314 locus are extremely closely linked or, more probably, one and the same. This hypothesis is confirmed by our studies of H-Y antigen in a previously described2 45, X male with no evidence of mosaicism in blood and skin cultures. At birth this patient was of normal height and weight, had some Turner-like features (i.e., nuchal cutis laxa, short neck, shielded chest, Turnerlike dermatoglyphics) but normal male sexual development in spite of mild hypogenitalism. Serological cross-reactivity between the H-Y antigen of mouse and man allows the detection of H-Y antigen on human cells by absorption of anti-mouse H-Y antiserum.3 This test showed (fig. 1) that cells from the 45, X male carried as much H-Y antigen as those from 46, XY normal males. The XO male is very rare: only one has been previously described.4 Like XX males and XX true hermaphrodites, XO males havea "sex reversed syndrome". Testicular tissue in these three conditions develops in the absence of the Y chromosome but our results suggest that H-Y antigen and the development. of testes are always associated, strengthening the likelihood that they have a common, or closely linked, structural genetic basis. Cattedra di Istologia ed Embriologia e Clinica Pediatrica II, Università di Modena, Italy Laboratoire du Centre Hospitalier,
A. FORABOSCO E. CHELI B. NOEL
RENAL GRAFT ACCEPTANCE WITHOUT AZATHIOPRINE
SIR,-In provocative articleSheriff and co-workers asked whether azathioprine is necessary in renal transplantation. They conclude that, when azathioprine is stopped there seems to be no good indication for restarting it. We have some experience with azathioprine withdrawal in renal-transplant patients. In seven patients with cadaveric renal grafts azathioprine was stopped for medical reasons (table). Mean observation period without azathioprine was 7.7 (maximum 18.7) months in four patients with good primary transplant function. Acute rejections in two of these patients were reversed by high-dose methylprednisolone. At the end of the period of observation time serum-creatinine values were no higher than those found before azathioprine was stopped. In three further patients with chronic renal rejection azathioprine withdrawal did not seem to accelerate the course of progressive transplant failure. a
Lancet, 1976, ii, 1008. Forabosco, A., and others. Clin. Genet. 1977, 12, 97. 3. Tous, J., Pochat, D., Noel, B. Rev. Franç. Endocr. Clin. 1978, 19, 49. 4. Lo Curto, F., and others, Am. J. Dis. Child. 1974, 128. 90. 5. Cattanach, B. M. in Birth Defects (edited by H. G. Motulsky and W. Lenz); p. 129. Amsterdam, 1974. 6. Sheriff, M. H. R., Yayha, T., Lee, H. A. Lancet, 1978, i, 118.
prednisolone therapy was slightly increased in two pa-
tients, diminished in four patients, and unchanged in
tient. We agree with Sheriff et al. that, when azathioprine is stopped for medical reasons, renal grafts can be well tolerated for long periods without any alternative immunosuppression. P. SCHMIDT H. KOPSA
1st Medical Department, University of Vienna,
P. PILS P. BALCKE
A 1090 Vienna, Austria
TEMPERATURE AND PLATELET AGGREGATION DURING STORAGE OF WHOLE BLOOD
SjR,—Cold storage of platelet-rich plasma, platelet
platelet aggregation and reduced platelet viability.1-6 Nevertheless, although many centres now advise short-term storage of platelet concentrates and platelet-rich plasma at room temperature, whole blood is still stored refrigerated, partly because of the unknown effects of long term (up to 35 days) storage at room temperature and also to inhibit bacterial multiplication. At least one blood-pack manufacturer (Fenwall) advises storage of whole blood at 1-6°C. However, in our experience whole blood storage at 1°C is considerably worse, in respect of cellular aggregation, than trates, and whole blood
storage at 4°C, and at room temperature little or no aggregation is observed even after 21 days storage. Cellular aggregation was measured using the screen filtration pressure (S.F.P.) method7 on samples from standard units of blood. The units were collected from fourteen healthy male volunteers aged 19-55 into polyvinyl-chloride blood packs (McGraw Laboratories) containing 63 ml citrate-phosphate-dextrose as anticoagulant. Storage temperatures of 1 ± 0.50 and 4 + 0.5OC were carefully maintained in cooled incubators. Ambient room temperatures varied between 14 and 21°C. All packs were gently mixed by hand during collection and immediately before sampling at 1, 2, 3, 4, 8, 14, and 21
days. Platelet aggregation occurred rapidly at 1°C (reaching the maximum measurable, 600 mm Hg, within 24 h) whereas at room temperature s.F.P. did not change. At 40C the results were variable but showed a general increased aggregation,
1. 2. 3. 4. 5. 6. 7.
Benner, K. U., Brunner, R. Thromb. Res. 1973, 2, 331. Murphy, S., Gardner, F. H. New Engl. J. Med. 1969, 280, 1094. Kattlove, H. E., Alexander, B. Blood, 1971,38, 39. Shively, J. A., Gott, C. L., De Jongh, D. S. Vox Sang. 1970, 18, 204. Baldini, M. G., Steiner, M., Kim, B. K. Transfusion 1976, 16, 17. Baldini, M. G., Costea, N., Dameshek, W. Blood, 1960, 16, 1669. Swank, R. L. New Engl. J. Med. 1961, 265, 728.
