A randomized trial of steroid avoidance in renal transplant patients treated with everolimus and cyclosporine.

In this randomized trial renal transplant recipients were treated with basiliximab, everolimus 3 mg/day, low-dose CsA. At transplantation, patients were randomized to stop steroids at the seventh day (group A) or to continue oral steroids in low doses (group B). Of the 113 patients enrolled, 65 were randomized to group A and 68 to group B. All patients were followed for 2 years. During the study 28 (43%) group A patients required reintroduced corticosteroids. One patient died, in group B. The Graft survival rate was 97% in group A and 90% in group B. There were more biopsy-proven rejections in group A (32% vs 16%; P = .044). The mean creatinine clearance was 54 +/- 21 mL/min in group A vs 56 +/- 22 mL/min in group B. Mean levels of serum cholesterol tended to be lower in group A, but the difference was of borderline significance (191 +/- 91 vs 251 +/- 188 mg/dL; P = .07). Vascular thrombosis (0 vs 5) and pneumonia requiring hospitalization (2 vs 7) tended to be more frequent in group B. Only three cases of CMV infection (1 vs 2) occurred. An immunosuppressive therapy with everolimus and low-dose CsA allows one to obtain excellent renal graft survival and stable graft function at 2 years. Early interruption of steroids in patients treated with this regimen may increase the risk of acute rejection, but neither affects graft survival nor graft function, while possibly reducing the risk of hyperlipemia and vascular thrombosis. About 60% of patients given everolimus and low-dose CsA can definitively stop steroids after 1 week.

[HCV+ patients on the waiting list for kidney transplantation. Retrospective analysis of data on the patient population with hepatitis C on the waiting list for kidney transplantation in the setting of the AIRT]. / Pazienti HCV+ in lista d'attesa per trapianto renale. Analisi retrospettiva dei dati relativi alla popolazione dei pazienti affetti da epatite C in lista d'attesa per trapianto di rene in ambito AIRT.

BACKGROUND: HCV infection in hemodialysis is still a matter of debate from an epidemiological and clinical point of view. Evaluation criteria for HCV-infected patients as transplant candidates are still not adequately standardized. Aims of the present study were to investigate: 1. the percentage of HCV positive patients on the waiting list of three Italian regions belonging to the Associazione InterRegionale Trapianti (AIRT); 2. to analyze the clinical approach in the evaluation of these patients in the attempt to define national guidelines for their pre- and post-transplant management. PATIENTS: We evaluated 2045 uremic patients on the waiting lists of four transplant centers (Bari, Bologna, Modena, Novara) belonging to AIRT at 31/12/2002. RESULTS: The overall prevalence of HCV positive patients was 14.2%, with a peak in the Puglia waiting list. The most common screening tests were AST and ALT serum levels and viral load (HCV RNA). Although there is a clear evidence that histological parameters are the main diagnostic and prognostic markers, a liver biopsy was performed in only 9.5% of patients. An even smaller percentage of HCV-infected patients underwent anti-viral therapy. CONCLUSIONS: Our retrospective analysis evidenced the need to improve common clinical strategies in approaching HCV-infected canditates to renal transplantation in the attempt to improve their post-transplant outcome.

[Malignant neoplasia and kidney transplantation. Retrospective analysis of data on the population having kidney transplantation with de novo neoplasia in the setting of the AIRT]. / Trapianto renale e neoplasie. Analisi retrospettiva dei dati relativi alla popolazione dei trapiantati di rene affetti da neoplasie de novo in ambito AIRT.

BACKGROUND: In transplanted patients undergoing immunossuppressive therapy the incidence of malignant neoplasia is 3-4 times higher than in the general population. Aim of the present study was to evaluate the prevalence of different tumours and the links between modulation of immunosuppressive therapy and patient and graft survival. PATIENTS: We evaluated 2029 kidney-transplanted patients from four Transplant Centres (Bari, Bologna, Modena, Novara) belonging to the Associazione InterRegionale Trapianti (AIRT). RESULTS: The incidence of neoplastic disease after transplantation was 3.9% in our population with a median time between transplantation and clinical onset of 23 months. We demonstrated a significant difference in the geographical distribution of different tumours. We did not observe any correlation with specific immunosuppressive drugs. Finally, dramatic reduction of the immunosuppression levels did not modify either the patients' or the graft's survival. CONCLUSIONS: Several factors can influence the post-transplant onset of neoplastic diseases with immunosuppressive therapy playing a pivotal role. The implementation of a National Registry would be the first step in an attempt to optimise immunosuppression in this particular group of patient's.

