ET-1 concentration was revealed between medium fibrosis and cirrhosis. The analysis of the Receiver Operating Characteristic (ROC) curve for SACE activity suggested a cut-off value to separate minimal from medium fibrosis at 59.00 U/L (sensitivity 100%, specificity 64.7%). The cut-off value for serum ET-1 concentration to separate medium fibrosis from cirrhosis was 12.4 pg/mL (sensitivity 96.8%, specificity 94.4%). A positive correlation between SACE activity and ET-1 concentration was registered (Spearman's ? = 0.438, p = 0.004). Both SACE activity and ET-1 concentration were increased in all stages of liver fibrosis. Cut-off points for SACE activity and ET-1 concentration could be a biochemical marker for the progression of fibrosis. Positive correlation between SACE activity and ET-1 concentration might indicate their interaction in the development of liver cirrhosis.     

Influence of glutathione<Emphasis Type="Italic"> S</Emphasis>-transferase M1 and T1 polymorphisms with acute rejection in Iranian liver transplant recipients

Glutathione-S-transferase (GST) has a major protective role against free radicals and plays a vital role in phase II of biotransformation of many substances. In liver transplantation, reperfusion injury, calcineurin drug consumption and infection produce free radicals that cause tissue injury and organ damage. Genetic variations of GST may influence individual susceptibility to some diseases associated with the deleterious effects of oxidative metabolism. Although it is well known that the rejection is an immunological process, however, in this study, we have investigated the gene frequency and relationship between human GST gene polymorphism and rejection in liver transplant recipients. We have assessed 51 liver transplant recipients from Shiraz, South of Iran. The GSTT1 and GSTM1 genotypes were identified by polymerase chain reaction (PCR). The gene frequency of GSTM1 and GSTT1 polymorphism were evaluated. We observed that GSTM1 null genotype was present in 68.62% of the liver transplant recipients while GSTT1 null genotype was present in 37.25% of the liver transplant subjects. There was a trend between increasing age and acute rejection episode. No statistically significant correlation was present between GSTM1 null and GSTT1 null genotypes with an acute rejection episode in transplant recipients. No relationship was observed between GST genotypes and acute rejection. It is likely that development and progression of rejection are determined by genes which is involved in immunological pathways rather than genes that is participated in free radicals destruction. However, these findings need to be confirmed in a larger series of patients.     

Involvement of interaction between viral VP466 and host tropomyosin proteins in virus infection in shrimp

The C3 component of complement has different roles in kidney disease and its local production in donor kidney may affect allograft function and rejection after organ transplantation. A single base substitution in c3 gene (rs2230199), defines two common allelic variants with different mobility on gel electrophoresis: S (Slow) and F (Fast). In order to evaluate the effect of this polymorphism on acute renal allograft rejection, one hundred samples of donor and recipients were collected and genotyping was done by PCR-RFLP method. The allelic frequencies were: C3S=0.791, C3F=0.209. There was no significant association between recipient's genotype and acute rejection (p value<0.05). No correlation between donor genotype and acute rejection was also present. Patients were divided into four groups, according to the recipient and donor genotypes: SS recipients and FS or FF donor, SS recipient and donor, FF or FS recipient and SS donor and FS or FF recipient and donor. There was no significant difference in rate of acute rejection between groups. Although the results didn't find any association between C3 complement polymorphisms and acute allograft rejection, there was no acute rejection in FS or FF donors and SS recipient group.     

