Stable Transplant Patients Research Articles

Immune responsiveness in stable kidney transplantation patients: Complete inhibition of T-cell proliferation but residual T-cell activity during maintenance immunosuppressive treatment.

The recommended immunosuppressive treatment after kidney transplantation consists of tacrolimus, mycophenolate mofetil, and low-dose corticosteroids. Drug concentrations are monitored using therapeutic drug monitoring (TDM), which does not necessarily correlate with pharmacodynamic activity. To find the balance between optimal efficacy and minimal toxicity, it might be more informative to monitor patients' immunological status rather than drug concentrations. We selected a panel of T-cell-based immune assays, which were used for immunomonitoring of 14 stable kidney transplantation patients. Whole blood was incubated with a T-cell stimulus, after which T-cell proliferation, T-cell activation marker expression and cytokine production were measured to study residual immune activity invitro (before drug intake; drug added to the incubation) and exvivo (after drug intake). T-cell proliferation was completely suppressed in all patients over the full day, while IL-2, IFN-γ, CD71, and CD154 showed fluctuations over the day with a strong inhibition (75%-25%) at 2 h post-dose. The level of inhibition was variable between patients and could not be related to pharmacokinetic parameters or the presence of regulatory or senescence immune cells. Moreover, the level of inhibition did not correlate with the invitro tacrolimus drug effect as studied by incubating pre-dose blood samples with additional tacrolimus. Overall, IL-2, IFN-γ, CD71, and CD154 seem to be good markers to monitor residual immune activity of transplantation patients. To evaluate the correlation between these pharmacodynamic biomarkers and clinical outcome, prospective observational studies are needed.

Correlates of atherosclerotic vascular disease in stable postrenal transplant patients from South India

Introduction: Renal transplant recipients (RTRs) show increased mortality after 1st year of undergoing renal transplantation. Cardiovascular disease (CVD) is the major cause of mortality in these patients. Oxidative stress (OS), inflammation, and endothelial dysfunction (ED) represent a key triad for the onset and progression of atherosclerosis. The present study was undertaken to assess OS, inflammatory biomarkers, and ED as a surrogate marker of atherosclerosis in stable RTRs. Materials and Methods: Thirty stable post-RTRs along with 30 healthy individuals as controls were included in the study conducted at a tertiary care teaching hospital in south India. Lipid profile; OS markers; malondialdehyde (MDA), ischemia-modified albumin (IMA), and ferric reducing ability of plasma (FRAP); inflammatory marker high-sensitivity C-reactive protein and interleukin 6 (IL-6); ED markers nitric oxide (NO) and P-selectin were estimated using standard methods. Lipid indices were calculated. Carotid intima-media thickness, two-dimensional echocardiogram, and renal Doppler scans were done. Results: No difference in lipid profile was observed between the RTRs and the control groups. RTRs had significantly higher oxidant markers (MDA and IMA), inflammatory marker (IL-6), marker of ED (NO), and lower antioxidant marker (FRAP) (P < 0.05) compared to the control group. RTRs had significantly more number of carotid plaques compared to the control group. A positive correlation was observed between number of carotid plaque and OS, ED, and inflammatory markers. Conclusion: RTRs have increased CVD risk despite undergoing renal replacement therapy. This can be attributed to the increased OS and inflammation which is seen in these patients.

Exercise training in heart transplantation.

