Decrease In Leukocyte Count Research Articles

The Importance of a Bone Marrow Biopsy to Distinguish Primary Immune Thrombocytopenia From Indolent Haematological Malignancies

AbstractAbstract 4676 BackgroundPrimary immune thrombocytopenia (ITP) is characterised by an immune-mediated destruction of platelets and impaired platelet production [1, 2].The diagnosis is one of exclusion, and any disorder presenting with isolated thrombocytopenia can mimic ITP [3]. AimsTo identify and describe patients initially diagnosed with ITP and included in an on-going clinical trial, when further diagnostics revealed other underlying disorders as the aetiology to the low platelet counts. MethodsPatients were identified from the on-going clinical trial ‘A randomised fase III study of the efficacy of rituximab in combination with dexamethasone vs dexamethasone in newly diagnosed patients with ITP’. All patients had given their written informed consent. The diagnosis of ITP was defined as isolated thrombocytopenia, normal bone marrow biopsy, no splenomegaly assessed by ultrasound, normal TSH-levels and exclusion of secondary immune-, viral- or drug-induced thrombocytopenia.Patients who were enrolled in the study but subsequently diagnosed with other underlying disorders and excluded from the protocol are described in the following. Results116 patients had been enrolled in the clinical study at the time of these analyses. 9 patients were subsequently diagnosed with other disorders and excluded from the study.The median time from inclusion in the ITP-protocol to diagnosis of the underlying disorder was 11 days (range 3 – 486 days).4 patients were diagnosed with other haematological disorders (debut symptoms, see figure 1).•DLBCL – Presenting with low platelet counts and anaemia. Bone marrow biopsy and peripheral smear were normal. A CT scan showed bilateral renal tumours (lymphomas) and a biopsy revealed diffuse large B-cell lymphoma.•MDS – Presenting with low platelet counts and anaemia. 6 days after inclusion, a bone marrow biopsy revealed a hypoplastic marrow with severe megakaryocytopenia.•Low-grade lymphoma – presenting with low platelet counts. 11 days after inclusion, a bone marrow biopsy revealed small lymphocytic lymphoma. There were no abnormalities in the peripheral blood smear and no peripheral lymphocytosis. A CT scan showed multiple marginally enlarged lymph nodes.•MDS/AML – Presenting with low platelet counts and mild iron deficiency anaemia. The bone marrow was hyperplastic with no apparent dysplastic abnormalities. After inclusion in the study, the patient had sustained platelet counts of 30–80 ×109, mild anaemia and recurrent infections. Myelodysplastic syndrome was suspected based on clinical findings. A second bone marrow biopsy was performed 1 year after inclusion due to a decreased leukocyte count. The patient was diagnosed with acute myeloid leukaemia FAB-M2.4 patients with CMV presented median platelet count of 6 ×109/L (range 4–12 ×109/L), petechiae (4 patients) and mucosal bleeding (3 patients). 1 patient had flu-like symptoms and elevated leucocyte count. CMV was diagnosed by positive IgM titer after a median of 17,5 days (range 7 –29).1 patient was diagnosed with antiphospholipid syndrome 17 days after inclusion. ConclusionThe diagnosis of ITP is one of exclusion, and it is essential that patients presenting with isolated thrombocytopenia be thoroughly tested for underlying disorders. The present study has shown that a bone marrow biopsy may be a prerequisite and the only diagnostic tool to distinguish ITP from MDS or other low-grade malignancies. A bone marrow biopsy is recommended in all elderly patients in whom indolent haematological malignancies initially may mimick ITP.Figure 1Symptoms of 4 patients with haematological disorders presenting with low platelet counts and initially diagnosed as ITPSymptomsPetechiaBleedingAnaemiaLDH > 450Recurrent infectionsDiagnosis/ageDLCBL/61 yearsYESYESYESYESNoMDS/69 yearsYESYESYESNoNoLow-grade lymphoma/73 yearsYESYESNoNoNoMDS-AML/79 yearsYESNoYESNoYES Disclosures:Gudbrandsdottir:GlaxoSmithKline: Research Funding; Amgen: Research Funding. Frederiksen:GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees.

Clinical and laboratory parameters associated with outcomes in patients with metastatic renal cell carcinoma treated with modified vaccinia Ankara delivering tumor antigen 5T4.

e13132 Background: Two separate studies have been conducted to study the efficacy of modified vaccinia Ankara delivering tumor antigen 5T4 (TroVax) alone, in combination with either interleukin-2 or interferon-α totaling 53 patients (Clin Cancer Res 2008; 14[22], J Immunother 2009; 32[7]). We will review the overall survival of this patient population of <12 months, >12 months and >24 months and provide correlation with their baseline clinical and laboratory parameters. Methods: We have reviewed baseline data of 53 patients. The entire baseline laboratory parameters were assessed. Clinical data such as pathology, diagnosed to initial therapy with TroVax, time of metastases development, the number of metastatic lesions and performance status. Both univariate and multivariate analyses were conducted. Results: Analysis of the data revealed the diagnosed time to start interval of therapy, metastasis to interval of receiving TroVax, the number of metastatic lesions, decreased leucocyte count, decreased platelet count, increased hemoglobin, decreased neutrophils, increased absolute lymphocyte, decreased corrected calcium, decreased lactate dehydrogenase, decreased albumin and decreased alkaline phosphatase correlated to overall survival. Conclusions: Results identify a specific subset of metastatic renal cell carcinoma patients with a favorable outcome based on clinical and laboratory parameters. These results can be applied as inclusion/exclusion criteria for prospective TroVax studies in addition to other cancer vaccine clinical trials. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Oxford BioMedica Oxford BioMedica

