Gene Expression Profiling of Peripheral Blood From Kidney Transplant Recipients for the Early Detection of Digestive System Cancer.

BACKGROUND: Kidney transplant recipients are at increased risk of developing cancer in comparison with the general population. To effectively manage post-transplantation malignancies, it is essential to proactively monitor patients. A long-term intensive screening program was associated with a reduced incidence of cancer after transplantation. This study evaluated the usefulness of the gene expression profiling of peripheral blood samples obtained from kidney transplant patients and adopted a screening test for detecting cancer of the digestive system (gastric, colon, pancreas, and biliary tract). STUDY DESIGN AND METHOD: Nineteen patients were included in this study and a total of 53 gene expression screening tests were performed. The gene expression profiles of blood-delivered total RNA and whole genome human gene expression profiles were obtained. We investigated the expression levels of 2665 genes associated with digestive cancers and counted the number of genes in which expression was altered. A hierarchical clustering analysis was also performed. The final prediction of the cancer possibility was determined according to an algorithm. RESULTS: The number of genes in which expression was altered was significantly increased in the kidney transplant recipients in comparison with the general population (1091 ± 63 vs 823 ± 94; P = .0024). The number of genes with altered expression decreased after the induction of mechanistic target of rapamycin (mTOR) inhibitor (1484 ± 227 vs 883 ± 154; P = .0439). No cases of possible digestive cancer were detected in this study period. CONCLUSION: The gene expression profiling of peripheral blood samples may be a useful and noninvasive diagnostic tool that allows for the early detection of cancer of the digestive system.

Kidney Transplantation, Cardiovascular Risk, and Long-Term Dialysis in Japan.

BACKGROUND: The waiting time for deceased-donor kidney-only transplantations in Japan is long. Herein, we assessed the effect of length of dialysis on the outcomes of these patients. METHODS: We divided patients into 2 groups based on length of dialysis (Group A, <15 years, and Group B, ≥15 years), and compared the background and outcomes after kidney transplantation. RESULTS: Group A included 210 patients and Group B included 35 patients. In Group B, 20% of transplants were from living donors. Patient age (P = .017) and the hepatitis C infection rate (P = .018) were significantly higher in Group B, whereas hypertension (P = .011), diabetes (P = .041), and ABO-incompatibility rates (P = .015) were significantly higher in Group A. The 5- and 10-year survival rates were 97.0% and 95.4%, respectively, in Group A and 97.1% and 97.1%, respectively, in Group B. The 5- and 10-year graft survival rates were 95.4% and 84.8%, respectively, in Group A and 97.1% and 73.1%, respectively, in Group B. There were no significant differences between the groups in patient survival (P = .74) and graft survival (P = .72). The 5- and 10-year cardiovascular event-free survival rates were 95.9% and 92.4%, respectively, in Group A and 88.6% and 76.8%, respectively, in Group B. Cardiovascular event-free survival was significantly higher in Group A (P = .038). Cox stepwise multivariate analysis indicated that length of dialysis was a significant predictor of cardiovascular events (hazard risk, 1.007; range, 1.001-1.012; P = .012). CONCLUSION: The prognosis after kidney transplantation is promising even after a long length of dialysis, although evaluation of the cardiovascular risk is needed in these cases.

Initial experience with a tailor-made simulation and navigation program using a 3-D printer model of kidney transplantation surgery.

INTRODUCTION: Three-dimensional (3-D) printing systems allow for the creation of surgical models mimicking real tissue. We developed a kidney graft and pelvic cavity replica as a patient-specific 3-D model using a 3-D printing system with simultaneous jetting of different materials and subsequently evaluated the usefulness of surgical simulation and navigation of living kidney transplantation. METHODS: After generating a stereolithographic file of the organ surface based on multidetector computed tomographic data, we created a 3-D organ model using an inkjet 3-D printer and manufactured a pelvic cavity replica using patient-specific data. RESULTS: The patients' individual 3-D printed models were used to plan and guide the surgical procedures for laparoscopic donor nephrectomy and recipient transplantation surgery. The 3-D organ replicas obtained using transparent materials allowed for the creation of models that showed the visceral organs, blood vessels, and other details, thereby overcoming the limitations of conventional image-guided navigation. Our pelvic replicas can be made according to each patient's specific anatomical data, thus representing personalized surgical procedures. This level of detail of the anatomy enables the surgeons and trainees to virtually treat various pelvic conditions before they perform the surgical procedure. The use of these replicas may also reduce the length of the operation and provide better anatomical reference tools for tailor-made simulation and navigation of kidney transplantation surgery, consequently helping to improve training for the operating room staff, students, and trainees. CONCLUSIONS: We believe that our sophisticated personalized donor graft and pelvic replications obtained using a 3-D printing system are advantageous for kidney transplantation surgery.