肝移植急性排斥反应时外周血Th17细胞的特征及意义

目的:观测肝移植患者术前及术后急性排斥时外周血中Th17细胞频率变化特征,探讨其与肝移植术后急性排斥发生的关系。方法:对18例于我院进行肝移植手术的患者进行随访研究,应用流式细胞仪检测各随访点外周血中Th17细胞频率。随访期间发生急性排斥反应的患者为急排组(n=7,男女比为5/2),未发生急性排斥反应者为非急排组(n=11,男女比为8/3),比较两组患者肝移植前后外周血中Th17细胞频率的变化规律。结果:急排组与非急排组患者肝移植术前外周血中Th17细胞频率无统计学差异(P=0.672),而急排组患者发生急性排斥反应时与非急排组患者相比Th17细胞频率明显升高(P=0.002)。在随访研究中,急排组患者在发生急性排斥反应时外周血中Th17细胞频率较未发生急性排斥反应时增高,且Th17细胞频率与ALT变化趋势一致,呈明显正性相关。而非急排组患者术后随访期间外周血中Th17细胞频率无统计学差异。结论:肝移植患者术后发生急性排斥反应时外周血中Th17细胞频率明显升高,变化趋势与ALT水平一致,呈正性相关,可能成为诊断急性排斥反应的潜在指标。     

Non-invasive oxidative stress markers for liver fibrosis development in the evolution of toxic hepatitis

Oxidative stress is related to the liver fibrosis, anticipating the hepatic stellate cells' (HSC) activation. Our aim was to correlate oxidative stress markers with the histological liver alterations in order to identify predictive, noninvasive parameters of fibrosis progression in the evolution of toxic hepatitis.CCl4 in sunflower oil was administered to rats intragastrically, twice a week. After 2, 3, 4 and 8 weeks of treatment, plasma levels of malondialdehyde (MDA), protein carbonyls (PC), hydrogen donor capacity (HD), sulfhydryl groups (SH), and glutathione (GSH) were measured and histological examination of the liver slides was performed. Dynamics of histological disorders was assessed by The Knodell score. Significant elevation of inflammation grade was obtained after the second week of the experiment only (p=0.001), while fibrosis started to become significant (p=0.001) after 1 month of CCl4 administration. Between plasma MDA and liver fibrosis development a good correlation was obtained (r=0.877, p=0.05). Correlation between PC dynamics and liver alterations was marginally significant for inflammation grade (r=0.756, p=0.138). HD evolution revealed a marginally inverse correlation with inflammation grade (r=-0.794, p=0.108). No correlations could be established for other parameters with either inflammation grade or fibrosis stage.Our study shows that MDA elevation offers the best prediction potential for fibrosis, while marginal prediction fiability could be attributed to high levels of plasma PC and low levels of HD.     

Role of cytokine gene polymorphism and hepatic transforming growth factor beta1 expression in recurrent hepatitis C after liver transplantation

Recurrent hepatitis C virus (HCV) infection after orthotopic liver transplantation (OLT) is nearly universal. Cytokines play an important role in the immune response to viral infection, and cytokine gene polymorphism affects the overall expression and secretion of cytokines. The objective of this study was to define the relationship between cytokine polymorphism and recurrent hepatitis C after OLT. Blood samples were collected from 36 patients at a mean of 44.6+/-30.4 months after OLT for chronic HCV infection. DNA was extracted from peripheral blood mononuclear cells, and polymerase chain reaction-sequence specific primers (PCR-SSP) analysis was performed on promoter sequences of transforming growth factor beta1 (TGF-beta1), interleukin 6 (IL-6) interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-alpha) and interferon gamma (INF-gamma). Liver biopsies performed at diagnosis of recurrent disease were graded with the Knodell score, and hepatic TGF-beta1 expression was determined semiquantitatively by immunohistochemistry. The gene polymorphism of TGF-beta1 was correlated with its expression on hepatocytes and sinusoids. Polymorphism in all studied cytokine genes was correlated with recurrence, and interval to recurrence (>12 or < or =12 months post-OLT), and clinical (ascites, Child-Pugh score and death), biochemical parameters of recurrent HCV (serum alanine aminotransferase (ALT)), INR, albumin, bilirubin), and virological parameters (HCV genotype and load). Biopsies revealed recurrent HCV in 31 patients (86.1%); in 21 (67.7%), the interval to recurrence was 12 months. There was a statistically significant correlation between TGF-beta1 gene polymorphism, i.e., the genetic ability to produce high levels of TGF-beta1, and the intensity of TGF-beta1 staining on hepatocytes (p=0.003) and sinusoids (p=0.003), and the degree of fibrosis (p=0.02). A borderline correlation was found with the presence of ascites (p=0.007), but not with Child-Pugh score, synthetic liver function tests or HCV genotype and load. The genetic ability to produce low levels of IFN-gamma was correlated with recurrent disease (p=0.015). No such correlation was found for TGF-beta1 gene polymorphism. In conclusion, polymorphism in the TGF-beta1 gene correlates with its in situ hepatic expression in patients with recurrent HCV after liver transplantation. INF-gamma, but not TGF-beta1 gene polymorphism, correlates with early recurrent hepatitis C after transplantation. These findings might help to design preemptive prevention therapy in selected patients at risk.     

