Progression Of Chronic Allograft Nephropathy Research Articles

CXC Chemokine Receptor Type 4 Antagonism Ameliorated Allograft Fibrosis in Rat Kidney Transplant Model.

In this study, we evaluated the effects of CXC chemokine receptor type 4 and stromal cell-derived factor 1 signaling in the progression of chronic allograft nephropathy in a rat model. Experimental rats were divided into 3 groups: Lewis-to-Lewis isograft transplant (group A), Fisher 344 rat-to-Lewis allograft transplant with immunosuppressant cyclosporine (group B), and Fisher 344 rat-to-Lewis allograft transplant treated with cyclosporine and the CXC chemokine receptor type 4 antagonist AMD3100 (1 mg/kg/d) (group C). On day 90 after the operation, renal graft function, proteinuria, and histologic Banff score were measured. The expression levels of transforming growth factor β1 and collagen IV were determined by quantitative real-time polymerase chain reaction. Renal function and urinary protein were increased in allografts of groups B and C compared with isografts of group A. The Banff score was significantly decreased in the AMD3100-treated animals (group C), with renal fibrosis being reduced. In addition, overexpressed levels of transforming growth factor β1 and collagen IV in group B allografts were significantly reduced versus that shown with treatment with the CXC chemokine receptor type 4 antagonist in group C. Together, these data strongly implicate that CXC chemokine receptor type 4 antagonism alleviated renal interstitial fibrosis in long-term surviving allografts by down-regulating expression of transforming growth factor β1.

Randomized Controlled Trial of Mineralocorticoid Receptor Blockade in Children with Chronic Kidney Allograft Nephropathy.

We showed that mineralocorticoid receptor blockade (MRB) prevented acute and chronic cyclosporine nephropathy (CsA-Nx) in the rat. The aim of this translational study was to investigate the effect of long-term eplerenone administration on renal allograft function in children with biopsy-proven chronic allograft nephropathy (CAN). Renal transplant children <18 years, biopsy-proven CAN, and a GFR>40 ml/min per 1.73 m2 were included. Patients with BK virus active nephritis, recurrence of renal disease, GFR decline in previous 3 months, or treated with calcium antagonists or antifungal drugs were excluded. They were randomized to receive placebo (n=10) or eplerenone 25 mg/d for 24 months (n=13). Visits were scheduled at baseline, 6, 12, and 24 months. At each period, a complete clinical examination was performed and blood and urine samples were taken. Urine creatinine, 8-hydroxylated-guanosine, heat shock protein 72 (HSP72), and kidney injury molecule (KIM-1) levels were also assessed. In kidney biopsy samples, the tubulo-interstitial area affected by fibrosis (TIF) and glomerulosclerosis were measured at baseline and after 24 months. The baseline eGFR was 80±6 in the placebo and 86±6 ml/min per 1.73 m2 in the eplerenone group; at 24 months it was 66±8 and 81±7 ml/min per 1.73 m2, respectively (P=0.33; 95% confidence intervals, -18 to 33 at baseline, and -11 to 40 after 24 months). The albumin-to-creatinine ratio was 110±74 in the placebo, and 265±140 mg/g in the eplerenone group; and after 24 months it was 276±140 and 228±88 mg/g, respectively (P=0.15; 95% confidence intervals, -283 to 593, and -485 to 391, respectively). In addition, the placebo exhibited a greater TIF, glomerulosclerosis, and urinary HSP72 compared with the eplerenone group. Although this study was underpowered to provide definitive evidence that long-term eplerenone administration attenuates the progression of CAN in pediatric transplant patients, it encourages testing the potential benefit of MRB in this pediatric population.

Absence of C4d urinary excretion in the early post-transplant period is associated with improved long-term kidney graft survival