[Polyomavirus infection in an immunocompetent patient and literature overview]. / Infezione da Polymavirus in paziente immunocompetente e revisione della letteratura.

BACKGROUND: Polyoma virus (PV) is a double-stranded DNA virus, member of the Papovaviridae family. BKV and JCV are the most studied in human pathology, whereas simian virus 40 (SV40) is pathogenic in the monkey and has been implicated in human carcinogenesis. PV is associated with renal and urinary tract pathology. The initial infection by PV occurs in childhood, probably by airways, and is usually asymptomatic. Subsequently, it remains latent in kidneys, tonsils and CNS and may reactivate in concomitance with significant T-cell dysfunction. Infection in immunocompromised patients can be clinically relevant. However, asymptomatic viruria may be detected in 0.3 % of individuals without a known history of immunodeficiency. CASE REPORT: We describe the case of a male patient, aged 31, admitted to our Unit for arterial hypertension and urinary abnormalities. He had a history of hemorrhagic cystitis in 1996 and persistent microscopic hematuria thereafter. Renal function was normal, arterial pressure well controlled with an ACE-inhibitor; urine culture was negative and most of the immunologic and rheumatologic tests were normal, with the exception of slightly reduced levels of C3 and an inverted CD4/CD8 ratio. Serology for HCV, HBV, HIV and screening for tumor markers were negative. Renal ultrasonography displayed an increased reflectivity, as seen in medical nephropathies; no nephrolithiasis was found. Urinary cytology showed "decoy cells", as typically found in PV infection, whose presence was confirmed by n-PCR. Diagnosis at discharge from the hospital was primary arterial hypertension and urinary JCV infection. Currently, no treatment of proven efficacy against PV is available. CONCLUSIONS: We think that there is an increasing amount of evidence to include screening for PV in the diagnosis of urinary tract abnormalities of unknown origin, even in apparently immunocompetent patients. Urinary cytology, in experienced hands, may be a useful and relatively inexpensive first step diagnostic tool.

Expression of inducible lymphocyte costimulatory molecules in human renal allograft.

BACKGROUND: CTLA-4/CD28-B7 and CD40-CD40L interactions constitute two key costimulatory pathways in lymphocyte signalling during experimental allograft rejection. Studies on the expression of these molecules in human transplant rejection are still lacking. METHODS: The immunohistochemical study was performed on renal biopsies obtained for various clinical complications from 25 renal transplant patients. Expression of B7-1 and B7-2 and their counter-receptor CTLA-4, and of CD40 and its counter-receptor CD40L was examined. RESULTS: In acute rejection a focal intense infiltration of B7-1+ and B7-2+ cells (mainly CD20- CD14+) and of CTLA-4+ T lymphocytes (mainly CD8+) was present. In contrast, CD40 and CD40L were rarely expressed. Accumulations of T lymphocytes were found in the interstitium in the same area containing B7-1+ and B7-2+ cells. The scattered CD40L+ cells found in the T-cell infiltrate exhibited the CD4+ phenotype. In chronic rejection only a few B7-1+, B7-2+ or CTLA-4+ cells were detectable. In contrast, several CD40L+CD4+ cells were present both in the interstitium and in glomeruli. Moreover, an intense expression of CD40 on the endothelium was observed. In patients with cyclosporin nephrotoxicity cells positive for B7-1, B7 2, CTLA-4, CD40, or CD40L were absent. CONCLUSIONS: These results demonstrate a differential expression of costimulatory molecules in renal biopsies of allograft recipients undergoing acute or chronic rejection. Moreover, their detection may prove useful to discriminate rejection from cyclosporin nephrotoxicity.