Heart transplantation remains the gold standard in the treatment of end-stage heart failure (HF). Heart transplantation patients present lower exercise capacity due to cardiovascular and musculoskeletal alterations leading thus to poor quality of life and reduction in the ability of daily self-service. Impaired vascular function and diastolic dysfunction cause lower cardiac output while decreased skeletal muscle oxidative fibers, enzymes and capillarity cause arteriovenous oxygen difference, leading thus to decreased peak oxygen uptake in heart transplant recipients. Exercise training improves exercise capacity, cardiac and vascular endothelial function in heart transplant recipients. Pre-rehabilitation regular aerobic or combined exercise is beneficial for patients with end-stage HF awaiting heart transplantation in order to maintain a higher fitness level and reduce complications afterwards like intensive care unit acquired weakness or cardiac cachexia. All hospitalized patients after heart transplantation should be referred to early mobilization of skeletal muscles through kinesiotherapy of the upper and lower limbs and respiratory physiotherapy in order to prevent infections of the respiratory system prior to hospital discharge. Moreover, all heart transplant recipients after hospital discharge who have not already participated in an early cardiac rehabilitation program should be referred to a rehabilitation center by their health care provider. Although high intensity interval training seems to have more benefits than moderate intensity continuous training, especially in stable transplant patients, individualized training based on the abilities and needs of each patient still remains the most appropriate approach. Cardiac rehabilitation appears to be safe in heart transplant patients. However, long-term follow-up data is incomplete and, therefore, further high quality and adequately-powered studies are needed to demonstrate the long-term benefits of exercise training in this population.

CXCL13 Is an Indicator of Germinal Center Activity and Alloantibody Formation Following Transplantation.

A murine skin graft model was utilized to define the production and kinetics of CXCL13 in response to alloantigen. Human Tfh:B-cell in vitro cocultures were performed to evaluate CXCL13 production by human lymphocytes, and serum from healthy controls and human transplant recipients with and without de novo DSA was tested for CXCL13. CXCL13 was detectable in the blood of allografted mice and correlated with Tfh and GC B-cell responses. Greater CXCL13 expression was observed in the draining lymph nodes of allografted mice as compared with naïve or syngeneic graft recipients, and serum levels preceded the detection of DSA posttransplant. Similarly, productive human Tfh:B-cell interactions that led to plasmablast differentiation and IgG formation also exhibited CXCL13 expression. CXCL13 levels in human transplant recipients with de novo DSA were greater than in healthy controls and stable transplant patients and also correlated with the development of alloantibodies in a small cohort of serially monitored recipients. CXCL13 indicates GC alloreactivity and alloantibody formation and correlated with DSA formation in kidney transplant recipients, thereby introducing CXCL13 as a potential biomarker for HLA antibodies.

Hemodialysis arteriovenous fistula ligation after renal transplantation: Impact on graft resistive index.

Kidney allograft resistive index (RI) is prognostic for graft and recipient survivals. Recipient hemodynamics could influence RI. In particular, dialysis arteriovenous fistula (AVF) has been involved in heart function changes, reversible after AVF ligation. Knowledge about AVF and RI is lacking. In this study, we prospectively evaluated RI changes after AVF ligation in kidney transplanted patients. We enrolled 22 stable transplanted patients. Mean RI was measured before AVF ligation (T0), 18 to 24 h (T1) and 6 months (T6) after surgery; mean blood pressure (mBP), heart rate (HR), serum creatinine (sCr), estimated glomerular filtration rate (eGFR), 24 h proteinuria (24 h-P), immunosuppressive drug blood levels (IS) and antihypertensive drugs were also recorded. AVF ligation was performed 3.1 years (IQR: 2.1-3.8) after transplantation. Median AVF flow (Qa) was 1868 mL/min (IQR: 1538-2712) and 8 AVF were classified as high flow (Qa ≥ 2 L/min). At baseline, median sCr was 1.32 mg/dL (IQR: 1.04-1.76) and median eGFR was 57.1 mL/min. Median RI was 0.71 at T0, 0.69 at T1, 0.66 at T6. RI reduction at T1 and T6 was statistically significant (p < 0.05 and p < 0.001 respectively); in particular, 90.4% of patients had persistently improved values at T6. Furthermore, mBP increased while HR decreased. These changes were independent from sCr, 24 h-P, IS, antihypertensive drugs number, Qa and AVF type. AVF ligation improves kidney allograft RI; it may reflect better kidney perfusion.

Circular RNAs in Urine of Kidney Transplant Patients with Acute T Cell-Mediated Allograft Rejection.