IntroductionC4d urinary excretion varies according to the risk of graft rejection or progression of chronic allograft nephropathy, but its influence on long-term kidney transplant (KTx) outcomes remains unclear.The aim of the study was to determine whether the initial (1–3 months post KTx) level of C4d urinary excretion may help to predict long-term kidney allograft transplantation outcomes. Materials and methodsThe study involved 185 patients who had undergone KTx. The urinary specimens taken from the morning urine portion were assessed by ELISA test for C4d excretion. To increase the objectivity of the assessment, all measurements were divided by urinary creatinine excretion (ng/mgCr). The study population was grouped according to the C4d excretion cut-off value into low (LC4d, 109 participants) and high (HC4d, 76 participants) C4d excretion groups. Additionally a subgroup with absence of C4d in the urine (ZC4d, 26 patients) was formed. ResultsThe calculated Roc curve indicated the cut off value of the urinary C4d excretion as 12.4ng/mgCr (AUC 0.77; 95%CI 0.73–0.95). The mean C4d urinary excretions in LC4d and HC4d were 1.9±3.27 and 20.6±4.6ng/mgCr, respectively, whereas after exclusion of ZC4d subgroup, the mean C4d was 14.9±6.3ng/mgCr in the remainder. Kaplan–Meier curve analysis demonstrated a slightly higher graft survival rate (GSR) in LC4d than in HC4d group (p=0.04 by log-rank). The subsequent analysis showed the highest GSR in ZC4d subgroup (p=0.0006 by log-rank). ConclusionAlthough lower C4d urinary excretion in the early post-transplant period seems to be associated with better long-term kidney allograft transplantation outcomes, only its absence in the urine appears to be a solid predictor of improved graft survival.

Everolimus-induced epithelial to mesenchymal transition in immortalized human renal proximal tubular epithelial cells: key role of heparanase.

BackgroundEverolimus (EVE) is a drug widely used in several renal transplant protocols. Although characterized by a relatively low nephrotoxicity, it may induce several adverse effects including severe fibro-interstitial pneumonitis. The exact molecular/biological mechanism associated to these pro-fibrotic effects is unknown, but epithelial to mesenchymal transition (EMT) may have a central role. Additionally, heparanase, an enzyme recently associated with the progression of chronic allograft nephropathy, could contribute to activate this machinery in renal cells.MethodsSeveral biomolecular strategies (RT-PCR, immunofluorescence, zymography and migration assay) have been used to assess the capability of EVE (10, 100, 200 and 500 nM) to induce an in vitro heparanase-mediated EMT in wild-type (WT) and Heparanase (HPSE)-silenced immortalized human renal epithelial proximal tubular cells (HK-2). Additionally, microarray technology was used to find additional biological elements involved in EVE-induced EMT.ResultsBiomolecular experiments demonstrated a significant up-regulation (more than 1.5 fold increase) of several genes encoding for well known EMT markers [(alpha-smooth muscle actin (α-SMA), Vimentin (VIM), Fibronectin (FN) and matrix metalloproteinase-9 (MMP9)], enhancement of MMP9 protein level and increment of cells motility in WT HK2 cells treated with high concentrations of EVE (higher than 100 nM). Similarly, immunofluorescence analysis showed that 100 nM of EVE increased α-SMA, VIM and FN protein expression in WT HK2 cells. All these effects were absent in both HPSE- and AKT-silenced cell lines. AKT is a protein having a central role in EMT. Additionally, microarray analysis identified other 2 genes significantly up-regulated in 100 nM EVE-treated cells (p < 0.005 and FDR < 5%): transforming growth factor beta-2 (TGFβ2) and epidermal growth factor receptor (EGFR). Real-time PCR analysis validated microarray.ConclusionsOur in vitro study reveals new biological/cellular aspects of the pro-fibrotic activity of EVE and it demonstrates, for the first time, that an heparanase-mediated EMT of renal tubular cells may be activated by high doses of this drug. Additionally, our results suggest that clinicians should administer the adequate dosage of EVE in order to increase efficacy and reduce adverse effects. Finally heparanase could be a new potential therapeutic target useful to prevent/minimize drug-related systemic fibrotic adverse effects.

Post Operative Monitoring of Donor Specific T Cells Response as a Prognostic Factor in Organ Transplantation by the Assay Using the Indirect Presentation of Autologous Dendritic Cells