AZATHIOPRINE WITHDRAWAL AFTER RENAL TRANSPLANTATION
*Acute rejection 5 days after azathioprine stopped (max. serum-creatinine 0.20 mmol/1). tAcute rejection 15.7months after azathioprine stopped (max. creatinine 0.16 mmol/1). #Returned to regular dialysis.
IN SERA AND KIDNEY BIOPSIES OF
Screen filtration pressures
usually reaching the measurable maximum between 4 and 21 days. The results were the same whether s.F.P. was measured on samples maintained at storage temperature or on samples allowed to warm to ambient temperature first. Measurements of catecholamines, serotonin, and A.D.P. concentrations and pH suggest that the pattern of platelet release and/or degradation was similar at all three temperatures, but that it was more striking at 1°C. One explanation for the lack of aggregation at room temperature may be that, in the absence of the cold stimulus, platelet release is slower so that by the time the plasma concentrations of released A.D.P., catecholamines, and serotonin are high enough to induce platelet aggregation, the platelets are unaggregable, perhaps due to a much reduced pH or loss of viability. With efficient microfiltration, platelet aggregation may be of little consequence for many routine transfusions of whole blood. However if cold storage is to continue, the striking difference in aggregation seen between 1° and 40C suggests that the storage temperature should be no lower than 4°C. The work is part of a project funded by the Medical Research Council. The blood packs were kindly donated by McGraw Laboratories. W. E. Dunn Unit Keele University,
Keele, Staffordshire ST5 5BG and North Staffordshire Royal
R. A. OAKES G. WRIGHT J. M. SANDERSON
HBsAg IN RENAL DISEASE SIR,-Renal disease has often been associated with hepatitis-B-antigen positive liver diseases. Brzosko et al.,’ however, identified HBsAg-antibody complexes in 50% of sera and 56% of renal-biopsy samples of 32 children with immune-complex glomerulonephritis (G.N.) and/or nephrotic syndrome but without
clinical liver disease.
In the past four years we have examined 276 patients with G.N., nephrotic syndrome, and other kidney diseases for the presence of HBsAg in serum and kidney. All patients were adults, 171 being males and 105 females. 7 had histories compatible with acute icteric hepatitis, 6 had received transfusions, and 6 had been treated with steroids and immunosuppressives. Only 5 patients had increased transaminases during the period of observation. We tested sera for HB sAg by passive heemagglutination (’Hepanosticon’) and for anti-HBsAg-antibody by immunoelectroosmophoresis. Kidney-biopsy tissue was studied by indirect immunofluorescence first with rabbit anti-HB,Ag antiserum 1. Brzosko, W. J., Krawczynski, K., Nazarewicz, T., Morzycka, M., Nowosawski, A. Lancet, 1974, ii, 477. 2. Vos, G. H., Grobbelaar, B. G., Milner, L. V. S. Afr. med. J. 1973, 47, 911. 3. Reznikoff-Etievant, M. F., Lagrue, G. Lancet, 1971, ii, 234. 4. Conte, J. J., Fournie, G. J. Nouv. Presse méd. 1975, 4, 429. 5. Guardia, J., Pedreira, J. D., Martinez-Vázquez, J. M., Vidal, M. T., Vilardell, M., Caralos, A., Ferrer, E., Bacardi, R. ibid. 1975, 4, 2923. 6. Powell, K. C., Meadows, R., Anders, R., Draper, C. C., Lauer, C. Aust. N.
Z. Jl Med. 1977, 7, 243.
The broken lines encompass immune-complex G.N.
(Behring, Marburg) and, then with fluorescein-labelled goat anti-rabbit-7S-globulin (Cappel, Downingtown). Specificity was checked by blocking experiments and by simultaneous staining of a known HBAg-positive liver section. Immunohistochemical analysis of kidney tissue was done by direct immunofluorescence using fiuoresceinlabelled anti-human IgG, IgM, IgA, IgE, C3, and fibrinogen (Hyland, Costa Mesa).
summarises the results. HBsAg was identified in and in 13-4% of kidney tissue. These figures were slightly higher in 196 patients with immune-complex G.N. (primary G.N. without minimal change and G.N. associated with systemic diseases), being 16-3% for serum and 16-8% for kidney, and much lower (5%) and 3%) for the patients with "other renal diseases". In a parallel study HB antigenaemia was identified in 45 (0-45%) of sera from 10 000 healthy blood-donors. Except in 1 patient, no anti-HBAg antibody was noted in the sera. In 20 of the 32 immune-complex glomerulonephritic patients with HB. antigenaemia we re-examined sera after 6-10 months and found only 10 positive cases. In contrast to what Brzosko et a1.1 found in children, there was I
TABLE II-COMPARISON OF DATA ON THE