[Early diagnosis of HCMV infections in patients undergoing transplantation of the kidney]. / Diagnosi precoce di infezione da HCMV in pazienti sottoposti a trapianto di rene.

HCMV infection is a major cause of morbidity and mortality following kidney transplantation. Clinical diagnosis is difficult, and rapid and sensitive diagnostic methods are needed since antiviral therapy is available. One hundred-forty-five consecutive kidney-transplanted patients were studied during a period of three months after transplantation. For laboratory diagnosis of HCMV infection, we looked for the presence of pp-65 antigen in polymorphonuclear leukocytes, HCMV-DNA and IgM. Demonstration of HCMV pp-65 antigen by immunofluorescence and HCMV DNA by PCR in leukocytes were efficient methods for early diagnosis of infection.

[99mTc-DTPA scintigraphy in renal transplantation. Limitations related to the immunosuppressor used]. / La scintigrafia con 99mTc-DTPA nel trapianto renale. Limiti correlati all'immunodepressore usato.

The diagnostic tools used to achieve an assessment of allograft dysfunction should be as noninvasive as possible, because kidney graft recipients are fragile patients and quite often the need is for repeated investigations. In order to evaluate the reliability and accuracy of such a method, in this case scintigraphy with 99mTc-DTPA, the authors retrospectively studied 2 groups of kidney transplanted patients, having two different basic immunosuppressive regimens: group A--86 patients--taking steroids and azathioprine; group B--93 patients--taking steroids and cyclosporine. A total of 722 scans were retrospectively compared with scintigraphic information: 196 episodes of allograft dysfunction were due to acute rejection: 118 in group A, 78 in group B; 117 episodes were due to ATN: 75 in group A, 42 in group B; 11 episodes were ascribed to CyA acute nephrotoxicity. Group A and B behave differently in respect of the perfusion index. Only in group A were perfusion indexes statistically different in rejection, ATN and nephrotoxicity. Anyway, it must be stressed that, even if in group B, scintigraphy cannot be considered an accurate diagnostic method, it is somehow a helpful tool because it gives information about a worse perfusion of the graft, independently of the underlying pathology.

[Comparison between biopsy data and the resistive index obtained by Doppler echography in the evaluation of the transplanted kidney]. / Confronto fra dato bioptico ed indice di resistenza ottenuto con eco-Doppler nella valutazione del rene trapiantato.

Doppler sonography is nowadays considered as a "first step" tool for diagnosis of vascular complications in kidney transplantation. Quite recently, it has been sometimes considered useful and effective investigation in order to obtain information about parenchymal dysfunctional pathologies, particularly about acute rejection. This has been obtained by studying the variation of resistive indexes. The goal of the following investigation was compare Doppler sonography data and histological examination in 50 kidney transplanted recipients in whom the renal biopsy was performed on a clinical basis. In the Authors' experience. Doppler sonography and study of the resistive index does not offer any reliable help in differentiating acute rejection from cyclosporine A toxicity.

Platelet-activating factor biosynthesis by cultured mesangial cells is modulated by proteinase inhibitors.

Rat mesangial cells stimulated with calcium ionophore A23187 and phagocytosis were shown to produce platelet-activating factor (PAF), a mediator of inflammation and endotoxic shock. In the study presented here, the cultured human mesangial but not epithelial cells synthetized PAF not only in response to calcium ionophore A23187 and phagocytosis of immunoglobulin G-coated latex beads, but also after stimulation with cytokines such as tumor necrosis factor-alpha and interleukin-1 beta. PAF synthetized after stimulation with A23187 and to a lesser extent with phagocytosis was partially released. In contrast, PAF synthesized by stimulation with tumor necrosis factor-alpha and interleukin-1 beta remained cell associated. Experiments with labeled precursors demonstrated that PAF was synthetized via the remodeling pathway that involves the activation of phospholipase A2 and of an acetyl-coenzymeA:2-lyso-PAF acetyltransferase. Synthetic inhibitors of serine proteases as well as plasma alpha 1-proteinase inhibitor inhibited the activation of phospholipase A2 detected as release of (14C) arachidonic acid and the activation of acetyl-CoA:2-lyso-PAF acetyltransferase at concentrations 100-fold lower than those present in plasma. This raises the question about the ability of mesangial cells to synthetize PAF in vivo. However, the inhibitory effect of plasma alpha 1-proteinase inhibitor may be abrogated by oxidative inactivation due to a concomitant stimulation of mesangial cell respiratory burst or in zones of close contact among cells or matrix, which have been shown to exclude antiproteinases.