In spite of current immunosuppressive regimen, chronic allograft nephropathy remains the crucial clinical barrier for long term survival. The aim of present study is to elucidate whether the study regarding indirect allorecognition predicts the well functioning or ongoing rejection kidney allograft. As an assay for indirect T cell recognition in vitro, we performed indirect MLR in 10 kidney transplantation patients. Five patients are with a well preserved graft function at post operative 8-11 years and others with a poor functioning graft at 2-7 years. Because T cell recognition of alloantigens presented by recipient antigen presenting cells, namely indirect pathway, plays a critical role in the development and progression of chronic allograft nephropathy, we generate the alloantigen presenting autologous dendritic cells (DC) from recipient peripheral blood monocytes. We cultured monocytes with GM-CSF plus IL-4 for 6 days and induced their maturation with TNF-α and PGE2 for additional 2 days in the presence donor cell lysate as an alloantigen. The T cell mediated responses were characterized by the indirect MLR using autologous DCs as well as the direct MLR using donor PBMC. Cytokines or chemokines released from indirect and direct MLR, and cytokines from patient serum were measured by Luminex assay. Patient with poor functioning graft had elevated proinflammatory mediators such as MMP-1 and IP-10 in the sera (p< 0.05) but other cytokines were not significantly different between the 2 groups. In the cytokine assay for indirect MLR, all the patients with functioning graft had significantly elevated cytokine secretion such as IL-4, IL-5 and IL-10 compared with poor functioning group. However, IL-12(p70), IL-23 and IL-1β were increased in the poor functioning group. Interestingly, no significant difference was found in the cytokine levels in direct MLR assay, although IL-10 and IL-5 was increased in some well functioning patients (3 out of 5) compared with poor functioning group. From these results, we can conclude that the assay of cytokine released in indirect MLR might be a favorable predictor for long-term function in renal allograft patient in addition to as a non invasive method. Wee need further study to confirm this result in more patient pool.

Mycophenolate mofetil and FK506 have different effects on kidney allograft fibrosis in rats that underwent chronic allograft nephropathy

BackgroundTacrolimus (FK506) is associated with renal fibrosis in long-term use. Mycophenolatemofetil (MMF) can also inhibit or attenuate the progression of renal fibrosis. This study aimed to determine the different effects of FK506 and MMF on fibrosis-associated genes in the kidney in rats that underwent chronic allograft nephropathy (CAN).MethodsFisher (F344) kidneys were orthotopically transplanted into Lewis rat recipients. All recipients were given Cyclosporin A (CsA) 10 mg/kg-1.d-1 × 10 day and were then randomly divided into three oral treatment groups (n = 9 in each group): (1) the vehicle group was given vehicle orally; (2) the FK506 group was given 0.15 mg/kg-1.d-1 FK506; and (3) the MMF group was given 20 mg/kg-1.d-1 MMF. At 4, 8, and 12 weeks post-transplantation, serum creatinine (SCr), collagen deposition, Connective tissue growth factor (CTGF), alpha smooth muscle actin (α-SMA) and E-cadherin expressions were determined and hematoxylin-eosin (HE) and Periodic acid-Schiff (PAS) stains were performed.ResultsRenal function progressively deteriorated and showed typical CAN morphology in the vehicle and FK506 groups, while SCr and inflammatory infiltration (Banff score) showed a significant decrease in the MMF group after 8 weeks post-transplantation compared with those in the other groups (p < 0.05). Furthermore, expression levels of CTGF and α-SMA in the MMF group were significantly reduced, and the down-regulated expression of E-cadherin was abated (p < 0.05).ConclusionsMMF showed favorable effects on renal interstitial fibrosis, thus efficiently retarding the progression of CAN.

Synergistic therapy of enalapril and Cordyceps sinensis in the improvement of renal function in chronic allograft nephropathy patient

Chronic allograft nephropathy (CAN) still remains an important factor that affects the long-term survival of renal recipients. The aim of the study was to investigate synergistic effect of enalapril (an angiotensin converting enzyme inhibitor, ACEI) and Cordyceps sinensis (Bailing capsule, fermented agent of C. sinensis ) on CAN and pursue an effective therapy to control CAN progression. A total of 84 CAN patients who underwent transplantation (live related donor, no prisoners were used in this study) were involved in the study and randomized into four groups. Group A (n=22) received combined treatment of enalapril (10 mg/day) and C. sinensis (2.0 g/per times, three times per day), group B (n=20) was treated with enalapril (10 mg/day), group C (n=21) with C. sinensis (same dose as in group A) and group D (n=21) treated with immunosuppressive agents was set as control. Serum creatinine (SCr), blood urea nitrogen (BUN), creatinine clearance rate (CCr), urinary protein in 24 h (24 h Upro) and urinary transforming growth factor beta 1 (TGF-s 1 ) of all patients were measured before treatment, and at six months after treatment. After treatment for six months, SCr and CCr were improved while 24 h Upro and urinary TGF-s 1 decreased in group A , and SCr improved and 24 h Upro decreased in group C. Patients of group A obtained the highest degree of improvement, and more patients obtained renal improvement and stability than in the other groups. The results of the study show that combined use of enalapril and C. sinensis takes advantages of reducing excretion of urinary protein, improving renal function and retarding CAN progression for CAN patients compared with single use of enalapril or C. sinensis . Keywords: Chronic allograft nephropathy, renal transplantation, enalapril, Cordyceps sinensis