Circular RNAs (circRNAs) have recently been described as novel noncoding regulators of gene expression. They are detectable in the blood of patients with acute kidney injury. We tested whether circRNAs were present in urine and could serve as new predictors of outcome in renal transplant patients with acute rejection. A global circRNA expression analysis using RNA from urine of patients with acute T cell-mediated renal allograft rejection and control transplant patients was performed. Dysregulated circRNAs were confirmed in a cohort of 62 patients with acute rejection, 10 patients after successful antirejection therapy, 18 control transplant patients without rejection, and 13 stable transplant patients with urinary tract infection. A global screen revealed several circRNAs to be altered in urine of patients with acute rejection. Concentrations of 2 circRNAs including hsa_circ_0001334 and hsa_circ_0071475 were significantly increased. These were validated in the whole cohort of patients. hsa_circ_0001334 was upregulated in patients with acute rejection compared with controls. Concentrations of hsa_circ_0001334 normalized in patients with acute rejection following successful antirejection therapy. hsa_circ_0001334 was associated with higher decline in glomerular filtration rate 1 year after transplantation. CircRNA concentrations are significantly dysregulated in patients with acute rejection at subclinical time points. Urinary hsa_circ_0001334 is a novel biomarker of acute kidney rejection, identifying patients with acute rejection and predicting loss of kidney function.

Validation of diagnostic utility of fasting plasma glucose and HbA1c in stable renal transplant recipients one year after transplantation

BackgroundThe use of HbA1c ≥6.5% for diagnosis of diabetes has been challenged for post-transplantation diabetes mellitus (PTDM) also known as new onset diabetes after transplantation (NODAT) due to a low sensitivity early after renal transplantation. PTDM diagnosed with an oral glucose tolerance test (OGTT) is highly predictable for long-term patient mortality. HbA1c was introduced for diagnosis based on the risk of developing diabetic retinopathy. The utility of HbA1c measures versus glucose criteria has not been widely assessed in stable transplant patients but still HbA1c is widely used in this population. The aim of the present analyses was to validate the utility of fasting plasma glucose (FPG) together with HbA1c in diagnosing PTDM in stable renal transplant recipients (RTRs).MethodsOGTT’s were performed one year after transplantation in 494 consecutive RTRs without diabetes. FPG and HbA1c were obtained the same day, before starting the OGTT. Validation was performed using C-statistics and logistic regression analyses.ResultsPTDM was diagnosed in 51 patients (10.3%) by glucose criteria, 38 (74%) patients were diagnosed by FPG ≥7.0 mmol/L [126.1 mg/dl], and 13 (26%) only by 2-h plasma glucose. Six of the latter had HbA1c ≥6.5%. Only seven patients out of the 51 (13.7%) PTDM patients remained undiagnosed when HbA1c ≥6.5% was used together with FPG, and five of these regressed to normal after a median follow-up of 14 months. ROC curves including FPG and HbA1c versus OGTT derived criteria revealed an AUC of 0.858.ConclusionsCombining standard diagnostic FPG and HbA1c criteria captured almost all patients with persistent PTDM in stable RTRs. The combined use of the criteria appears to be an applicable diagnostic strategy for PTDM without the need of an OGTT one year post-transplant.Trial registrationRetrospectively registered.

Extended Release Tacrolimus (LCP-TAC) Prolongs Calcineurin Activity Inhibition During Drug Doses Intervals