Nutritional status in Japanese renal transplant recipients with long-term graft survival.

BACKGROUND: Nutritional status affects clinical outcomes in patients with chronic renal failure. Glucose intolerance, dyslipidemia, obesity, hypertension, and a calcium-phosphorus-vitamin D imbalance are the major nutritional and metabolic problems that occur in posttransplant patients. In this study, we assessed the daily intake in long-term renal transplant recipients to determine whether they have sufficient nutrients based on the Japanese nutrition recommendations (recommended dietary allowances [RDA] in Japan 2010). SUBJECTS AND METHODS: Thirty-one renal allograft recipients followed for >10 years (median, 16.3) were recruited. The median serum creatinine level was 1.2 g/dL (95% CI, 0.6-3.4). We estimated the intake of nutrients, including protein and salt, using a simple food frequency questionnaire. RESULTS: The median body mass index was 20.1 kg/m(2). The median total energy intake was 1566 kcal/d (95% CI, 892-2556). The daily intake of protein and salt was 65.1 and 9.1 g/d, respectively. The calcium, iron, vitamin D, and vitamin K intakes were 423 mg, 7.0 mg/d, 9.7 µg/d, and 197 µg/d, respectively. Patients with dyslipidemia displayed greater amounts of lipid and calcium than those with normal lipid levels. DISCUSSION: Our findings suggest that long-term renal transplant recipients in Japan seem to restrict caloric intake, while maintaining appropriate intake of protein, lipids, carbohydrates, and vitamins A, D, and K. However, daily calcium and iron intake were insufficient; salt intake was greater than the recommended dietary allowances in all subjects. In patients with dyslipidemia, calcium intake was lower than those in patients without dyslipidemia, although their intake of lipids was also lower than those without dyslipidemia. CONCLUSION: Nutritional guidance beginning during the early posttransplant phase helps to foster a healthy body mass index and nutritional balances for long-term renal transplant recipients. However, greater salt restriction was needed, and additional nutritional guidance aiming to prevent osteoporosis seems to be considered.

Should we discard the graft? Analysis of the renal grafts with a total ischemia time of more than 24 hours donated after cardiac death.

The objective is to investigate the outcome of transplantation using kidney grafts from donors after cardiac death (DCDs) with a total ischemia time (TIT) longer than 24 h. All 373 kidneys were procured from DCDs. They were procured using the in-situ regional cooling technique. Grafts were classified into two groups according to TIT. Fifty-three grafts had a TIT longer than 24 h (group 1), and the other 320 grafts (group 2) were less than 24 h. The numbers of never functioning grafts (PGF) were 3 in group 1 (5.7%) and 17 in group 2 (5.3%), a nonsignificant difference. Graft survival rates at 3, 5 and 10 years posttransplant were 84.9%, 73.0% and 64.1% in group 1, and 76.3%, 69.9% and 57.1% in group 2, which demonstrate no significant difference. The significant risk factors for graft failure were donor age, serum creatinine level on hospitalization and WIT. However, TIT longer than 24 h was not employed. Multivariate logistic regression indicated that only WIT was associated with an increase in the risk of PGF. Our results demonstrate that kidneys from DCDs, even if their TIT is more than 24 h, should be considered a worthwhile source of renal grafts.

Up-regulation of osteopontin, chemokines, adhesion molecule, and heat shock proteins in 1-hour biopsy from cardiac death donor kidneys.