Renal allograft nephropathy in patient with type 1 diabetes mellitus

Renal allotransplantation is the most effective and safest mode of renal replacement therapy in patients with diabetes mellitus (DM),and currently is recognized as method of choice for patients with end-stage renal disease. Due to variety of factors damaging transplantedkidney in patients with DM, issues of long-term survival of the graft constitute a serious problem. Therefore, special attentionshould be directed at correction of rejection risk factors in order to prolong graft survival - and prevent development and progressionof chronic allograft nephropathy.

Effect of Spironolactone on Chronic Allograft Nephropathy in Rats

Objective: Chronic allograft nephropathy (CAN) is common following renal transplantation in cats and people. Aldosterone potentiates ongoing renal injury; however its role in CAN is less defined. Spironolactone, an aldosterone receptor blocker, is protective in other rodent models of renal injury. The purpose of this study was to evaluate spironolactone on the development of CAN in a rat model Animals: Fisher and Lewis, adult, male rats. Procedures: A Lewis to Fisher model of CAN was used. Rats were divided into 4 groups, 2 nephrectomy controls (CON) and 2 transplantation (TX) groups. Two groups (a CON and TX) received tap water (0.25 ml/day orally), and the remaining 2 received spironolactone (10 mg/kg orally) daily for 16 weeks post transplantation. Serum creatinine concentration, urine-protein: urine-creatinine (UP: UC), and changes in renal cortex gene expression were measured during and at 16 weeks after transplantation. Results: There were no significant differences in any of the outcome measures when the 2 TX groups were compared. TX rats had significantly more (p=0.0002) histological lesions consistent with CAN and elevation in TNF-α (p=0.0402) compared to CON animals. Conclusions and clinical relevance: In this study, spironolactone did not protect against the development or progression of CAN. Impact for human medicine: The impact of aldosterone on the occurrence of CAN in humans following renal transplantation remains an area of investigation.

Correction of Postkidney Transplant Anemia Reduces Progression of Allograft Nephropathy

Retrospective studies suggest that chronic allograft nephropathy might progress more rapidly in patients with post-transplant anemia, but whether correction of anemia improves renal outcomes is unknown. An open-label, multicenter, randomized controlled trial investigated the effect of epoetin-β to normalize hemoglobin values (13.0-15.0 g/dl, n=63) compared with partial correction of anemia (10.5-11.5 g/dl, n=62) on progression of nephropathy in transplant recipients with hemoglobin <11.5 g/dl and an estimated creatinine clearance (eCrCl) <50 ml/min per 1.73 m(2). After 2 years, the mean hemoglobin was 12.9 and 11.3 g/dl in the normalization and partial correction groups, respectively (P<0.001). From baseline to year 2, the eCrCl decreased by a mean 2.4 ml/min per 1.73 m(2) in the normalization group compared with 5.9 ml/min per 1.73 m(2) in the partial correction group (P=0.03). Furthermore, fewer patients in the normalization group progressed to ESRD (3 versus 13, P<0.01). Cumulative death-censored graft survival was 95% and 80% in the normalization and partial correction groups, respectively (P<0.01). Complete correction was associated with a significant improvement in quality of life at 6 and 12 months. The number of cardiovascular events was low and similar between groups. In conclusion, this prospective study suggests that targeting hemoglobin values ≥13 g/dl reduces progression of chronic allograft nephropathy in kidney transplant recipients.