Static and dynamic scintigraphy of the liver using labeled erythrocytes in the diagnosis of hepatic hemangioma]

In order to find hemodynamic differences between hemangioma (n = 10) and other tumours of the liver (n = 15) dynamic angioscintigraphy and late vascular scintigraphy of the liver were performed. Late vascular scintigraphy has revealed focal cumulation of the labelled erythrocytes in 7 hemangiomas of the diameter of 35 mm, 3 hemangiomas below this size have not been diagnosed with this technique. Beside hemangiomas, a focus of erythrocytes cumulation was found also in the hepatocellular adenoma. Arterial blood supply to hemangioma was significantly higher, than that in the malignant tumours of the liver (54.6% vs 31.7%). Other parameters of the early phase of angioscintigraphy have no diagnostic value in the differentiating the hepatic tumours. Vascular scintigraphy of the liver proved to be a valuable technique in the diagnosis of large hemangiomas only.     

Estimation of collagen content of liver specimens. Variation among animals and among hepatic lobes in cirrhotic rats

We undertook a study to evaluate the correlation between morphometric evaluation and colorimetric determination of hepatic collagen content, and to analyze the variation among animals as well as among lobes of the same liver in hepatic collagen content after CCl4-induced micronodular cirrhosis. The results revealed a significant correlation (r = 0.9458; p less than 0.001) between the morphometric and colorimetric methods of collagen evaluation of liver specimens; both methods also significantly distinguished data obtained from controls and from cirrhotic rats (p less than 0.0005). After induction of micronodular cirrhosis by chronic CCl4 administration, a highly significant variation in hepatic collagen content was observed among animals (p less than 0.0001). By contrast, no significant difference in collagen content was observed (p less than 0.05) among hepatic lobes of a given animal. These results indicate that in this animal model of liver cirrhosis, interpretation of biochemical data would benefit by being related to the severity of the hepatic collagen infiltration of each animal. Our data also show that representative values for total hepatic collagen infiltration can be obtained from a single liver specimen; we suggest, however, that the specimen be taken from a major lobe of the liver and that a sufficiently large number of animals be used to avoid occasional sampling errors.     

A proteomic analysis of allograft rejection in rats after liver transplantation

In order to understand the allograft rejection in orthotopic liver transplantation (OLT), an allograft rejection rat model was established and studied by proteomic approach. The protein expression profiles of liver tissues were acquired by fluorescence two-dimensional difference gel electrophoresis (2D DIGE) that incorporated a pooled internal standard and reverse fluorescent labeling method. The expression levels of 27 protein spots showed significant changes in acute rejection rats. Among these spots, 19 were identified with peptide mass fingerprinting using matrix-assisted laser desorption ionization time of flight mass spectrometry (MALDI-TOF MS) after tryptic in-gel digestion. The results of the present paper could be helpful for our better understanding of allograft rejection in organ transplantation.     