Anti-inflammatory Activity of Myricetin Isolated fromMyrica rubraSieb. et Zucc. Leaves

MYRICA RUBRA Sieb. et Zucc. leaves are commonly used in folk medicine to treat inflammatory disorders in China. Present studies on the anti-inflammatory effect of myricetin from MYRICA RUBRA Sieb. et Zucc. leaves was evaluated with various IN VIVO models of both acute and chronic inflammations such as xylene-induced ear edema, acetic acid-induced vascular permeability, carrageenan-induced paw edema, leukocyte migration assay, and cotton pellet granuloma models. Myricetin showed a significant inhibition on ear edema and hind paw edema caused by xylene and carrageenan, respectively. Furthermore, it also inhibited the increase in capillary permeability induced by the production of acetic acid in the human body. Myricetin significantly decreased the serum levels of MDA and, in turn, increased the serum levels of SOD in the carrageenan-induced paw edema model. Concurrently, myricetin also significantly decreased leukocyte count. During chronic inflammation, myricetin inhibited the formation of granuloma tissue. These results, collectively, demonstrate that myricetin possesses a potent anti-inflammatory function on acute and chronic inflammation. Its anti-inflammatory mechanisms are probably associated with the inhibition of antioxidant activity. These results also support the claims of traditional Chinese medicine practitioners about the use of MYRICA RUBRA Sieb. et Zucc. leaves in the treatment of inflammatory diseases.

Determining maximal tolerable dose of the MAb BR96 labeled with 90Y or 177Lu in rats-Establishment of a syngeneic tumor model

Objective To compare the maximal tolerable dose (MTD) of MAb BR96 labeled with 90Y or 177Lu in immunocompetent rats. Methods Increasing activity levels of BR96 labeled with 90Y or 177Lu were administered to groups of rats. Blood parameters, body weight and general performance were monitored for 8 weeks. Results Two days post injection (p.i.) all groups had decreased leukocyte counts down to 5 %-15 % of initial values. Initiation of recovery (at 14-21 days) showed a dose-response relationship. All groups except the one given the highest activity of 90Y fully recovered in leukocyte number. The decrease in platelets was delayed to day 7-14 p.i. with a dose-dependent response regarding both severity of the nadir value (10 %-40 % of initial value) and the start of recovery. The animals in the groups given the highest activities of both 90Y and 177Lu exhibited skin infections on day 21. Conclusion The results showed good reproducibility and dose-dependent toxicity for both radionuclides indicating that the MTD for 177Lu-BR96 (1000 MBq/kg) is 1.7 times that for 90Y-BR96 (600 MBq/kg) in rats; therefore, the therapeutic gain-T/N could be improved in former group. This model makes it feasible to evaluate strategies to escalate therapeutic doses to tumors without increasing normal tissue toxicity, such as radioimmunotherapy. Key words: Rats; 90Y; 177Lu; Antibodies, monoclonal; Maximum tolerated dose; Radioimmunotherapy

Gene Expression Patterns Associated with Cytarabine Pharmacology and Outcome in Pediatric Acute Myeloid Leukemia.

Abstract 114To identify genes that influence responses to cytarabine (ara-C) treatment, we explored the association of gene expression in leukemic cells at diagnosis with multiple pharmacological and clinical end-points in children with acute myeloid leukemia (AML) treated with ara-C on the St. Jude AML97 clinical trial. We applied a novel statistical procedure, PRojection Onto the Most Interesting Statistical Evidence (PROMISE; PR), to identify genes with expression levels associated with clinical and pharmacological endpoints. To do this, we first defined the following values of the clinical and pharmacological variables as “therapeutically beneficial” :higher leukemic cell ara-C triphosphate levels, lower DNA synthesis values on days 1 and 2 of treatment relative to baseline, decreases in leukocyte counts on day 2 of treatment, improved response and decreased risk of relapse, death, or second malignancy. We considered a gene to show a therapeutically beneficial pattern of association if its expression was positively correlated with ara-CTP levels, negatively correlated with DNA synthesis levels, negatively correlated with decrease in leukocyte counts on day 2, positively correlated with better treatment response, and negativelycorrelated with the risk of relapse or death. A gene showed a therapeutically detrimental pattern of association if its expression had the opposite correlations with the clinical and pharmacological variables. We performed five variable (PR5 using early pharmacologically interesting phenotype measures) or seven variable (PR7 all the above indicated phenotypes) PROMISE analyses. PR5 identified 275 beneficial probe sets and 69 detrimental probe sets (p ≤ 0.005). PR7 analysis identified 112 beneficial probe sets and 115 detrimental probe sets (p ≤ 0.005). To confirm these results, we performed a PROMISE for a cohort of patients treated with ara-C and other agents on the AML02 protocol. Gene expression in leukemic cells at diagnosis was analyzed for a beneficial or detrimental pattern of association with three phenotypes (PR-3); diagnostic blast ara-C cytotoxicity, minimal residual disease (MRD) and event-free survival (EFS). Eighty-one probe sets identified by PR5 or PR7 analyses in the initial cohort were confirmed in the PR-3 analysis of AML02 data. Genes identified in the present study may serve as predictive markers of response and candidates for future drug development. Disclosures:No relevant conflicts of interest to declare.