Introduction Tacrolimus (TAC) is the cornerstone calcineurin inhibitors most commonly used in renal transplantation. New extended release formulation of tacrolimus (LCPT-ER) (Envarsus®) offers better bioavailability and less fluctuation between maximum concentration (Cmax) and trough and with a lower peak level compared to immediate-release (TAC-IR) formulation (Prograf® or Adoport®). The more stable and less fluctuating TAC exposure of LCPT-ER may result in an optimized pharmacodynamic (PD) profile with a more sustained inhibition of calcineurin activity (CNA) during dose intervals. The goal of this study is to compare the CNA area under the curve (AUC) between LCPT-ER and TAC-IR formulation in kidney stable transplant patients and their correlation with their corresponding TAC exposures. Methodology An open-label, prospective, non-randomized study investigator-driven was conducted. Ten patients receiving TAC-IR in steady state were subsequently switched to LCPT-ER (dose conversion rate 1:0.7). Before and after conversion, pharmacokinetic (PK) and PD intensive analysis were conducted along 24 hours (Pre-dose, 0.5, 1, 1.5, 2, 3, 4, 6, 8, 12, 12.5, 13, 13.5, 14, 15, 20 and 24h). A validated method by UPLC-MS based on peptide dephosphorilation was used to measure CNA in peripheral blood mononuclear cells. TAC levels in whole blood were measured also by UPLC-MS. Concentration of TAC in blood is expressed in μg/L. CN activity is expressed in pmol of dephosporilated peptide/time x protein (pmol/m·mg). To evaluate the duration of CNA inhibition between drug doses intervals, the CNA Imax was subtracted to CNA at each time point (AUC PD Imax). Results PK results showed that LCPT-ER presented lower Cmax and higher dose normalized AUC PK0-24 than TAC-IR statistically significant. These results are illustrated in Table 1.AUC PDIo displayed similar values between LCPT-ER and TAC-IR, but as PK, LCPT-ER achieved significative higher inhibition when they were normalized by doses. A lower AUC PDImax value of LCPT-ER was obtained, indicating more maintained inhibition along the curve. PD parameters are shown in table 2 and an illustration of CN activity during 24 hours with both formulations is presented in Figure 1.Conclusions Our results expressed that with lower doses of LCPT-ER similar TAC exposure and CNA inhibition were obtained. Furthermore, LCPT-ER showed a CNA inhibition-time curve strongly more maintained along drug doses intervals compared with TAC-IR formulation. Only with LCPT-ER formulation, CNA levels did not reach the pre-dose in any point of the PD study. An unrestricted grant from Chiesi.

VE/VCO2 Slope and Functional Capacity in Patients Post-Heart Transplantation

BackgroundThe ventilatory efficiency represented cardiovascular, pulmonary, and musculoskeletal performance into an integrate index has been used as long-term and short-term prognostic variables in congestive heart failure. The heart failure patients post heart transplantation, whether the ventilatory efficiency was also normalized is still unknown. MethodsThis was a cross-sectional study. We measured ventilation to carbon dioxide production slope and oxygen consumption in peak exercise (peak VO2) by cardiopulmonary exercise test, which represented ventilatory efficiency and functional capacity respectively. Strength of hand grip, the 30-second chair stand test, and 6-minute walking test were also evaluated. Patients with ventilation to carbon dioxide production slope <30 were defined as the normal group; others were defined as the abnormal group. Independent t tests and paired t tests were used when appropriate. The level of statistical significance was set at .05. ResultsThere were 51 clinically stable post-heart transplantation patients (age 53 ± 12.4 years; 86.3% were male) at 65.14 ± 41.17 months after transplantation. The ventilation to carbon dioxide production slope was 29.2 ± 5.6, which significantly improved compared to that recorded 1 month after heart transplantation (32.6 ± 6.4). There were 20 patients in the abnormal group, characterized by lower 6-minute walking test distance (normal vs abnormal, 422.5 ± 97.8 vs 532.6 ± 87.6 m) and peak VO2 (normal vs abnormal, 14.9 ± 5.3 vs 18.8 ± 5.1 mL/kg/min). The abnormal ventilation to carbon dioxide production slope was significantly correlated with 6-minute walking test distances in multivariate analyses. ConclusionOur findings indicate that the ventilation to carbon dioxide production slope is partially abnormal among patients post-heart transplantation. A ventilation to carbon dioxide production slope above the normal range is characterized by a lower peak VO2 during cardiopulmonary exercise test and lower 6-minute walking test distance. The ventilation to carbon dioxide production slope is also significantly negatively correlated with peak VO2, peak work rate, and 6-minute walking test distance. The prognostic utility of the ventilation to carbon dioxide production slope for patients post-heart transplantation requires further investigation.

Acute Rejection After Kidney Transplantation Associates With Circulating MicroRNAs and Vascular Injury.

