Efficacy of subcutaneous epoetin-zeta on anemia in renal transplant recipients: a single-center experience.

BACKGROUND: Persistent or "de novo" anemia (plasma hemoglobin<11 g/dL) may complicate the graft outcome in a significant number of renal transplant recipients. We describe a single-center experience with epoetin-zeta (EPO-Z), the biosimilar form for epoetin-alfa. METHODS: Twenty patients were included in the study, 10 in treatment with different erythropoiesis-stimulating agents (ESA) and shifted to EPO-Z (shift group) and 10 who started EPO-Z treatment for anemia (naive group). All the patients had stable renal function and normal values of main inflammation markers and were prospectively followed up for 12 months. Iron supplements were administered during the study, as needed. RESULTS: In the shift group, mean plasma hemoglobin levels>11 g/dL were maintained for the entire 1-year follow-up period, with average EPO-Z doses 3.4% higher than the corresponding doses of previous ESA; in the naive group, the target value was reached between the first and third months and remained stable throughout the study. Mean corpuscular volume did not vary in either group. No change was observed in glomerular filtration rate, nor in proteinuria or in main laboratory data. No drug-related side effect was reported. CONCLUSIONS: EPO-Z may be considered a valid alternative to different ESAs in renal transplant recipients, with an interesting pharmaco-economic profile, considering its lower cost.

Complicated diverticulitis in kidney transplanted patients: analysis of 717 cases.

INTRODUCTION: This study aims to investigate possible risk factors for diverticulitis in kidney transplant recipients affected by colonic diverticulosis. METHODS AND RESULTS: We investigated 717 patients transplanted between 2000 and 2010. Diverticular disease was endoscopically diagnosed in 17 of 717 examined patients. Eight patients were diagnosed with autosomal dominant polycystic kidney disease (ADPKD); 9 of 17 patients underwent emergency surgery. We performed Hartmann's procedure on all patients, with a second stage performed at least 6 months later. DISCUSSION: Although the incidence of colonic diverticular perforation in kidney transplanted patients is similar to that observed in the general population, perforation in immunosuppressed patients is associated with a higher morbidity/mortality rate. In our study, the incidence of perforation is 1.25% (9 of 717), with almost half of the cases observed in patients with ADPKD (4 of 9). Such an observation is consistent with published data, in which patients with ADPKD are reported to more frequently develop colonic diverticulosis and its complications. One possible explanation might be related to a belated diagnosis of diverticulitis, which could initially simulate an inflammatory disease as a consequence of renal cysts. Also, steroids seem to be a predisposing factor for colonic perforation in these patients. CONCLUSIONS: A timely surgery can significantly reduce mortality. In cases of elective surgery, mortality and morbidity are similar to those of immunocompetent patients; accordingly, this is the goal to be pursued. Early signs and symptoms are often masked by immunosuppressive therapy. In these patients, surgeons should always perform (1) abdominal computed tomography scanning and, in the presence of diverticulitis, reduce or withdraw immunosuppressive therapy; and (2) early surgery, with Hartmann's procedure being, in our opinion, the best choice. Before transplantation, elective surgery for colonic resection should be considered in patients with ADPKD or with a history of 1 or more episodes of acute diverticulitis who then regressed with medical therapy.

Thyroid function and morphology after a successful kidney transplantation.

Although thyroid disorders related to the end-stage renal disease (ESRD) are well known, there are discordant data on the function and morphology of the thyroid gland after renal transplantation (RT). The objective of this cross-sectional, case-control study was to investigate the prevalence and risk factors for disorders in the thyroid function and morphology after a successful RT. Fifty consecutive patients (25 females, 25 males) with fully functioning allograft were enrolled. Their age at transplant ranged from 23 to 44 yr (median, 38) and their post-RT follow-up lasted 15-86 months (median, 23). One hundred healthy subjects matched for sex, age and body mass index (BMI) were included as controls. Serum free thyroid hormones, TSH, thyroglobulin, thyroid hormone-binding globulin (TBG) and iodine urinary excretion were determined; ultrasonographic exam of the thyroid gland was performed in all subjects. Age, gender, time elapsed from RT, dialysis duration, kidney function, type of immunosuppression and corticosteroid dose were considered as possible influencing factors for the thyroid function. Hypothyroidism was found in 6% of patients, "low T3 syndrome" in 52%, while another 26% had free T3 (FT3), free T4 (FT4) and TSH in the lowest third of the normal range, suggesting inhibition of the whole hypothalamic-pituitary-thyroid (HPT) axis. Iodine excretion and prevalence of anti-thyroid antibodies were similar in both patients and controls. There was no significant difference in the thyroid function according to different immunosuppressive regimens. In patients, an ultrasonographic exam revealed a very variable thyroid volume ranging from 7.2 to 24.8 ml. Solid nodules were detected in 12 (24%) cases and cystic lesions in another four (8%); they were proven negative at cytological examination. Dialysis duration was longer in patients with thyroid nodules than in those without (p<0.05). Inhomogeneous hypoechoic pattern typical for chronic thyroiditis was more frequent than its biochemical expression. In conclusion, a high prevalence of abnormal thyroid morphology was found in patients after a successful RT, being partly related to a previous uremia. Abnormalities in the thyroid function are likely an expression of the post-transplant general and immunological conditions. Endocrinological follow-up is advisable in patients after RT, in order to discriminate thyroid dysfunctions which need specific treatments from those that can only be followed-up, avoiding inappropriate treatments of biochemical abnormalities.