The reaction of leukocytes of sterlet Acipenser ruthenus to hormone-induced stress

The influence of cortisone on the part of leukocytes in the differential leukocyte count of peripheral blood of sterlet is described. The changes in particular groups of leukocytes are characterized quantitatively. To the hormone, the fish reacted by a decrease in leukocyte count, blastic (juvenile) cells, and eosinophils and an increase in neutrophils and monocytes. It is concluded that the stress hormone suppresses lymphopoiesis by the hormone-induced apoptosis of lymphocytes while, on the contrary, myelopoiesis activates it.

Acute Effects Of Diazinon On Blood Paramters In The African Catfish (&lt;italic&gt;Clarias Gariepinus&lt;/italic&gt;)

The aim of this study was to assess the effect of diazinon (0,0-diethyl 0-(2-isopropyl-6-methylpyrimidin-4yl) phosphorothioate) on cultured and wild African catfish (Clarias gariepinus).The effect was assessed based on results of acute toxicity tests and on a comparison of results of haematological examination of a control and an experimental group exposed to Diazintol R pesticide preparation (active substance 162mg.l -1 showed significantly lower values (p < 0.05) of erythrocyte count (RBC), haemoglobin content (Hb) and haematocrit (PCV) compared to the control group. Values of MCV, MCH and MCHC were comparable in both groups during the study. In contrary, there was a significant decrease in leucocyte count (p < 0.05), as well as in both the relative and absolute lymphocyte count (p < 0.05) and a significant increase in both the relative and absolute count of developmental forms of neutrophile granulocytes: myelocytes (p < 0.05) and metamyelocytes (p < 0.05) in the experimental group. Relative and absolute count of monocytes and both the band- and segmented neutrophile granulocytes was comparable in both groups during the study. Changes in values of both the erythrocyte and leucocyte profile after exposure to diazinon-based preparation may be referred to disruption of haematopoiesis as well as to a decrease on non-specific immunity of the fish.

Mutations That Cooperate with Nf1 Inactivation in Leukemogenesis Influence Therapeutic Response to MEK Inhibition.

Hyperactive Ras is a common feature of many cancers, including myelodysplastic syndrome (MDS), myeloproliferative disease (MPD), and acute myeloid leukemia (AML). Conditional inactivation of the Nf1 tumor suppressor, which encodes a GTPase activating protein that negatively regulates Ras, in murine hematopoietic cells in Mx1-Cre, Nf1flox/flox mice induces MPD with 100% penetrance. This MPD does not evolve to AML, which implies that cooperating mutations are necessary for transformation to acute leukemia. Upon infection with MOL4070LTR, a retroviral insertional mutagen, ∼25% of Mx1-Cre, Nf1flox/flox mice develop AML. The Ras effectors MEK and ERK are hyper-phosphorylated in Nf1 mutant MPDs and AMLs with Nf1 inactivation. We investigated the effects of CI-1040, a highly selective inhibitor of the MEK kinase, on the growth of hematopoietic progenitor and blast colonies in methylcellulose cultures stimulated with GM-CSF. Blast colony formation from Nf1 mutant AML cells was abrogated at much lower CI-1040 concentrations (0.25 μM) than wild-type or Nf1 mutant MPD cells (50 μM) suggesting a therapeutic index. Nf1 mutant mice with MPD that were treated with CI-1040 showed no improvement in leukocyte counts or survival despite transient MEK inhibition in vivo. In contrast, mice transplanted with three unique Nf1 deficient AMLs responded to CI-1040 treatment with decreased leukocyte counts and markedly prolonged survival compared to vehicle treated controls (24 versus 7 days in the vehicle-treated cohort; OR 3.5 95% CI 3.0–3.8). Despite lower white blood cell counts and prolonged survival, all of the leukemic mice receiving CI-1040 eventually developed reemergence of peripheral blood blasts and died from AML. Leukemias that relapsed during CI-1040 treatment are remarkably less sensitive to CI-1040 in vitro than the vehicle treated AMLs, and do not respond to treatment in secondary recipients. This cellular resistance is not due to an acquired change in kinase sensitivity to CI-1040 as we observe equivalent inhibition of pERK in sensitive and resistant AMLs that are exposed to a range of CI-1040 concentrations. Importantly, when compared with untreated leukemias, CI-1040-resistant AMLs contain new retroviral integrations. Cloning the integration sites from sensitive and resistant Nf1 deficient leukemia pairs resulted in identification of several candidate resistance genes including members of the RasGRP family and Mapk14, which encodes p38. Inhibition of p38 with SB 202190, a relatively selective inhibitor, confers resistance to CI-1040 in sensitive leukemias. Our data support the idea that MEK is a relevant biochemical target in myeloid leukemia, and show that cooperating mutations strongly modulates response. CI-1040 and related MEK inhibitors merit further investigation in myeloid malignancies. This model provides a tractable system for identifying cooperating mutations that result in progression to acute leukemia and modulate drug sensitivity.

