Acute renal failure following kidney transplantation associated with myoglobinuria in patients treated with rapamycin.

BACKGROUND: Since using an immunosuppression regimen that includes rapamycin, we have occasionally encountered renal transplant patients who develop unexpected severe acute renal dysfunction. Biopsies obtained in these recipients demonstrate acute tubular necrosis (ATN) occasionally associated with tubular casts giving the classic appearance of myoglobin casts. METHODS: We retrospectively reviewed all biopsies from consecutively transplanted kidneys engrafted between April 9, 2002 and June 29, 2004 to determine the incidence of ATN, ATN with intratubular casts, and casts with the classic myoglobin appearance. The clinical setting, treatment, and outcomes of those patients with classic myoglobin-appearing casts are reviewed. RESULTS: Histological ATN as the principal finding in at least one biopsy occurred in 10.5% (57/543) of patients. About half of these patients (30/57) had tubular casts present in at least one biopsy and in 14 of these the casts had a classic appearance of myoglobin casts. These myoglobin-appearing casts were only noted in patients receiving rapamycin. A review of 28 ATN biopsies from an earlier prerapamycin era did not demonstrate similar myoglobin-appearing casts. Immunostaining for myoglobin was positive in all 14 recipient biopsies. This was confirmed by western blot analyses in three of five patient biopsies tested. Three of three recipients tested had elevated serum creatine phosphokinase levels and detectable serum myoglobin. All 14 patients slowly resolved their acute renal dysfunction and no grafts were lost. CONCLUSION: We conclude that myoglobinuria with myoglobin cast formation can occur following rapamycin administration, and may be a causative factor in the development of unexpected severe acute renal dysfunction.

The plant S-adenosyl-L-methionine:Mg-protoporphyrin IX methyltransferase is located in both envelope and thylakoid chloroplast membranes.

Chlorophyll biosynthesis requires a metabolic dialog between the chloroplast envelope and thylakoids where biosynthetic activities are localized. Here, we report the first plant S-adenosyl-l-methionine:Mg-protoporphyrin IX methyltransferase (MgP(IX)MT) sequence identified in the Arabidopsis genome owing to its similarity with the Synechocystis sp. MgP(IX)MT gene. After expression in Escherichia coli, the recombinant Arabidopsis thaliana cDNA was shown to encode a protein having MgP(IX)MT activity. The full-length polypeptide exhibits a chloroplast transit peptide that is processed during import into the chloroplast. The mature protein contains two functional regions. The C-terminal part aligns with the Synechocystis full-length protein. The corresponding truncated region binds to Ado-met, as assayed by UV crosslinking, and is shown to harbor the MgP(IX)MT activity. Downstream of the cleaved transit peptide, the 40 N-terminal amino acids of the mature protein are very hydrophobic and enhance the association of the protein with the membrane. In A. thaliana and spinach, the MgP(IX)MT protein has a dual localization in chloroplast envelope membranes as well as in thylakoids. The protein is active in each membrane and has the same apparent size corresponding to the processed mature protein. The protein is very likely a monotopic membrane protein embedded within one leaflet of the membrane as indicated by ionic and alkaline extraction of each membrane. The rationale for a dual localization of the protein in the chloroplast is discussed.