Effect of Cordyceps sinensis on Renal Function of Patients with Chronic Allograft Nephropathy

Objective: To investigate the effect of Cordyceps sinensis (Bailing Capsule, fermented agent of C. sinensis) on renal function of patients with chronic allograft nephropathy (CAN). Methods: A total of 231 CAN patients who underwent transplantation between 2005 and 2008 and experienced chronic graft dysfunction were randomly divided into 2 groups. Patients in group A (n = 122) were treated with immunosuppressive agents and C. sinensis (2.0 g/day, 3 times a day), while patients in group B (n = 109) were treated with traditional immunosuppressive drugs. Serum creatinine (SCr), blood urea nitrogen (BUN), creatinine clearance rate (C_Cr) and urinary protein in 24 h (24-hour Upro) of all patients were measured before and after treatment. Urinary concentrations of transforming growth factor (TGF)-β₁, retinol-binding protein (RBP) and β₂-microglobulin (β₂-MG) were detected at the same time. Results: After 6-month treatment with C. sinensis, SCr and C_Cr in group A were significantly improved (p < 0.05), while there was no significant improvement observed for group B. There was no significant change in BUN in groups A and B (p > 0.05). 24-hour Upro, RBP and β₂-MG were lower in group A after treatment with C. sinensis (p < 0.05 or p < 0.01), and urinary TGF-β₁ in group A was significantly lower than the values before C. sinensis treatment (p < 0.05), but showed no change in patients of group B. In group A, renal function had improved in 72 cases, stabilized in 38 cases, and worsened in 12 cases. In group B, renal function had improved in 14 cases, stabilized in 50 cases, and worsened in 45 cases (p < 0.05). Conclusion:C. sinensis therapy is advantageous in improving renal function of CAN patients by retarding CAN progression.

Oral hydrogen water prevents chronic allograft nephropathy in rats

Reactive oxygen species (ROS) contribute to the development of interstitial fibrosis and tubular atrophy seen in chronic allograft nephropathy (CAN). As molecular hydrogen gas can act as a scavenger of ROS, we tested the effect of treatment with hydrogen water (HW) in a model of kidney transplantation, in which allografts from Lewis rats were orthotopically transplanted into Brown Norway recipients that had undergone bilateral nephrectomy. Molecular hydrogen was dissolved in water and recipients were given HW from day 0 until day 150. Rats that were treated with regular water (RW) gradually developed proteinuria and their creatinine clearance declined, ultimately leading to graft failure secondary to CAN. In contrast, treatment with HW improved allograft function, slowed the progression of CAN, reduced oxidant injury and inflammatory mediator production, and improved overall survival. Inflammatory signaling pathways, such as mitogen-activated protein kinases, were less activated in renal allografts from HW-treated rats as compared with RW-treated rats. Hence, oral HW is an effective antioxidant and antiinflammatory agent that prevented CAN, improved survival of rat renal allografts, and may be of therapeutic value in the setting of transplantation.

Detection of Citrate Synthase Autoantibodies in Rats with Chronic Allograft Nephropathy

Citrate synthase (CS) is the one of the key enzymes in the citric acid cycle and an important mitochondrial autoantigen. The autoimmune responses against CS have not been studied in chronic allograft nephropathy (CAN). This study investigated the role of specific CS autoantibodies in rats bearing renal allografts affected with CAN. Methods Fisher344 rat renal grafts were orthotopically transplanted into Lewis rats following the procedure of Kamada with our modification. Lewis-to-Lewis and Fisher344-to-Fisher344 kidney transplantations were also performed as autologous control groups (each n = 9). All the allograft recipients given cyclosporine (10 mg/kg −1d −1 × 10 d) were divided into four groups (each n = 9): (1) vehicle: normal saline orally; (2) cyclosporine: 6 mg/kg −1d −1; (3)FK506: 0.15 mg/kg −1d −1; (4) mycophenolate mofetil (MMF): 20 mg/ kg −1d −1. At 4, 8, and 12 weeks posttransplantation, the animals were sacrificed to harvest sera and renal allografts. The serum creatinine (SCr) was measured and pathological changes assessed according to Banff 97 criteria. IgM and IgG isotypes of CS antibodies were detected in all recipient sera by enzyme linked immunosorbent assays. Results Both IgM and IgG isotype CS autoantibodies were observed in the sera of all the recipients before and after transplantation, but the levels of IgM CS autoantibody were obviously higher than IgG isotype in all the blood samples. It was stable not only in autologous but also in allograft groups. In both autologous groups, the SCr and IgM and IgG isotype CS autoantibodies showed no obvious change before and after transplantation, and no typical CAN occurred. The values of IgG isotype of CS autoantibody (ΔOD) at 4, 8 and 12 weeks were stable. At 4 weeks, the values of SCr, Banff score, and IgG isotype CS autoantibody (ΔOD) were not significantly different ( P > .05) among the allograft groups. At 8 and 12 weeks, with progression of CAN in vehicle, cyclosporine and FK506 groups' values of SCr, Banff score, and IgG (ΔOD) also increased dramatically ( P = .005) in all three groups when compared with the baseline and 4 week values, but the differences among the three groups were not significant ( P > .05). At 8 and 12 weeks, the MMF group suffered mild-to-moderate CAN, but the values of SCr and Banff score were significantly lower than those in the other three groups. MMF significantly inhibited the formation of IgG (ΔOD) when compared with the other three groups ( P = .02). Conclusion This study suggested that the IgG isotype of CS autoantibody contributes to CAN after kidney transplantation. The IgM isotype is physiological. MMF significantly inhibited the formation of IgG isotype CS autoantibody, which may be related to its effects to alleviate CAN.