Opinions on renal transplantation and organ donation in high school students in two large northern (Torino) and southern (Napoli) Italian cities.

UNLABELLED: Organ shortage for transplantation has focused attention on educational interventions. Italy is a nonhomogenous country whose cultural and economic differences are reflected in the health-care system: dialysis is mainly public in the north versus private in the south; and transplantation rates display a wide range from 3.4 to 37.8 per million people in 2002. The aim of the present study was to analyze the opinions of population of high school students (last two years) in two large cities: northern (Torino) and southern (Napoli) Italy, as a knowledge base for a randomized controlled trial on the efficacy of educational interventions on renal replacement therapy and organ donation, targeted to high school students. METHODS: This preliminary study included eight public high schools that completed a first and anonymous semistructured questionnaire. Five hundred and eighty nine questionnaires were retrieved in Torino and 539 in Napoli. In both cities most students answered that they would give a kidney to a brother, sister, or partner needing dialysis (Torino: yes 80.6%; no 2.2%, uncertain-blank 17.2%; Napoli: yes 86.1%, no 1.1%; uncertain-blank 12.8%). Only 36.3% of the students in Torino and 37.7% in Napoli answered that they would consent to organ donation, if they had to choose for a strict relative with brain death. Opposition was 28% in Torino and 23.7% in Napoli; 35.7% in Torino and 38.6% in Napoli were blank-uncertain. These data underline the need for detailed information on the opinions of the overall population as basis for tailored educational campaigns.

Safety and immunogenicity of HIV-1 DNA constructs in chimpanzees.

A global effort to control the HIV epidemic is likely to rely heavily on immunization strategies. As our closest genetic relative, the chimpanzee provides the most important model for preclinical safety and immunogenicity studies. We have immunized adult, pregnant and infant chimpanzees with our plasmid vaccines. We have found these vaccines to be safe and well tolerated in all of these groups. The same vaccines have induced both humoral and cellular immunity in each instance.

DNA vaccination as anti-human immunodeficiency virus immunotherapy in infected chimpanzees.

The role of the immune response in controlling human immunodeficiency virus type 1 (HIV-1) replication is controversial. Immunotherapeutic strategies that have the ability to broaden immune responses might play a role in slowing disease progression. DNA immunization was studied as immunotherapy in infected chimpanzees. Two HIV-1-infected chimpanzees were vaccinated with DNA plasmid vaccines, one with plasmid pCMN160, which expresses the envelope glycoprotein of HIV-1MN and rev, and the other with a control plasmid. The chimpanzee immunized with pCMN160 demonstrated enhanced humoral responses. Virus load was monitored. Virus load in the chimpanzee receiving pCMN160 decreased at week 20 and has remained at background levels. The control chimpanzee was subsequently vaccinated with pCMN160. After immunization, the antibody responses increased and, as in the first animal, the virus load decreased. These results indicate the potential of the immune response to have a direct impact on HIV-1 replication in chimpanzees.

In vivo protective anti-HIV immune responses in non-human primates through DNA immunization.

An effective immune response involves the specific recognition of and elimination of an infectious organism at multiple levels. In this context DNA immunization can present functional antigenic proteins to the host for recognition by all arms of the immune system, yet provides the opportunity to delete any genes of the infectious organism which code for antigens or pieces of antigens that may have deleterious effects. Our group has developed the use of nucleic acid immunization as a possible method of vaccination against Human immunodeficiency virus type 1 (HIV-1) [1,2,3,10,11,12]. Sera from non-human primates immunized with DNA vectors that express the envelope proteins from HIV-1 contain antibodies specific to the HIV-1 envelope. These sera also neutralize HIV-1 infection in vitro and inhibit cell to cell infection in tissue culture. Analysis of cellular responses is equally encouraging. T cell proliferation as well as cytotoxic T cell lysis of relevant env expressing target cells were observed. In addition, evidence that DNA vaccines are capable of inducing a protective response against live virus was demonstrated using a chimeric SIV/HIV (SHIV) challenge in vaccinated cynomologous macaques. We found that nucleic acid vaccination induced protection from challenge in one out of four immunized cynomolgus macaques and viral load was lower in the vaccinated group of animals versus the control group of animals. These data encouraged us to analyze this vaccination technique in chimpanzees, the most closely related animal species to man. We observed the induction of both cellular and humoral immune responses with a DNA vaccine in chimpanzees. These studies demonstrate the utility of this technology to induce relevant immune responses in primates which may ultimately lead to effective vaccines.