Tumor necrosis factor alters cytoskeletal organization and barrier function of endothelial cells.

Treatment of human umbilical cord vein endothelial cells with tumor necrosis factor results in marked changes in cell shape and cytoskeletal organization. After 4 h of treatment, these cells loose reciprocal contacts with the formation of intercellular gaps. This retraction reaches a maximum after 6 h when most stress fibers staining for F-actin disappear and vinculin becomes diffused in the cytoplasm. Such changes spontaneously reverse after 24 h in the presence of tumor necrosis factor or after 2 h of incubation in fresh medium. After treatment with tumor necrosis factor, endothelial monolayers become permeable to albumin because of gaps that form between cells. Normal human serum, plasma alpha 1-proteinase inhibitor and an anti-inflammatory peptide that decrease synthesis of platelet-activating factor inhibit the changes induced by tumor necrosis factor. Furthermore, receptor antagonists of platelet-activating factor have the same effect. These findings suggest that platelet-activating factor is a secondary mediator responsible for the changes in cell shape and cytoskeletal organization, and for the leakiness of endothelial monolayers.

Effect of leukocyte stimulation on rabbit immune complex glomerulonephritis.

Phytohemagglutinin (PHA), a leukocyte mitogen, induces a lymphocyte and blast cell glomerulonephritis in rat renal allografts (Cell Immunol 13:146, 1974). The aim of this study was to assess whether PHA similarly enhances rabbit monocyte-dependent experimental, acute immune complex glomerulonephritis, and whether this effect is associated with local release of interleukin-1 (IL-1) and tumor necrosis factor (TNF). Rabbits with experimental acute serum sickness (AcSS: Group I) had focal proliferative and exudative glomerulonephritis with immune deposits, scattered subepithelial electron-dense deposits (humps), mild and transient proteinuria, normal creatinine clearance and slightly increased production of IL-1 and TNF from isolated glomeruli. Rabbits with AcSS and injected with PHA (Group II) developed severe lymphocyte and blast cell glomerulonephritis with diffuse endothelial damage; immune deposits were significantly reduced, focal subepithelial electron-dense deposits were absent, proteinuria was increased, creatinine clearance was decreased and production of IL-1 and TNF was markedly augmented as compared to rabbits in Group I. Rabbits with AcSS and injected with IL-1 beta and TNF alpha (Group V) had lesions comparable to those seen in Group II. These results show that PHA, IL-1 and TNF enhance the severity of acute immune complex glomerulonephritis, presumably by activating glomerular endothelial and mesangial cells and resident or infiltrated leukocytes.

Tumor necrosis factor induces contraction of mesangial cells and alters their cytoskeletons.

Cultures of human mesangial cells (MC) were established from the renal cortex of surgical specimen. The characteristic spindle-shaped or stellate appearance of MC was altered after treatment with tumor necrosis factor (TNF). After two hours, the MC retracted and lost reciprocal contacts. Furthermore, this treatment altered the cytoskeletal organization of MC, since a peripheral band of actin and stress fibers disappeared while the streaks of vinculin at focal contacts decreased. These changes were reversible when the MC were cultured in fresh medium. After five minutes of treatment with platelet activating factor (PAF), changes similar to those induced by TNF were observed. Inhibitors of PAF synthesis, such as plasma alpha 1-proteinase inhibitor and an anti-inflammatory peptide, blocked changes induced by TNF, PAF receptor antagonists inhibited changes induced by PAF and also by TNF. These results and the finding that MC are stimulated to produce PAF by TNF suggest that PAF is a secondary mediator of the changes in cell shape and cytoskeletal organization induced by this cytokine.