The relationship between transforming growth factor β1 expression and cold ischemia injury of rat donor kidney

Objective Cold ischemia injury represents an independent risk factor which favors chronic allograft nephropathy (CAN). In order to investigate the role of transforming growth factor-beta 1( (TGF-β1) in the progression of CAN, we studied the relationship between the expression of TGF-β1 and cold ischemia injury in the renal tubular epithelia of rat donor kidney. Methods A total of 24 Wistar rats were used in this study. In terms of the time of cryopreservation of donor kidney, the 24 Wistar rats were randomly divided into 3 groups: 0h group(control group), 24h group, 48h group. A block removal of donor kidney with in situ perfusion of cooling HC-A preservation solution was adopted. The rat kidney was preserved 0h, 24h and 48h at 0-4 °C respectively. The morphologic changes of proximal tubular epithelial cells in different cryopreservation time were observed under light microscope and transmission electron microscope. The expression of TGF-β1 mRNA and protein in proximal tubular epithelial cells of different cryopreservation time group were detected by in situ hybridization and immunohistochemistry analysis. Results 1. In 24h group, part of the proximal tubular epithelial cells showed slight degeneration. In 48h group, the proximal tubular epithelial cells demonstrated severe hydropic degeneration and part of the cells developed necrosis and effluxion. 2. Only a small amount of TGF-β1 protein and mRNA were expressed in the renal tubular epithelial cells of 0h group. The positive unit (PU) value of TGF-β1 protein and mRNA were 6.37 ± 2.77 and 5.29 ± 2.15, respectively. As the cold ischemia time prolonged, the PU value of TGF-β1 protein increased at 24h group (10.20 ± 3.27) and 48h group (17.17 ± 3.96) . The PU value of TGF-β1 mRNA also increased at 24h group (11.31 ± 3.34) and 48h group (19.01 ± 3.53). There was the significant difference of TGF-β1 protein PU value or mRNA PU value among these groups(P < 0.05). Conclusion There was the significant correlation between the expression of TGF-β1 and the degree of cold ischemia injury. The results suggest that TGF-β1 might play the key role in regeneration and reparation of renal tubular epithelial cell injury. The overexpression of TGF-β1 might be one of the mechanisms that initiate chronic allograft nephropathy.

Conversion from Cyclosporin a to Sirolimus Retards the Progression of Chronic Allograft Nephropathy in the Long Term in a Rat Kidney Transplantation Model

In a rat renal allograft model, the long-term effect of conversion from cyclosporin A (CsA) to sirolimus on recipient kidneys and growth factor expression were compared with continuous use or withdrawal of CsA. Kidneys from Fisher 344 rats were orthotopically transplanted into Lewis rats. Four Fisher 344 to Lewis allograft groups were treated post-transplant as follows: (i) CsA (transplant to week 8) then sirolimus (weeks 8 - 24); (ii) CsA (transplant to week 24); (iii) CsA (transplant to week 8) then vehicle (weeks 8 - 24); (iv) control vehicle (transplant to week 24). A fifth group underwent syngeneic isograft (Lewis to Lewis) with no drug treatment. Proteinuria was measured every 4 weeks and grafts harvested at 24 weeks for morphological and immunohistochemical analysis. Conversion from CsA to sirolimus resulted in a significant decrease in proteinuria at 24 weeks, a lower Banff sum score and lower expression of transforming growth factor mRNA compared with continuous use or withdrawal of CsA. In conclusion, conversion from CsA to sirolimus retarded progression of chronic allograft nephropathy in the rat model.