Acute rejection (AR) of kidney transplants is associated with the loss of endothelial integrity, microvascular rarefaction and, ultimately, graft dysfunction. Circulating angiogenic microRNAs (miRNAs) may serve as markers for microvascular injury. Here, we investigated the short- and long-term effects of AR after kidney transplantation on systemic vascular injury and the associated circulating miRNA profile. Systemic vascular injury was determined by measuring capillary tortuosity and density within the oral mucosa as well as by assessing circulating levels of angiopoietin-2/angiopoietin-1 ratio, vascular endothelial growth factor and soluble thrombomodulin. After a pilot study, we selected 48 miRNAs to assess the AR- and microvascular injury associated circulating miRNAs. In stable transplant recipients (n = 25) and patients with AR (n = 13), which were also studied longitudinally (1, 6, and 12 months post-AR), we found an AR-associated increase in markers of systemic vascular injury, of which vascular endothelial growth factor and soluble thrombomodulin normalized within 1 year after AR. Of the 48 selected miRNAs, 8 were either decreased (miR-135a, miR-199a-3p, and miR-15a) or increased (miR-17, miR-140-3p, miR-130b, miR-122 and miR-192) in AR. Of these, miR-130b, miR-199a, and miR-192 associated with markers of vascular injury, whereas miR-140-3p, miR-130b, miR-122, and miR-192 normalized within 1 year after AR. AR after kidney transplantation is characterized by systemic microvascular injury and associates with specific circulating miRNA levels.

Evaluation of CD4+ CD25+/- CD39+ T-cell populations in peripheral blood of patients following kidney transplantation and during acute allograft rejection.

Regulatory T cells (Treg) are important in mediating immune tolerance and outcomes of allotransplantation. CD4+ CD25+ CD39+ co-expression identifies memory Treg; CD4+ CD25- CD39+ memory T effectors. We sought to determine CD4+ CD25+/- CD39+ expression from the peripheral blood of patients with end stage renal failure, following transplantation and during episodes of acute cellular rejection. CD4+ T cells were isolated from peripheral blood leucocytes and analysed for CD25 and CD39 expression by flow cytometry. Treg suppressive function was measured by suppression of autologous effector T-cell proliferation by Treg in co-culture. CD4+ CD25+/- CD39+ T-cell subsets were tracked longitudinally in the peripheral blood of 17 patients following renal transplantation. Patients with acute T-cell-mediated rejection diagnosed on biopsy had reduced CD4+ CD25+ CD39+ mTreg (P<0.05) and CD4+ CD25- CD39+ mTeff (P<0.01) cells compared with non-rejecting patients. CD4+ CD25+ CD39+ mTreg (P<0.05) and CD4+ CD25- CD39+ mTeff (P=0.057) were reduced in long-term transplant patients (>1year) compared with non-immunosuppressed controls. Interestingly, remaining CD4+ CD25+ CD39+ mTreg in the stable transplant patients displayed more potent suppressive capacity compared with non-immunosuppressed controls (83.2%±3.1% vs 45.7%±8.0%, nTeff:Treg ratio 8:1, P<0.01). CD4+ CD25+ CD39+ mTreg and CD4+ CD25- CD39+ mTeff in peripheral blood can be tracked in renal transplant patients. Acute cellular rejection was accompanied by reduced mTreg and mTeff. Determining changes in these T-cell subsets may help to identify patients with, or at high risk of, renal allograft rejection.

Presence of T-275A and C-2152T Polymorphisms of the Promoter Region of Uridine Diphosphate-Glucuronosyltransferase 1A9 Increases Mortality From Digestive Tumors: Results After 10 Years of Follow-up in a Renal Transplant Population

BackgroundThe aim of this study was to determine the distribution of uridine diphosphate-glucuronosyltransferase 1A9 (UGT1A9) promoter region T-275A and C-2152T single-nucleotide polymorphisms (SNPs) in stable transplant patients and to investigate the impact of these SNPs on the evolution of this population after 10 years of follow-up. MethodsWhite renal transplant recipients (n = 873) were studied. The median time of follow-up was 91.8 months (P25–75 46–146). Amplification with specific “primers” to delimit the study area was performed for each polymorphism. Amplification was performed with the use of real-time polymerase chain reaction. ResultsT-275A promoter mutation was detected in 13% of patients and C-2152T in 12% of patients. Survival analysis was performed on 873 renal transplants, carried out between 2004 and 2013. We found a higher frequency of death from cancer among polymorphism carriers (P = .001). ConclusionsIt appears that carriers of T-275A and C-2152T SNPs of the UGT1A9 gene promoter region show a greater incidence of death from cancer, with a significantly higher cumulative incidence of death from gastrointestinal tumors.