AIMS: Since April 1979, 471 kidneys were retrieved from donors after cardiac death (DCD) using an in situ regional cooling technique, with excellent renal function and good long-term graft survival. However, the precise cascade of events following transplantation of DCD kidneys and the influence of ischemia-reperfusion injury remain unclear. In this study, we performed gene expression profiling using 1-hour biopsy samples from DCD kidneys versus those from living sources. METHODS: All kidney grafts were procured at our center using an in situ regional cooling technique from DCD. Living donor kidneys (LD) were harvested by open nephrectomy. All graft biopsies were performed 1 hour after reperfusion (DCD n = 8, LD n = 9). We analyzed the expression profile of 20,173 genes. RESULTS: One hundred seventy eight genes were up-regulated (>2-fold difference and DCD/LD > 1.5) and 120 down-regulated (<1/2-fold and LD/DCD > 1.5) in DCD kidneys. Expression of osteopontin (22.5 +/- 2.6-fold DCD vs 7.7 +/- 1.7 LD; P < .001), chemokines (CCL4 4.4 +/- 0.7 vs 2.5 +/- 0.3; P < .01), (CCL2 6.0 +/- 1.3 vs 2.8 +/- 0.5), CXCL1 (9.5 +/- 0.4 vs 2.0 +/- 0.2), and CXCL2 (16.7 +/- 5.3 vs 4.8 +/- 1.3; P < .05), adhesion molecule (ICAM-1 4.7 +/- 0.7 vs 2.5 +/- 0.4; P < .05), and heat shock proteins (HSPA1L 6.7 +/- 0.7 vs 1.6 +/- 0.3, HSPA1A 17.7 +/- 2.6 vs 2.4 +/- 0.5, HSPA1B 13.3 +/- 0.2 vs 3.0 +/- 0.7, HSPA5 6.7 +/- 0.8 vs 3.2 +/- 0.3, HSPB1 2.9 +/- 0.2 vs 1.0 +/- 0.1, and HSPH1 19.4 +/- 3.0 vs 5.9 +/- 1.1; P < .001) were up-regulated in the kidneys from DCD. CONCLUSION: This report analyzed global gene expression using 1-hour biopsy samples from DCD kidneys. These results may provide new insight into the identification of novel target genes for the development of therapeutic approaches and for determining graft viability of kidneys from DCD.

Should we discard the renal allografts from cardiac death donors that have total ischemic time longer than 24 hours?

PURPOSE: The objective of this study was to investigate the outcome of transplantation using kidney grafts donated after cardiac death (DCD) with a total ischemic time (TIT) longer than 24 hours. PATIENTS AND METHODS: We followed 373 kidneys recovered from DCD donors and transplanted at 41 centers. All kidneys were procured from uncontrolled DCD donors. Grafts were classified into two groups according to TIT. We recorded renal function and duration of the survival period for each graft. RESULTS: Fifty-three grafts had a TIT longer than 24 hours (group 1). The other 320 grafts had a TIT less than 24 hours (group 2). The number of never functioning grafts were three in group 1 (5.7%) and 17 in group 2 (5.3%). Delayed graft function (DGF) occurred in 44 group 1 (83.0%) and 254 group 2 kidneys (79.4%) for intervals of 13.5 +/- 12.6 versus 10.9 +/- 12.6 days, respectively. Graft survival rates at 3, 5, and 10 years posttransplant were 84.9%, 73.0%, 64.1% for group 1, and 76.3%, 69.9%, 57.1% for group 2. In a Cox proportional hazards model, TIT longer than 24 hours was not a significant independent risk factor. CONCLUSION: Our results showed that even kidneys with TITs of over 24 hours yielded comparable results despite a higher incidence of DGF.

Is pulsatile perfusion necessary for renal transplantation engrafting kidneys from cardiac death donors?

BACKGROUND: There has been a considerable literature describing the use of pulsatile perfusion (PP) to evaluate the efficacy of organs from deceased donors. Since 1979, we recovered 469 kidneys from deceased donors after cardiac death (DCDs), using an in situ regional cooling technique and preservation by simple cold storage. In this study, the posttransplantation outcomes as well as long-term survivals of renal grafts from DCDs were compared with PP data in the recent literature. MATERIALS AND METHODS: We compared our recent data with 176 kidneys recovered between 1993-2002 using an in situ regional cooling technique. Patient and graft survivals were compared with those from the Scientific Registry of Transplant Recipients (SRTR) database. RESULTS: Following transplantation, 4.5% of the grafts never recovered; 10.3% of the grafts showed immediate renal function; 85.2% of the grafts had delayed graft function (DGF) with an average acute tubular necrosis (ATN) period of 13.1 days compared with 54.3% DGF from DCD using PP. Graft survival rates at 1, 3, 5, and 10 years were 90.8%, 86.5%, 77.8%, and 69.0%, respectively, compared with 89% at 1 year and 80% at 3 years reported for DCD by the SRTR in which almost 30% of the grafts underwent PP. CONCLUSIONS: Although PP seemed to have some advantage to decrease the DGF ratio, an in situ regional cooling technique with simple cold storage may provide excellent graft function and long-term graft survival as well as having benefits in cost and transportation.