Heat shock preconditioning reduces the formation of 8-hydroxy-2'-deoxyguanosine and 4-hydroxy-2-nonenal modified proteins in ischemia-reperfused liver of rats

Heat shock preconditioning (HSPC) is a promising strategy for providing ischemic tolerance. The objective of this study is to investigate the effectiveness of HSPC in preventing oxidative damage of cellular proteins and DNA during ischemia-reperfusion of the liver. Male Wistar rats were divided into a heat shock group (group HS) and control (group C). Forty-eight hours prior to ischemia, rats in group HS received HSPC at 42 degrees C for 15 min. All rats received hepatic warm ischemia for 30min and subsequent reperfusion. The formation of 8-hydroxy-2'-deoxyguanosine (8-OHdG), 4-hydroxy-2-nonenal (HNE) modified proteins in liver tissue, survival rate of the animals, and changes in biochemical and histological parameters were compared between groups. Heat shock protein 72 was produced only in group HS. The 7-day survival of rats was significantly better in group HS (10/10) than in group C (5/10) (p < 0.01). The serum release of alanine aminotransferase (n = 10, p < 0.01) and the concentration of adenosine triphosphate in liver tissue (n = 10, p < 0.01) 40min after reperfusion was significantly better in group HS than in group C. The formation of 8-OHdG in liver tissue measured by high-performance liquid chromatography was suppressed in group HS (p < 0.01). The production of HNE-modified proteins as determined by Western-blot analysis was also decreased in group HS. These results were also confirmed by immunohistochemical analysis. As determined by levels of 8-OHdG and HNE-modified proteins produced during ischemia-reperfusion of the liver, HSPC reduced the oxidative injury of cellular proteins and DNA in the liver tissue.     

The structural-functional disorders in the liver of wild rodents from areas of the accident at the Chernobyl Atomic Electric Power Station]

A study was made of the morphological status of hepatocytes, the antioxidant activity of lipids and composition of phospholipids, and dehydrogenase activity in the liver of field mice taken from seven regions of the Chernobyl A.P.S. zone with different levels of contamination in 1987. There observed multiple types of destructive damages to the organ; depletion of liver lipids by antioxidants; diminution of phospholipids within the total lipid level; considerable increase in the phosphatidyl choline/phosphatidyl ethanolamine ratio and in the relative content of phospholipid lysoforms; and inhibition of dehydration processes. In the absence of a strict correlation between the changes in the biophysical and biochemical parameters or between the severity of degenerative changes in hepatocytes and the level of external irradiation, certain relationship was followed up between liver lipid depletion by antioxidants, inhibition of dehydration processes and the number of wild rodents which developed dystrophic changes in the organ. These structural and functional changes were found in the liver of wild rodents taken from all the regions: this indicated a considerable sensitivity of the parameters of the regulatory cell systems and hepatocytes to the effect of technogenic contamination.     

The Ratio of Circulating Regulatory T Cells (Tregs)/Th17 Cells Is Associated with Acute Allograft Rejection in Liver Transplantation

CD4⁺CD25⁺FoxP3⁺ regulatory T cells (Tregs) and Th17 cells are known to be involved in the alloreactive responses in organ transplantation, but little is known about the relationship between Tregs and Th17 cells in the context of liver alloresponse. Here, we investigated whether the circulating Tregs/Th17 ratio is associated with acute allograft rejection in liver transplantation. In present study, thirty-eight patients who received liver transplant were enrolled. The patients were divided into two groups: acute allograft rejection group (Gr-AR) (n = 16) and stable allograft liver function group (Gr-SF) (n = 22). The frequencies of circulating Tregs and circulating Th17 cells, as well as Tregs/Th17 ratio were determined using flow cytometry. The association between Tregs/Th17 ratio and acute allograft rejection was then analyzed. Our results showed that the frequency of circulating Tregs was significantly decreased, whereas the frequency of circulating Th17 cells was significantly increased in liver allograft recipients who developed acute rejection. Tregs/Th17 ratio had a negative correlation with liver damage indices and the score of rejection activity index (RAI) after liver transplantation. In addition, the percentages of CTLA-4⁺, HLA-DR⁺, Ki67⁺, and IL-10⁺ Tregs were higher in Gr-SF group than in Gr-AR group. Our results suggested that the ratio of circulating Tregs/Th17 cells is associated with acute allograft rejection, thus the ratio may serve as an alternative marker for the diagnosis of acute rejection.     