Continuing Clozapine Therapy Despite Morning Pseudoneutropenia

INTRODUCTION Clozapine is an atypical antipsychotic agent with demonstrated effectiveness for patients with psychoses that are refractory to treatment with other antipsychotic drugs.1,2 Clozapine is not recommended as first-line therapy for schizophrenia because of its side effects, which include agranulocytosis (0.5% to 2.0% of patients receiving the drug), seizures, weight gain, glucose and lipid disturbances, sedation, sialorrhea, hypotension, and tachycardia.2,3 A trial of clozapine is recommended if there is suboptimal response to adequate trials of antipsychotics from 2 different classes and for patients who cannot tolerate the side effects of other antipsychotic agents.1,2 Clozapine may induce 2 distinct types of neutropenia. The milder form occurs more frequently (in 1.5% to 2% of patients receiving the drug).3,4 The exact mechanism of this form of neutropenia is unknown, but it is thought to be due to the premature destruction of neutrophils in the blood or spleen.3,4 Recovery from this type occurs rapidly, within 3 to 7 days after drug discontinuation, since myeloid maturation in the bone marrow is unaffected. The second type is more severe, manifesting as agranulocytosis, but occurs less frequently (0.8% cumulative incidence at 3 years of treatment). With this form, there is selective depletion of the granulocyte precursors in the bone marrow, and recovery may take from 14 to 22 days.4,5 These patients are at risk of neutropenic sepsis. The risks of morbidity and mortality associated with agranulocytosis necessitate a strict hematologic monitoring program for patients receiving clozapine. Each of the 3 Canadian manufacturers of this drug coordinates a national registry and monitoring program for patients. The risk of agranulocytosis is greatest during the first 6 months of treatment; therefore, weekly assessment of leukocyte count and absolute neutrophil count is essential to ensure that the values remain above 3.5 x 109/L and 2.0 x 109/L, respectively. After 6 months of therapy, the frequency of monitoring is reduced to every 2 weeks.2 The 3 clozapine monitoring programs generate alerts that are identified by colour: green, yellow, and red. A patient is deemed to be in the green zone, and blood tests are obtained weekly, if the leukocyte and absolute neutrophil counts are above the stated minimum values (3.5 x 109/L and 2.0 x 109/L, respectively). A patient is deemed to be in the yellow zone if the leukocyte count is between 2.0 x 109/L and 3.5 x 109/L or the absolute neutrophil count is between 1.5 x 109/L and 2.0 x 109/L, or if a significant decline in either count (i.e., a single decrease or sum of decreases in leukocyte count of at least 3.0 x 109/L or in absolute neutrophil count of at least 1.5 x 109/L) occurs over a 4-week period; for these patients, leukocyte and absolute neutrophil counts must be determined twice weekly until the counts return to green zone values. If neutropenia occurs (defined as leukocyte count below 2.0 x 109/L or absolute neutrophil count below 1.5 x 109/L), the patient is deemed to be in the red zone, and clozapine is discontinued with no opportunity for reinitiation. “Morning pseudoneutropenia”, or diurnal variation in absolute neutrophil count that necessitates afternoon monitoring of both leukocyte and neutrophil counts, has been reported during clozapine therapy.1,6-10 We describe 2 patients for whom multiple antipsychotic trials had failed and clozapine therapy was initiated. In both patients, hematologic monitoring revealed a pattern of diurnal variation in the absolute neutrophil count. Without close monitoring to detect these trends, the patients might have been classified as being in the yellow zone or perhaps the red zone, which would have led to frequent blood sampling or even discontinuation of therapy. By identifying the diurnal variation, we were able to continue therapy for these treatment-refractory patients.

Changes of selected hematologic parameters during long-term immunoadsorption therapy

Changes of selected hematologic parameters were studied in six patients treated with immunoadsorption for myasthenia gravis. The mean duration of therapy was 18.6 months; 245 procedures were performed in total. Before and after each procedure the full blood count was examined. A decrease was noted in the hemoglobin concentration (median −7.27%) and in platelet count (median −5.63%) after each procedure. On the other hand, an increase in leukocyte count was noticed after each procedure (median 6.63%). However, in three patients, it was observed that with increasing numbers of procedures, the leukocyte count rises were lower during long-term treatment. We suppose that the decrease in hemoglobin concentration was induced both by the large volume of blood samples collected for laboratory testing and by the residual volume of blood which remains in the tubing. From the continuous decrease in leukocyte count after long-term treatment with immunoadsorption in our three patients, it may be concluded, that some type of immunomodulatory effect (immunosuppression) is involved.