IP-10, apoptotic genes, and calcineurin subtype messenger RNA kinetics occurring in rat renal isografts from brain-dead donors.

BACKGROUND: Brain death (BD) and following ischemia/reperfusion(I/R) injury has cardinal implications in kidney transplantation (Tx). We hypothesize that inflammation, apoptosis, and drug nephrotoxicity are central mechanisms leading to initial organ damage in transplantation from BD donors. In this study, the gene kinetics of a chemokine (IP-10), an apotosis-related gene, and of calcineurin (Cn) subtype were compared using kidney isografts from BD versus living donors. METHODS: Donors were intubated and mechanically ventilated for 6 hours. Grafts were harvested 6 hours after BD, and at 1, 6, and 24 hours and 5 days after engraftment. Messenger RNA (mRNA) expression was assessed using real-time reverse transcriptase-polymerase chain reaction. RESULTS: Gene expression of IP-10 was up-regulated only among BD donor kidneys, particularly following I/R injury. These changes recovered to baseline levels thereafter. Bcl-2 was suppressed within 6 hours of BD and 1 hour after engraftment. In contrast, Bax in kidneys from BD donors was significantly up-regulated at 6 hours after engraftment. These changes were minimal in the controls. Cn Aalpha and Abeta were decreased in kidneys from BD donors before and within 1 hour after engraftment. However, these differences became insignificant thereafter. CONCLUSIONS: Marked up-regulation of IP-10 may predict the initial graft injury and the onset of delayed graft function. Apoptotic gene changes may lead kidney grafts to a preapoptotic condition and up-regulate renal toxicity caused by Cn inhibitors. This initial antigen-independent donor circumstance may be one risk factor for chronic rejection.

Mycobacterium tuberculosis infection of bilateral cervical lymph nodes after renal transplantation.

We report the case of a 52-year-old man who underwent a renal transplantation and subsequently developed extrapulmonary tuberculosis. The immunosuppressive agent was intravenously administered continuously together with antituberculosis drugs. The tuberculosis improved and renal function has been well preserved for more than 3 years post transplantation.

[The impact of rejection episodes during acute tubular necrosis--diagnosis and allograft outcome after cadaveric renal transplants].

Diagnosis of acute rejection (AR) is difficult during acute tubular necrosis (ATN), and a delay of rejection treatment could result in negative impacts on the renal transplant outcome. At our center, 68 cadaveric kidneys were transplanted during the past 7 years. The 1-, 3- and 5-year graft survival rates were 95.4%, 93.8% and 81.4%, respectively. After the transplants, 16 patients had immediate graft function (G-I), 51 patients experienced ATN for 12.0 +/- 9.3 days, and one patient had a non-functioning graft due to diffuse arteriolar thrombosis caused by DIC in the donor. During ATN, 41 patients had no rejection episodes (G-II) and 10 patients had ARs (G-III). Nine patients were treated with bolus steroid and one with steroid and OKT-3. Although scintigraphic and sonographic examinations were routinely employed, only the histopathological findings of needle biopsies were helpful for the diagnosis of AR during ATN. When the transplant outcome was compared, the serum creatinene level was highest in G-III and lowest in G-I (1.48 vs 1.06 mg/dl, p < 0.05). The posttransplant ATN period was also longer in G-III compared to G-II (23.9 vs 9.1 days, p < 0.005). The 5-year graft survival rate was 85.2% in G-I, 88.0% in G-II and 59.3% in G-III. We conclude that routine serial renal biopsies should be scheduled when ATN develops after the cadaveric renal transplant, since only the histopathological diagnosis is reliable during ATN.

The fate of 359 renal allografts harvested from non-heart beating cadaver donors at a single center.