Clinical Application of Cordyceps sinensis on Immunosuppressive Therapy in Renal Transplantation

Objective We sought to explore the adjunctive effects of Cordyceps sinensis (CS) in clinical renal transplantation. Materials and Methods Patients (n = 202) were divided randomly by lottery into a treatment (n = 93) and a control group (n = 109). Patients in the treatment group were treated with CS 1.0 g 3 times a day in addition to the immunosuppressive regimen given to the control group. We compared patient and graft survivals, incidence, time and severity of acute rejection episodes, chronic allograft nephropathy (CAN), hepatotoxicity and nephrotoxicity, biochemistry parameters including indicators of liver and kidney functions, fats, proteinuria, dosages, and whole blood concentrations of cyclosporine (CsA). Results Patient and graft survival rates, serum creatinine (SCr), and blood urea nitrogen (BUN) were not significantly different between the 2 groups ( P > .05). Serum uric acid (UA) and 24-hour urinary total protein (24-hour UTP) were significantly lower in the treatment group than in the control group ( P < .05). The incidences (11.83% vs 15.60%) and times to acute renal allograft rejection (23.48 ± 7.22 vs 22.27 ± 8.03 days posttransplantation) were not significantly different between the treated and control groups ( P > .05). Patients receiving thymoglobulin antirejection therapy (3 cases) were fewer in the heated versus control group (13 cases; P = .014). The incidences of hepatotoxicity and nephrotoxicity in the treated group were 12.90% and 19.35%, significantly lower than 24.77% and 33.94% in the control group, respectively ( P < .05). At 2 to 6 months posttransplantation, the CsA dosages in the treated group were significantly lower than those in the control group ( P < .05). The whole blood trough CsA concentrations in the treated group were significantly lower than those in the control group at 3 to 6 months posttransplantation ( P < .05). The decreasing trends of the 2 aforementioned parameters in the treatment group were approximately linear among treated subjects compared with approximately quadratic in the control group ( P < .05). The incidence of CAN in the treated group was 7.53%, which was significantly lower than 18.35% in the control group ( P = .024). The 24-hour UTP level in CAN patients within the treated group was significantly lower than the control group after transplantation ( P = .045). The differences in total bilirubin, SCr, serum UA, and total cholesterol levels among otherwise normal patients in the treated group were significantly lower than those among the control group ( P < .05). Conclusions The use of CS may allow decreased dosages and concentrations of CsA causing fewer side effects without an increased risk of acute rejection. In addition, CS with reduced dose CsA may decrease proteinuria and retard CAN progression.

The use of everolimus in renal-transplant patients

Despite advances in immunosuppressive therapy, long-term renal-transplantation outcomes have not significantly improved over the last decade. The nephrotoxicity of calcineurin inhibitors (CNIs) is an important cause of chronic allograft nephropathy (CAN), the major driver of long-term graft loss. Everolimus is a proliferation signal inhibitor with a mechanism of action that is distinct from CNIs. The efficacy and tolerability of everolimus in renal-transplant recipients have been established in a wide range of clinical trials. Importantly, synergism between everolimus and the CNI cyclosporine (CsA) permits CsA dose reduction, enabling nephrotoxicity to be minimized without compromising efficacy. Currently, everolimus is being investigated in regimens where reduced exposure CNIs are used from the initial post-transplant period to improve renal function and prevent CAN. By inhibiting the proliferation of smooth muscle cells, everolimus may itself delay the progression or development of CAN. Although everolimus is associated with specific side effects, these can generally be managed. By targeting the main causes of short- and long-term graft loss, everolimus has a key role to play in renal transplantation, which is being explored further in a number of ongoing Phase III-IV trials.

Synergistic effect of mycophenolate mofetil and angiotensin-converting enzyme inhibitor in patients with chronic allograft nephropathy