Determining Maximal Tolerable Dose of the Monoclonal Antibody BR96 Labeled with 90Y or 177Lu in Rats: Establishment of a Syngeneic Tumor Model to Evaluate Means to Improve Radioimmunotherapy

To evaluate therapeutic strategies, it is essential to use biological models reflecting important aspects of the clinical situation. The aim of the present study was to compare the maximal tolerable dose of the monoclonal antibody BR96 labeled with 90Y or 177Lu in immunocompetent rats. Maximal tolerable dose was defined as the highest activity that allows 100% of the animals to survive without clinical signs, such as infections, bleeding, or diarrhea, and with <20% loss in body weight. Increasing activity levels of BR96 labeled with 90Y or 177Lu were administered to groups of rats. Blood parameters, body weight, and general performance were monitored for 8 weeks. Two days postinjection, all groups had decreased leukocyte counts down to 5% to 15% of initial values. Initiation of recovery (at 14-21 days) showed a dose-response relationship. All groups, except the group given the highest activity of 90Y, had complete resolution in their leukopenia. The decrease in platelets was delayed to days 7 to 14 postinjection with a dose-dependent response regarding both severity of the nadir (10-40% of initial value) and the start of recovery. Animals in the groups given the highest activities of both 90Y and 177Lu exhibited skin infections on day 21. The results showed good reproducibility and dose-dependent toxicity for both radionuclides, indicating that the maximal tolerable dose for 177Lu-BR96 (1,000 MBq/kg) is 1.7 times that for 90Y-BR96 (600 MBq/kg) in rats. This model makes it feasible to evaluate strategies to escalate therapeutic doses to tumors without increasing normal tissue toxicity.

Chronomodulation of topotecan or X-radiation treatment increases treatment efficacy without enhancing acute toxicity

Topotecan (TPT), a camptothecin analog, is currently used to treat human ovarian and small-cell lung cancer and is in clinical trials for other tumor sites. However, it is unknown whether chronomodulation of TPT treatment is beneficial. We examined the effects of administering TPT or X-radiation (XR) alone at different times of the day or night. We treated mice bearing human colorectal tumor xenografts at four different times representing the early rest period (9 am or 3 HALO [hours after light onset]), late rest period (3 pm or 9 HALO), early active period (9 pm or 15 HALO), and late active period (3 am or 21 HALO) of the mice. We gave either TPT (12 mg/kg, injected i.p.) or XR (4 Gy, directed to the tumor) twice weekly on Days 0, 4, 7, 10 within 2 weeks. Treatment with either TPT or XR at 3 am demonstrated the greatest efficacy (measured by a tumor regrowth assay) without significantly increasing acute toxicity (assessed by a decrease in leukocyte counts or body weight). Conversely, treatment at 3 pm, in particular, showed increased toxicity without any enhanced efficacy. Our study provided the first evidence that chronomodulation of TPT treatments, consistent with the findings of other camptothecin analogs, is potentially clinically beneficial. Additionally, our findings suggest that chronomodulation of fractionated XR treatments is also potentially clinically beneficial.

Does Mycophenolate Mofetil Increase the Incidence of Cytomegalovirus Disease Compared With Azathioprine After Cadaveric Kidney Transplantation?

Although most of the published papers had not found increase in the incidence of CMV disease in kidney transplant recipients treated with mycophenolate mofetil (MMF), we had feeling from everyday practice that after its introduction number of patients with CMV disease has increased. To test this hypothesis, we performed retrospective analysis of our database, comparing the incidence of CMV disease in patients treated with azathioprine (AZA) and patients treated with MMF. CMV disease was defined as CMV antigenemia (positive CMV pp65 determined by ELISA test) plus any of the following: decrease leucocytes or platelets, increased transaminases, increase in serum creatinine. The azathioprine treated group (AZA group) included 280 patients (132 female) treated for 17,672 months with AZA + Cyclosporine A (CyA) + steroid, or AZA + steroid, while the MMF group included 219 patients (112 female) treated for 5079 months with MMF + CyA + steroid, or MMF + steroid. There was no difference in acute rejection episodes between the AZA and the MMF group. The AZA group had 51 CMV disease episodes (1 episode per 346.5 treatment months), and the MMF group experienced 43 episodes (1 per 118.1 months) ( P < .01). Mean onset of CMV disease was 32.65 ± 47.69 (SD) months after transplantation in the AZA group, and 3.72 ± 4.43 in the MMF group. There was no difference between two treatment groups regarding the donor-recipient CMV status mismatch. Despite having the increased incidence of CMV disease, MMF group had less severe disease compared to AZA group with decrease in leukocyte count in 11.6% vs 15.7% of episodes, decrease in platelet count in 20.9% vs 21.6%, elevation of transaminases in 18.6% vs 29.4% respectively, and finally increase in serum creatinine greater than 20% in 51.2% in MMF vs 74.5% in AZA group. Five patients from the AZA group experienced CMV pneumonitis with the mortality rate of 80%. Only one patient from the MMF group had CMV pneumonitis, and he survived. According to our results, patients treated with MMF have increased risk for development of CMV disease. However, the disease course is less severe, and less frequently accompanied with deterioration of renal function in comparison to the AZA group.