Involvement of cytokines and platelet-activating factor in renal pathology.

Platelet-activating factor (PAF) is a phospholipid that exhibits a wide range of biological activities as a secondary mediator of inflammation and anaphylaxis. Primary mediators of inflammation, such as interleukin-1 and tumor necrosis factor, stimulate PAF release by monocytes/macrophages, neutrophils and endothelial cells. PAF has also been implicated in cell-mediated hypersensitivity reactions. This review will focus on recent data suggesting that the local production of these mediators in glomeruli by infiltrating inflammatory cells or resident cells may influence the clinicopathological expression of glomerular disease. Results from in vitro and experimental studies suggest that these mediators alter the growth pattern of glomerular cells and the composition of secreted matrix, leading to scar formation and eventually to glomerulosclerosis.

Production of cytokines in hemodialysis.

Tumor necrosis factor (TNF-alpha) and interleukin-1 (IL-1 beta) are cytokines primarily produced by monocytes/macrophages when stimulated by endotoxin, complement-derived anaphylatoxins and the specific antigen. In the present study, the plasma levels of TNF-alpha and IL-1 beta were evaluated before and after hemodialysis with cuprophane membrane (in 9 patients) and hemodiafiltration (in 9 patients) using three high-permeability membranes such as polymethylmethacrylate, polyacrylonitrile (AN-69) and polysulfone. In vitro spontaneous production of TNF-alpha and IL-1 beta was evaluated in the supernatants from short-term cultured monocytes obtained before and after treatment. The predialytic levels of TNF-alpha and IL-1 beta were significantly higher (p less than 0.05) in the uremic population than in 21 healthy subjects taken as controls. The analysis of the uremic population regarding the mode of therapy indicated that in hemodialysis the predialytic plasma levels of TNF-alpha and IL-1 beta did not significantly differ from those of healthy subjects. In contrast, in hemodiafiltration with polymethylmethacrylate and AN-69, but not with polysulfone, the predialytic plasma levels of both cytokines were significantly (p less than 0.05) increased. No significant variation in plasma levels of both cytokines was observed after hemodialysis with cuprophane membranes. Hemodiafiltration with polymethylmethacrylate and AN-69, but not with polysulfone, brought about a consistent reduction in plasma levels of both cytokines. Detectable amounts of TNF-alpha and IL-1 beta were spontaneously produced by peripheral-blood monocytes 6 h after the end of hemodialysis but not of hemodiafiltration. These studies suggest a possible role of TNF-alpha and IL-1 beta in the biocompatibility of different extracorporeal treatments.

The production of platelet-activating factor during hemodialysis.

Regenerated cellulosic membranes (CU) induced the aggregation of plasma-free human neutrophils when recirculated in a dynamic model of dialysis without the patient on the circuit. Neutrophil aggregation was linked to the production of PAF by these cells. In the absence of detectable PAF production, no neutrophil aggregation occurred, as observed during recirculation with polymethylmethacrylate (PMMA) membranes. With polycarbonate (PC), PAF production and aggregation of neutrophils were both almost half the values with CU. PAF production was studied in ten hemodialysis (HD) patients tested twice with CU and once with PC and PMMA membranes. PAF was extracted in the venous blood during filling of the dialyser for 9/20 of patients with CU (3.1 +/- 2.9 ng/ml, mean +/- 1 S.D.) a membrane that induced marked leukopenia (greater than 50% of basal values at 15 min), C3a des Arg generation (greater than 500% at 5 min), and plasma levels of the elastase-alpha 1-proteinase inhibitor complex (greater than 500% at the end of HD). Membranes such as PC and PMMA showing intermediate or low potential to induce leukopenia and C3a des Arg generation, respectively, did not trigger the production and release of PAF in detectable amounts at any interval. However, with PMMA, plasma neutrophil elastase was significantly higher than baseline at the end of dialysis. These levels were not significantly different (p less than 0.05) from those observed with CU and PC membranes.