DNA inoculation induces neutralizing immune responses against human immunodeficiency virus type 1 in mice and nonhuman primates.

DNA, or genetic, inoculation mimics aspects of attenuated vaccines in that synthesis of specific foreign proteins is accomplished in the host. These proteins can be processed and presented on the relevant major histocompatibility complex (MHC) antigens and ultimately become the subject of immune surveillance. Very recently, we have described the use of the new technology to generate immune responses in mice against the human immunodeficiency virus type 1 (HIV-1) envelope using a gp160 DNA construct. Further analysis of this technology specifically in regard to HIV vaccine design is clearly important. In this report, we describe the analysis of additional HIV constructs as immunogens in both mice and report the use of this genetic immunization technology in nonhuman primates. In these studies, successful seroconversion occurs in more than 70% of the mice following the second immunization with 100 micrograms of construct DNA; three and four immunizations result in routinely 100% seroconversion of the mice. Furthermore, the same strategy has successfully seroconverted primates following their second inoculation, resulting in the generation of both antiviral and neutralizing antibodies in this animal species. These studies are the first report of which we are aware that demonstrate successful immunization of nonhuman primates through genetic vaccination technology and the first to describe genetic immunization of primates against HIV antigens. This technology has relevance for the development of safe and efficacious immunization strategies against HIV because it provides for relevant antigen production in vivo without the use of infectious agents.

Phase I trial of multiple large doses of murine monoclonal antibody CO17-1A. I. Clinical aspects.

Twenty-five patients with metastatic gastrointestinal adenocarcinoma received one to four infusions (400 mg) of murine monoclonal antibody CO17-1A. Eleven patients had mild gastrointestinal symptoms, and one had a transient flushing episode. Two of five who received three weekly infusions had readily reversible anaphylactic reactions at the time of the third infusion (day 15). There were no other toxic effects. One patient had a complete remission and is surviving at greater than 104 weeks, and four had stable disease. The median survival for the whole group was 57 weeks. In general, the antibody infusions were well tolerated but had modest antitumor effects.

Phase I trial of multiple large doses of murine monoclonal antibody CO17-1A. II. Pharmacokinetics and immune response.

Twenty-five patients with metastatic gastrointestinal adenocarcinoma received one to four infusions of large doses (400 mg) of murine monoclonal antibody CO17-1A (17-1A). The pharmacokinetics of 17-1A at the time of first, second, third, or fourth infusion were not statistically different; plasma half-lives were 15.0 +/- 1.7 hours (n = 5), 15.1 +/- 1.8 (n = 10), 25.3 +/- 6.2 (n = 3), and 14.4 +/- 1.8 (n = 5), respectively. Most patients had an antibody response to 17-1A, with peak levels occurring 15-22 days after infusion. The presence of serum antibody to 17-1A at the time of the second or third infusion did not significantly alter the pharmacokinetics of this large dose of antibody. Four of 25 patients failed to develop an antibody response, but this did not correlate with the amount of 17-1A administered. The administration of four doses of 400 mg over 1 week provided continuously circulating 17-1A for 10 days.

Phase I clinical trial of CO17-1A monoclonal antibody.

Twenty patients with metastatic gastrointestinal cancer received one or more weekly infusions of 400 mg CO17-1A monoclonal antibody. The most common side effect was mild gastrointestinal symptoms in 9/20 patients. Two of five patients receiving three weekly infusions had reversible anaphylactic reactions at the time of their third infusion. The pharmacokinetics of the antibody were similar at the first, second or third infusion. Human antibody to 17-1A occurred in 17/20 patients with 11/20 having antibody detectable by 8 days following initial infusion. Thus, one or two infusions (weekly) of large doses of 17-1A were well tolerated but allergic responses limit ability to administer therapy by 15 days post-initial infusion.

Cartilage-staining technique for the examination of unskinned fetal rat specimens previously processed with alizarin red S.