40 Does Mycophenolate Mofetil Increase the Incidence of Cytomegalovirus Disease Compared To Azathioprine After Cadaveric Kidney Transplantation?

Although most published papers had not found an increase in the incidence of cytomegalovirus (CMV) disease with the use of mycophenolate mophetil (MMF) in kidney transplant patients, we had the feeling from our everyday practice that after its introduction, the number of patients with the CMV disease increased. In order to test this hypothesis, we performed retrospective analysis of our database, comparing the incidence of CMV disease in patients treated with azathioprine (AZA) and patients treated with MMF. Cytomegalovirus disease was defined as CMV antigenemia (positive CMV pp65 determined by ELISA test) plus any of following: decreased leucocytes or thrombocytes, increased transaminases, or an increase in serum creatinine.The azathioprine treatred group (AZA group) included 280 patients (132 female) treated for a total of 17,672 months with AZA + Cyclosporine A (CyA) + steroid, or AZA + steroid, while the MMF group included 219 patients (112 female) treated for a total 5079 months with MMF + CyA + steroid, or MMF + steroid. There was no difference in acute rejection episodes between the AZA and the MMF groups. The AZA group had 51 CMV disease episodes (1 episode per 346.5 treatment months), and the MMF group experienced 43 epizodes (1 per 118.1 months) (P &lt; 0.01). Mean onset of the CMV disease was 32.65 ± 47.69 months (SD) after transplantation in the AZA group, and 3.72 ± 4.43 in the MMF group. There was no difference between two treatment groups regarding the donor–recipient CMV status mismatch. Despite having the increased incidence of CMV disease, the MMF group had less severe disease compared to the AZA group with decrease in leucocyte count in 11.6% vs 15.7% of episodes, decrease in thrombocyte count in 20.9% vs 21.6%, elevation of transaminases in 18.6% vs 29.4% respectively, and finally increase in serum creatinine greater than 20% in 51.2% in the MMF vs 74.5% in the AZA group. Five patients from the AZA group experienced CMV pneumonitis with the mortality rate of 80%. Only one patient from the MMF group had CMV pneumonitis, and he survived.According to our results, patients treated with MMF have an increased risk for development of the CMV disease. However, the disease course is less severe, and less frequently accompanied with the decrease in renal function in comparison to the AZA group.

A Phase II Study of CC-5013 Treatment for Myelofibrosis with Myeloid Metaplasia: A Preliminary Report.

Background: CC-5013 (Revlimid™) is an immunomodulatory analog of thalidomide that is substantially more potent than the parent drug in terms of both anti-angiogenic and anti-TNF-α activity. CC-5013 has shown therapeutic activity in thalidomide-responsive hematological malignancies including relapsed multiple myeloma (Blood 2002; 100:3063) and myelodysplastic syndrome (Blood 2002; 100:96a). Myelofibrosis with myeloid metaplasia (MMM) has also been shown to respond to thalidomide (BJH 2002; 117:288). Furthermore, both angiogenesis and altered TNF-α activity have been pathogenetically implicated in MMM.Methods: The current report considers the first 15 patients in an ongoing phase II treatment trial of single agent CC-5013 in MMM based on a minimum of 3 month follow-up from day 1 of protocol treatment. Study eligibility criteria included no concomitant MMM-directed therapy, a hemoglobin (Hgb) level of < 10 g/dL, an absolute neutrophil count (ANC) of ≥ 1 x 109/L, and a platelet count of ≥ 100 x 109/L. Previous thalidomide therapy in the absence of high-grade skin toxicity was allowed. All patients were started with daily oral CC-5013 (10 mg/day) to be taken for three 28-day treatment cycles. Three additional treament cycles were planned in case of anemia response.Results: Median age was 64 years (range, 40–75) and 10 pts were males. Twelve of the 15 study pts (80%) were red cell transfusion-dependent, 14 (93%) were previously treated including 12 with cytoreductive and 4 with thalidomide therapy. The spleen was palpably enlarged in 13 pts (median 18 cm, range 7–23). Eight of the 15 pts (53%) successfully completed 3 months of protocol treatment. Treatment was discontinued in the remaining 7 pts because of drug toxicity (2 pts), disease progression (1 pt), other co-morbid condition (3 pts), or patient discretion (1 pt).Treatment response data: Clinically relevant responses were documented in 4 patients (27%) and consisted of measurable improvements in anemia (2 pts), splenomegaly (2 pts), and/or constitutional symptoms (3 pts). One pt experienced an increase in Hgb level from 8.3 to 13.4 g/dL, a decrease in leukocyte count from 66.2 to 7.7 x 109/L, and complete resolution of myelophthisis including disapperance of circulating blasts that measured 9% before treatment. Another pt became transfusion-independent (Hgb level increased to > 10 g/dL) as well as enjoyed a profound improvement in constitutional symptoms. Interestingly, serum lactate dehydrogenase (LDH) level decreased in 11 pts (73%) to either within the normal ramge (5 pts) or by more than 30 % (6 pts).Treatment toxicity data: Grade 3 or 4 adverse events that were possibly, probably, or definitely attributed to CC-5013 included rash (2 pts), neutropenia (5 pts), thrombocytopenia (3 pts), and fatigue (2 pts). In addition, 3 patients experienced drug-associated extreme thrombocytosis while a histologically-proven disseminated extramedullary hematopoiesis was documented in one patient after one month of CC-5013 treatment.Conclusion: The current preliminary report suggests a substantial biological activity of CC-5013 in MMM with a therapeutic potential for a subset of patients. Additional studies with a longer duration of therapy, different dose schedules, and combinations of CC-5013 and corticosteroids are warranted.