Quantification of C4d deposition and hepatitis C virus RNA in tissue in cases of graft rejection and hepatitis C recurrence after liver transplantation

Histology is the gold standard for diagnosing acute rejection and hepatitis C recurrence after liver transplantation. However, differential diagnosis between the two can be difficult. We evaluated the role of C4d staining and quantification of hepatitis C virus (HCV) RNA levels in liver tissue. This was a retrospective study of 98 liver biopsy samples divided into four groups by histological diagnosis: acute rejection in patients undergoing liver transplant for hepatitis C (RejHCV+), HCV recurrence in patients undergoing liver transplant for hepatitis C (HCVTx+), acute rejection in patients undergoing liver transplant for reasons other than hepatitis C and chronic hepatitis C not transplanted (HCVTx-). All samples were submitted for immunohistochemical staining for C4d and HCV RNA quantification. Immunoexpression of C4d was observed in the portal vessels and was highest in the HCVTx- group. There was no difference in C4d expression between the RejHCV+ and HCVTx+ groups. However, tissue HCV RNA levels were higher in the HCVTx+ group samples than in the RejHCV+ group samples. Additionally, there was a significant correlation between tissue and serum levels of HCV RNA. The quantification of HCV RNA in liver tissue might prove to be an efficient diagnostic test for the recurrence of HCV infection.     

Electroporation-mediated interleukin-10 overexpression in skeletal muscle reduces acute rejection in rat cardiac allografts

OBJECTIVES: Human interleukin 10 (hIL-10) may reduce acute rejection after organ transplantation. Our previous data shows that electroporation-mediated transfer of plasmid DNA to peripheral muscle enhances gene transduction dramatically. This study was designed to investigate the effect of electroporation-mediated overexpression of hIL-10 on acute rejection of cardiac allografts in the rat. METHODS: The study was designed to evaluate the effect of hIL-10 gene transfer on (a) early rejection pattern and (b) graft survival. Gene transfer was achieved by intramuscular (i.m.) injection into the tibialis anterior muscle of Fischer (F344) male recipients followed by electroporation 24 h prior to transplantation. Heterotopic cardiac transplantation was performed from male Brown Norway rat to F344. Four groups were studied (n = 6). Treated animals in groups B1 and B2 received 2.5 microg of pCIK hIL-10 and control animals in groups A1 and A2 distilled water. Graft function was assessed by daily palpation. Animals from group A1 were sacrificed at the cessation of the heart beat of the graft and those in group B1 were sacrificed at day 7; blood was taken for ELISA measurement of hIL-10 and tissue for myeloperoxidase (MPO) measurement and histological assessment. To evaluate graft survival, groups A2 and B2 were sacrificed at cessation of the heart beat of the graft. RESULTS: Histological examination revealed severe rejection (IIIB-IV) in group A1 in contrast to low to moderate rejection (IA-IIIA) in group B1 (p = 0.02). MPO activity was significantly lower in group B1 compared to group A1 (18 +/- 7 vs. 32 +/- 14 mU/mg protein, p = 0.05). Serum hIL-10 levels were 46 +/- 13 pg/ml in group B1 vs. 0 pg/ml in group A1. At day 7 all heart allografts in the treated groups B1 and B2 were beating, whereas they stopped beating at 5 +/- 2 days in groups A1 and A2 vs. 14 +/- 2 days in group B2 (p = 0.0012). CONCLUSIONS: Electroporation-mediated intramuscular overexpression of hIL-10 reduces acute rejection and improves survival of heterotopic heart allografts in rats. This study demonstrates that peripheral overexpression of specific genes in skeletal muscle may reduce acute rejection after whole organ transplantation.     

Use of bile cytology for early diagnosis of complications in orthotopic liver transplantation

carrasco l., sanchez-bueno f., sola j., robles r., rodriguez j. m., ramirez p., lujan j. a., acosta f. and parrilla p. (1998) Cytopathology 9, 406–414
Use of bile cytology for early diagnosis of complications in orthotopic liver transplantation
We conducted a daily analysis of bile cellularity in 25 patients undergoing 29 orthotopic liver transplants (OLT) and correlated the cytological parameters with the clinical outcome of each patient. The 16 patients without complications only showed slides with cells during the first 4–5 postoperative days. The four patients with primary non-function (PNF) of the graft had a high cell density up to the time of the retransplant, with a preponderance of polymorphonuclear (PMN) leucocytes (59.2%) and epithelial cells (29.2%). During the episodes of sepsis ( n  = 3) and rejection ( n  = 7) we noted the sudden appearance of high cellularity, almost exclusively PMN leucocytes (96.5%), and a preponderance of PMN leucocytes (84.2%) with appreciable percentages of mononuclear cells and macrophages as well as the early appearance of lymphoblasts in the rejection episodes. Our results show that bile cytology can be a useful method for diagnosing graft complications in liver transplantation.     