A novel staining technique has been devised that permits a cartilage examination of unskinned fetal rats that have been previously processed for skeletal examination with alizarin red S. The procedure consists of rinsing alizarin red S-stained specimens in distilled water and placing the specimens in a 3% acetic acid solution. A transfer of the stain from bone to adjacent cartilage occurs, producing purple-stained cartilaginous structures that can be differentiated from still-discernible bone structures.

Novel accessory skull bone in fetal rats after exposure to aspirin.

Aspirin was administered by oral gavage to 25 gravid Sprague-Dawley rats on gestation day 10, as a single dose of 500 mg/kg, in a concentration of 50 mg/ml. The aspirin was suspended in a mixture of 0.5% w/v hydroxypropylmethylcellulose (Methocel E-4M) and 0.1% w/v polysorbate 80 (Tween 80). A control group of 25 gravid rats was given 10 ml/kg/day of the suspending vehicle alone, by oral gavage, on gestation days 6 through 15. C-sections were performed on gestation day 20. Approximately two-thirds of the fetuses were processed for skeletal examination with Alizarin Red S; the remaining fetuses were placed in Bouin's solution. Examination of the fetal skeletal specimens from the aspirin-treated group revealed a 20% fetal (43% litter) incidence of an accessory skull bone, located between the nasal and frontal bones. This structure ranged in size from a small, barely discernible, circular ossification site (less than 0.5 mm) to a relatively large, bilobate bone (approximately 2 mm). This anomaly has not been previously reported in fetal rats.

Penetration of trolamine salicylate into the skeletal muscle of the pig.

Studies to determine the extent of local tissue penetration of topically applied trolamine [14C]salicylate were conducted in domestic pigs. The preparation was applied onto a 100-cm2 shaved area of skin overlying the biceps femoris at a concentration of 0.7 mg of salicylate/cm2 to closely approximate the actual use in humans. At least 82% of the topically applied trolamine salicylate was absorbed over a 2-h period. Based on blood and muscle salicylate levels, a localization of the absorbed drug occurred in muscle underlying the treated area within 120 min. Muscle from the treated area had a concentration of salicylate that was 13 times that of blood and 49 times that of muscle taken from untreated areas. Blood samples taken from the treated area at 10, 20, and 30 min showed that salicylate levels ranged from 15.8 to 5.3 micrograms/g. Less than 0.5% of the applied drug was excreted in the urine during the 2-h period.

Myocardial effects of mitoxantrone and doxorubicin in the mouse and guinea pig.

Mitoxantrone (DHAQ) was compared to doxorubicin for myocardial effects in the mouse and the guinea pig. Histologically, DHAQ induced a high incidence of focal myocardial damage in mice, similar to that observed with doxorubicin. Functionally, like doxorubicin, DHAQ significantly reduced the rate of contraction and histamine responsiveness of guinea pig right atria in vitro. Additionally, long-term ip administration of either DHAQ or doxorubicin reduced the atrial response to histamine in vitro. These data suggest that DHAQ may have a spectrum of myocardial activity similar to that of doxorubicin.

Effect of ICRF-187 on doxorubicin-induced myocardial effects in the mouse and guinea pig.

ICRF-187 was tested for cardioprotective activity in doxorubicin-treated mice and guinea pigs. Pretreatment with i.p. ICRF-187 caused a significant decrease in the indicence of i.v. doxorubicin-induced myocardial histological damage in the mouse. I.p. ICRF-187 did not, however, reduce the effect of i.p. doxorubicin on a functional myocardial effect of this antitumour drug, a reduced histamine responsiveness of right atria in vitro. These data suggest that ICRF-187 may not be specific for all the cardiac effects of doxorubicin.

Comparison of the relative mutagenic activity for eight antineoplastic drugs in the Ames Salmonella/microsome and TK+/- mouse lymphoma assays.

Eight antineoplastic drugs were evaluated for their ability to induce mutation in the Ames Salmonella/microsome and the TK+/- mouse lymphoma assay. Dose response data were utilized to determine the relative potency of each of these drugs. They were then ranked based on this information. Vincristine, the most potent compound tested in the mouse lymphoma assay, was not active in the Salmonella assay, nor were DTIC and Methotrexate. Excluding these compounds from the comparison ranking, we found that the only difference in the order between the Ames and lymphoma assays was between Daunomycin and Adriamycin. Daunomycin was most potent in the Ames assay, compounds was reversed in the mouse lymphoma assay. This observation of relative activity is of interest because it underscores the ability to extrapolate between microbial and mammalian test systems, provided one keeps in mind the differences associated with chromosome structure and modes of segregation in these two cell types. Furthermore, it is suggested that relative potency ranking may provide prospective insight into expectations of risk for human populations exposed to these drugs.