CD44 and hyaluronic acid regulate in vivo iNOS expression and metalloproteinase activity in murine air-pouch inflammation

To evaluate the effects of anti-CD44 IM7.8.1 antibody, HMW-HA and LMW-HA on leukocyte migration and adhesion, and the induction of proinflammatory mediators, in mouse air-pouch inflammation induced by zymosan. Leukocytes were obtained from zymosan-air pouches after the intra-pouch injection of anti-CD44 IM7.8.1, isotype control, HMW-HA, LMW-HA or PBS. TNF-alpha, IL-1beta and iNOS mRNA were estimated in leukocytes by semi-quantitative RT-PCR. Matrix metalloproteinases (MMPs) from exudates were evaluated by zymography and Western Blot. Adhesion and migration of leukocytes were evaluated in HA-coated plates and Boyden chambers respectively. IM7.8.1 decreased iNOS mRNA levels and the activity of both MMP-9 and MMP-2 eight h after injection into zymosan air pouch while IM7.8.1, HMW-HA and LMW-HA had no effect on IL1-beta or TNF-alpha mRNA levels. Leukocytes from air pouch adhered to and migrated in vitro against both HMW-HA and LMW-HA. LMW-HA increased the number of leukocytes in the air pouch and iNOS mRNA levels as compared to PBS injection. In contrast, HMW-HA decreased leukocyte count and reduced iNOS mRNA levels. Paradoxically, the activity of both MMP-9 and MMP-2 was increased by HMW-HA and decreased by LMW-HA. Both CD44 and HA can modulate leukocyte migration and induction of proinflammatory mediators in mouse zymosan air pouch inflammation. IM7.8.1 had consistent anti-inflammatory effects, reducing iNOS, MMP-9 and MMP-2. HMW-HA and LMW-HA were able to modulate both the induction of proinflammatory mediators and leukocyte count in the air pouch.

DOES MYCOPHENOLATE MOPHETIL INCREASE THE INCIDENCE OF CYTOMEGALOVIRUS DISEASE COMPARED TO AZATHIOPRINE AFTER CADAVERIC KIDNEY TRANSPLANTATION?

P737 Aims: Although most of the published papers had not found increase in the incidence of cytomegalovirus (CMV) disease with the use of mycophenolate mofetil (MMF) in kidney transplant recipients, we had feeling from our everyday practice that after its introduction, number of patients with the CMV disease increased. Methods: In order to test this hypothesis, we performed retrospective analysis of our database, comparing the incidence of CMV disease in patients treated with azathioprine (AZA) and patients treated with MMF. CMV disease was defined as CMV antigenemia (positive CMV pp65 determined by ELISA) plus any of the following: decreased leucocytes or thrombocytes, increased transaminases, increase in serum creatinine. Results: The AZA treated group (AZA group) included 280 patients (132 female) treated for 17672 months with either AZA+cyclosporine A (CyA), or AZA+CyA+steroid, while the MMF group included 219 patients (112 female) treated for 5079 months with MMF+CyA+steroid, or MMF+steroid. The AZA group had 51 CMV disease episodes (1 episode per 346,5 treatment months), and the MMF group experienced 43 episodes (1 per 118,1 months) (p<0.01). Mean onset of the CMV disease was 32,65 ± 47,69 months after transplantation in the AZA group, and 3,72 ± 4,43 in the MMF group. There was no difference between two treatment groups regarding the donor-recipient CMV status missmatch. Despite having the increased incidence of CMV disease, MMF group had less severe disease compared to the AZA group, with decrease in leucocyte count in 11,6% vs. 15,7% of episodes, decrease in thrombocyte count in 20,9% vs. 21,6%, elevation of transaminases in 18,6% vs. 29,4% respectively. CMV induced increase in serum creatinine (more than 20%) in 51,2% MMF patients vs. 74,5% of patients from the AZA group, with induction of acute rejection in majority of patients from the later group. Five patients from the AZA group experienced CMV pneumonitis with the mortality rate of 80%. Only one patient from the MMF group had CMV pneumonitis and he survived. Conclusions: According to our results, patients treated with MMF had increased risk for development of the CMV disease early in the posttransplantation course. However, the disease course was less severe in the MMF group, and less frequently accompanied with the deterioration of the renal function and acute rejection in comparison with the AZA group. It might be consequence of the more potential immunosuppressive effect of MMF, what prevents extensive immunologic reaction after activation of the CMV, thus preventing acute rejection.