Experimental data and few clinical non-randomized studies have shown that inhibition of the renin-angiotensin system by angiotensin-converting enzyme (ACE) associated or not with the use of mycophenolate mofetil (MMF) could delay or even halt the progression of chronic allograft nephropathy (CAN). In this retrospective historical study, we investigated whether ACE inhibition (ACEI) associated or not with the use of MMF has the same effect in humans as in experimental studies and what factors are associated with a clinical response. A total of 160 transplant patients with biopsy-proven CAN were enrolled. Eighty-one of them were on ACE therapy (G1) and 80 on ACEI_free therapy (G2). Patients were further stratified for the use of MMF. G1 patients showed a marked decrease in proteinuria and stabilized serum creatinine with time. Five-year graft survival after CAN diagnosis was more frequent in G1 (86.9 vs 67.7%; P < 0.05). In patients on ACEI-free therapy, the use of MMF was associated with better graft survival. The use of ACEI therapy protected 79% of the patients against graft loss (OR = 0.079, 95%CI = 0.015-0.426; P = 0.003). ACEI and MMF or the use of MMF alone after CAN diagnosis conferred protection against graft loss. This finding is well correlated with experimental studies in which ACEI and MMF interrupt the progression of chronic allograft dysfunction and injury. The use of ACEI alone or in combination with MMF significantly reduced proteinuria and stabilized serum creatinine, consequently improving renal allograft survival.

Low-dose carbon monoxide inhibits progressive chronic allograft nephropathy and restores renal allograft function

Chronic allograft nephropathy (CAN) represents progressive deterioration of renal allograft function with fibroinflammatory changes. CAN, recently reclassified as interstitial fibrosis (IF) and tubular atrophy (TA) with no known specific etiology, is a major cause of late renal allograft loss and remains a significant deleterious factor of successful renal transplantation. Carbon monoxide (CO), an effector byproduct of heme oxygenase pathway, is known to have potent anti-inflammatory and antifibrotic functions. We hypothesized that inhaled CO would inhibit fibroinflammatory process of CAN and restore renal allograft function, even when the treatment was initiated after CAN was established. Lewis rat kidney grafts were orthotopically transplanted into binephrectomized allogenic Brown Norway rats under brief tacrolimus (0.5 mg/kg im, days 0-6). At day 60, CO (20 ppm) inhalation was initiated to recipients and continued until day 150 or animal death. Development of CAN was confirmed at day 60 with decreased creatinine clearance (CCr), significant proteinuria, and histopathological findings of TA, IF, and intimal arteritis. Air-treated control recipients continued to deteriorate with further declines of CCr and increases of urinary protein excretion and died with a median survival of 82 days. In contrast, progression of CAN was decelerated when recipients received CO on days 60-150, showing markedly improved graft histopathology, restored renal function, and improved recipient survival to a median of >150 days. CO significantly reduced intragraft mRNA levels for IFN-gamma and TNF-alpha at day 90. Expression of profibrotic TGF-beta/Smad was significantly suppressed with CO, together with downregulation of ERK-MAPK pathways. Continuous CO (20 ppm) treatment for days 0-30, days 30-60, or days 0-90, or daily 1-h CO (250 ppm) treatment for days 0-90, also showed efficacy in inhibiting CAN. The study demonstrates that CO is able to inhibit progression of fibroinflammatory process of CAN, restore renal allograft function, and improve survival even when the treatment is started after CAN is diagnosed.

Long-term graft outcome in patients with chronic allograft nephropathy after immunosuppression modifications

This retrospective study was conducted to assess the efficacy and safety of immunosuppression conversion on progression of chronic allograft nephropathy (CAN). One-hundred and seventy-four cyclosporin (CsA)-treated renal transplant recipients were studied. Patients were included if they had a biopsy-proven CAN (mild to moderate) with serum creatinine < or =3.5 mg/dL. Patient treatment was switched to either: (A) MMF/reduced dose CsA (MMF for azathioprine (Aza); n = 132); or (B) Aza/Tac for CsA (n = 42). Patient records were checked for graft function and survival, and for co-morbidities after conversion. Mean follow-up before conversion was 52.2 +/- 31.1 and 47.9 +/- 27.4 months for groups A and B, respectively. There was significant deterioration of graft function in group B after five years (P < 0.5). Ten-year actuarial graft survival was 38% in group A and 19% in group B (P = 0.04). Nine patients (five patients and four patients in groups A and B, respectively) started dialysis within 12 months. Tacrolimus-treated patients had a lower insignificant incidence of hyperlipidemia (P = 0.05), but a significantly higher incidence of diabetes mellitus (P = 0.04).There was no significant change or difference in blood pressure between groups. Our results suggest that in patients with CAN and deteriorating allograft function, CsA minimization and addition of MMF achieved favorable efficacies in retarding the decline of graft function. Further prospective studies with larger cohorts are needed for validation.