The fates of 359 kidneys harvested from 181 non-heart beating donors (NHBD) at a single center, using a regional in situ cooling technique were retrospectively investigated. 1. Thirty-five kidneys (9.7%) were discarded mainly due to poor arterial perfusion and bacterial contamination. 2. The incidence of primary nonfunction in patients treated with Aza was significantly higher than that in patients receiving CsA or FK (20.5% [8 grafts] vs 6.0% [17 grafts], respectively, p < 0.01). 3. The incidences of immediate and delayed graft function were 16.1% and 77.9%, respectively, among 285 recipients treated with CsA/FK. The average of duration of posttransplant dialysis required in recipients with DGF was 13.7 days and the average lowest serum creatinine level in patients who recovered graft function was 1.58 mg/dl. 4. Patient survival rates in the CsA/FK group were 97.2%, 95.0%, 93.2% and 89.3% at one, 3, 5 and 10 years, respectively, and the graft survival rates at one, 3, 5 and 10 years were 83.3%, 72.0%, 64.7% and 48.6%, respectively. 5. Increasing donor age showed a significant correlation with increased serum creatinine levels as well as with prolonged posttransplant dialysis (p < 0.001 and p < 0.01, respectively). 6. Renal grafts from donors with cerebrovascular disease (CVD) had significantly higher lowest serum creatine levels than grafts from non-CVD donors (p < 0.0001). 7. Renal grafts harvested from NHBD using our in situ cooling technique had excellent renal function when the donor was young or the cause of death was non-CVD. However, when the donor was older (> or = 56 years) and the cause of death was CVD, the grafts were acceptable but the early posttransplant function was often impaired. 8. The current NHBD graft survival rate, the UNOS cadaveric renal graft survival rate and the Japanese living-related donor renal graft survival rate were almost identical at 10 years posttransplant. 9. NHBDs should provide an excellent opportunity to increase organ availability.

Human peripheral blood leukocyte-reconstituted severe combined immunodeficient mouse: analysis of the human immune response against porcine islet transplantation.

Human peripheral blood leukocyte (PBL)-reconstituted severe combined immunodeficient (SCID) mice (Hu-PBL-SCID) were used as a model to study xenograft rejection in humans. SCID mice were reconstituted with human PBL using a protocol that included a booster injection with anti-human CD3 antibody-primed cells. This protocol enhanced chimera establishment in SCID mice and resulted in the detection of higher levels of human Ig when compared with SCID mice receiving unprimed PBL alone. Human xenoreactive natural antibodies (XNA), both IgM and IgG subtypes, which recognized porcine islets (PI), were detected in sera of Hu-PBL-SCID by cytofluorometric analysis. Pretreatment of porcine cells with GS-IB4 lectin inhibited the XNA binding, demonstrating the specificity of the XNA from Hu-PBL-SCID. Western blot analysis showed that XNA from normal human serum and Hu-PBL-SCID serum recognized similar xenoantigens on PI, indicating that Hu-PBL-SCID contained a XNA repertoire representative of normal human serum. Immunofluorescent staining of the tissue sections revealed that both human IgG and IgM bound in vivo to the PI engrafted beneath the kidney capsule of Hu-PBL-SCID. In addition, mouse complement (C3) was detected on xenografted PI. The function of xenografted islets were monitored by measuring porcine insulin concentration using a radioimmunoassay. Porcine insulin concentration in the sera of both Hu-PBL-SCID and plain SCID xenografted with PI was similar for up to 14 days after transplantation, after which the insulin levels in Hu-PBL-SCID decreased, thereby indicating rejection. Therefore, PI transplanted into the Hu-PBL-SCID should be a useful model for the study of cellular as well as acquired humoral immune response against xenoislets.

Human peripheral blood lymphocyte-reconstituted, severe combined immunodeficient mice as a model for porcine islet xenograft rejection in humans.

Previously we established human peripheral blood lymphocyte-reconstituted severe combined immunodeficiency (SCID) (hu-PBL-SCID) mice as a model for human islet allograft rejection. The function of xenografted hu-PBL was confirmed to reject human alloislets in hu-PBL-SCID mice. In this study, we modified this model as a porcine islet xenograft to study porcine islet rejection in humans. Chimeric mice were used as the recipients of porcine islets to reveal the mechanisms of xenograft rejection in humans. SCID mice were reconstituted with 30 x 10(6) of hu-PBL initially, and 10 x 10(6) of antihuman CD3-primed PBL was injected intraperitoneally 2 days later as a booster. An additional booster injection provided greater possibility (86.7%, n = 15) of chimera establishment as well as a higher human immunoglobulin concentration in SCID mice than the single injection group. In an in vitro assay, sera from hu-PBL-SCID mice were found to recognize porcine islets by FACS staining. In an in vivo study, immunofluorescent analysis of a frozen section showed that human immunoglobulins adhered to the xenografted porcine islet under the kidney capsule of hu-PBL-SCID mice. Although no mouse immunoglobulins were detected on sections, mouse complement (C3) was shown to adhere to the xenografted porcine islet. Thus, hu-PBL-SCID mice provide a useful model for investigating the real-life situation of porcine islet xenograft rejection in humans.