Non-protein bound iron release during chemotherapy in cancer patients.

Non-protein bound iron (NPBI) is able to catalyse oxidative reactions, causing damage to vital structures. Adverse effects induced by cisplatin seem, in part, to be mediated by free radicals. In the present study, we have measured plasma NPBI, various other iron parameters and antioxidants in 28 cancer patients undergoing cisplatin-based chemotherapy at various time points before and during chemotherapy. No NPBI was present prior to therapy, but within 1-4 days following the first administration of chemotherapy, mean NPBI rose significantly to 10.6+/-6.6 micromol/l (range, 0.6-21.3 micromol/l) in 18 (64.3%) of the 28 patients measured. The rise in NPBI was accompanied by a significant rise in total plasma iron and ferritin and a marked decrease in the latent iron-binding capacity. Concomitantly, plasma vitamins C and E decreased significantly, indicating consumption of antioxidants. Similar observations were also made during the fourth chemotherapy cycle. The increase in NPBI preceded and correlated significantly with chemotherapy toxicity, such as a decrease in leucocyte count and haemoglobin, with a transient rise in various liver enzymes and with known cisplatin-related toxicity, i.e. the loss of renal and hearing function. In conclusion, cisplatin chemotherapy induces oxidative damage which rapidly leads to release of iron from intracellular proteins and the appearance of NPBI. Bone marrow, red blood cells, liver and kidney seem to be a likely source of NPBI. The observed high levels of NPBI may be a major causative determinant in chemotherapy-induced toxicity.

Side effects of azathioprine in patients with Crohn's disease.

In clinical trials 0-15% of patients discontinued azathioprine due to side effects. The aim of this study was to assess the rate of side effects leading to discontinuation of azathioprine and to determine predictive factors for discontinuation. A retrospective cohort analysis of clinical data regarding adverse events of azathioprine in Crohn's disease. Azathioprine had been prescribed for 54 of 112 consecutive patients with Crohn's disease. Because incomplete data were available in four patients, the data for 50 patients were analysed. In 15 of the 50 patients azathioprine was preliminary discontinued due to adverse events and in 11 of these patients (22%) adverse events were probably related to azathioprine. After the onset of therapy, a small, but significant, decrease in leucocyte count was observed within 6 weeks (median from 10.6 to 9.5 x 10(9)/l) and asymptomatic leucopenia (< 3.0 x 10(9)/l) occurred in two patients. Serious adverse events occurred in three patients who, as a result, required admission to hospital. All events were reversible after discontinuation of therapy. Patients who discontinued azathioprine due to adverse events used significantly lower initial doses of prednisone compared to patients who were able to continue azathioprine. The occurrence of side effects was not related to the initial dose of azathioprine or concomitant use of 5-aminosalicylates. Twenty-two per cent of patients discontinued azathioprine prematurely probably as a result of related adverse events. Patients who discontinued azathioprine prematurely used lower doses of prednisone initially. Therefore, concomitant use of prednisone may prevent some of the adverse events.

Drug interaction between infliximab and azathioprine in patients with Crohn's disease.

A drug interaction has been observed between infliximab and methotrexate in rheumatoid arthritis. To look for an interaction between infliximab and azathioprine in Crohn's disease patients using the active metabolites of azathioprine: 6-tioguanine nucleotides. Patients receiving azathioprine who required infliximab for ileo-colonic or ano-perineal Crohn's disease were recruited prospectively. 6-tioguanine nucleotide levels were evaluated before infusion, within 1-3 weeks after the first infusion and 3 months after the first infusion. The clinical outcome was evaluated by the Harvey-Bradshaw index or the closure of ano-perineal fistulas. Thirty-two patients were included (17 received one infusion and 15 received three infusions). The mean 6-tioguanine nucleotide level was comparable before and 3 months after the first infusion, but a significant increase was observed within 1-3 weeks after the first infusion (P < 0.001). In parallel, a significant decrease in leucocyte count and increase in mean corpuscular volume were observed; these modifications were normalized 3 months after infusion. An increase in 6-tioguanine nucleotide level of greater than 400 pmol/8 x 108 erythrocytes was strongly related to good tolerance and a favourable response to infliximab, with a predictive value of 100%. This prospective study provides evidence for a drug interaction between azathioprine and infliximab.