Prediction of acute cellular renal allograft rejection by urinary metabolomics using MALDI-FTMS

The present study investigated small molecule analysis of urinary samples as a noninvasive method to detect acute cellular renal allograft rejection. Matrix-assisted laser desorption/ionization Fourier transform mass spectrometry (MALDI-FTMS) was used to analyze 15 urinary samples from transplant patients with different grades of biopsy showing improved clinical acute cellular rejection (ACR) and 24 urinary samples from 8 transplant patients without evidence of rejection. Seven small molecules demonstrated highly successful diagnostic performance (m/z): 278.1 (t = 3.398, p = 0.004), 293.0 (t = 2.169, p = 0.048), 294.1 (t = 2.154, p = 0.05), 382.2 (t = 2.961, p = 0.010), 383.3 (t = 2.270, p = 0.040), 402.2 (t = 2.994, p = 0.010), 424.0 (t = 2.644, p = 0.019). Kidney transplant patients with ACR could be distinguished from those without ACR using four individual small molecules with a specificity of 100%. In conclusion, the combination of MALDI-FTMS technology with a clear definition of patient groups can detect urine small molecule associated with ACR.     

Increased Numbers of Circulating CD8 Effector Memory T Cells before Transplantation Enhance the Risk of Acute Rejection in Lung Transplant Recipients

The effector and regulatory T cell subpopulations involved in the development of acute rejection episodes in lung transplantation remain to be elucidated. Twenty-seven lung transplant candidates were prospectively monitored before transplantation and within the first year post-transplantation. Regulatory, Th17, memory and naïve T cells were measured in peripheral blood of lung transplant recipients by flow cytometry. No association of acute rejection with number of peripheral regulatory T cells and Th17 cells was found. However, effector memory subsets in acute rejection patients were increased during the first two months post-transplant. Interestingly, patients waiting for lung transplant with levels of CD8⁺ effector memory T cells over 185 cells/mm³ had a significant increased risk of rejection [OR: 5.62 (95% CI: 1.08-29.37), p=0.04]. In multivariate analysis adjusted for age and gender the odds ratio for rejection was: OR: 5.89 (95% CI: 1.08-32.24), p=0.04. These data suggest a correlation between acute rejection and effector memory T cells in lung transplant recipients. The measurement of peripheral blood CD8⁺ effector memory T cells prior to lung transplant may define patients at high risk of acute lung rejection.     

Treatment with cyclosporin and risks of graft rejection in male kidney and heart transplant recipients with non-O blood.

In a consecutive series of 146 kidney transplant recipients treated with cyclosporin A a strong correlation between matching for the HLA-A, HLA-B, and HLA-DR loci specificities and outcome of the grafts was observed in male recipients with non-O blood groups. Such a beneficial effect of matching was not found in female patients or male patients with blood group O. In these patients survival of the grafts at one year was good irrespective of the number of HLA-A, B, and DR mismatches. Also in 47 male heart transplant recipients immune responsiveness against mismatched HLA antigens was related to blood group. A significantly higher incidence of rejection episodes was observed in male patients with non-O blood groups (n = 32) than in those with blood group O (n = 15). Matching for HLA-DR reduced the number of acute rejection episodes in male patients with non-O blood. These findings may help explain the controversial reports about the importance of HLA matching in organ transplantation. Furthermore, as most candidates for heart transplantation are male and not of blood group O, the higher incidence of graft rejection in these patients underscores the need for an exchange strategy of donor hearts.