OP.4D.08] DISORDERED SLEEP BREATHING (SDB) IS THE MAJOR DETERMINANT OF NON-DIPPING AND NOCTURNAL HYPERTENSION IN KIDNEY TRANSPLANT PATIENTS

Objective: In renal transplant patients, the prevalence of nocturnal hypertension by far exceeds that of hypertension as assessed by clinic, daytime, and average 24-hour ABPM and night-time systolic BP (SBP) and the night-day ratio but no other BP metrics are independently associated with IMT in this population (Transplantation 2015 Dec 17). BP during nighttime may provide information for the assessment of CV risk attributable to BP burden in renal transplant patients but the determinants of this phenomenon are still undefined in these patients. Design and method: We recorded 24h-ABPM and performed polysomnography in 215 clinically stable transplant patients. Major classical CV risk factors and CKD-specific risk factors (including phosphate, eGFR, proteinuria and C Reactive Protein) were measured alongside. Our primary goal was to identify the functional correlates of average BP during night-time and of the night/day ratio, a parameter quantifying the BP dipping phenomenon. Results: The Apnea-Hypopnea Index (AHI) exceeded 5 episodes/h in 56 patients and 15 episodes/h in 19. Thus, 17% of patients had mild-to-moderate SDB and 9% severe SDB. In unadjusted analyses, AHI was directly related with night-time SBP (r = 0.19, P = 0.005) and the night/day SBP ratio (r = 0.18, P = 0.01). AHI also associated with average 24h-SBP and DBP (both r = 0.14, P = 0.04). Furthermore, age, gender, BMI, diabetes, phosphate, C-Reactive Protein, and background CV comorbidities were all associated with AHI. In multiple regression analyses adjusting for these parameters as well as for average day-time SBP, Hb, and proteinuria, AHI remained related with average night-time SBP (beta = 0.10, P = 0.02) and with the night/day SBP ratio (beta = 0.17, P = 0.02). In these models, the AHI ranked as the strongest correlate of nigh-time SBP burden. These results did not change also forcing into the model immunosuppressive treatment. Conclusions: In stable transplant patients, sleep disordered breathing is the most powerful functional correlate of nocturnal BP. These relationships are independent of age and comorbidities, eGFR and proteinuria and likely represents irreversible effects of long-term past exposure to kidney failure on the central nervous system.

Humoral immunity in phenotypes of chronic lung allograft dysfunction: A broncho-alveolar lavage fluid analysis

BackgroundRecently, antibody mediated rejection (AMR) has been associated with a higher incidence of chronic lung allograft dysfunction (CLAD) and mortality after lung transplantation (LTx). We investigated markers related to AMR and matrix remodeling in CLAD, with special attention for its two phenotypes being bronchiolitis obliterans syndrome (BOS) and restrictive CLAD (rCLAD). MethodsImmunoglobulins (IgA, IgE, IgG1–IgG4, total IgG and IgM) and complement (C4d and C1q) were quantified in lung lavage samples at the moment of BOS (n=15) or RAS (n=16) diagnosis; and were compared to stable transplant patients who served as control (n=14). Also, airway remodeling and metalloproteinases (MMPs) were investigated via zymography and gelatin degradation. The presence of DSA was additionally assessed in blood. ResultsTotal IgG, IgG1-IgG4 and IgM were increased in rCLAD versus control (p<0.001) and BOS patients (p<0.01). IgA and IgE were increased in rCLAD compared to control (respectively p<0.05 and p<0.01), but not to BOS. Total IgG and IgE were increased in BOS versus control (respectively p<0.01 and p<0.05). Complement proteins were exclusively present in rCLAD and correlated positively with immunoglobulins. Additionally, in blood, DSA were more present in rCLAD (p=0.041). MMP-9 levels increased in RAS and BOS versus control (p<0.001) and MMP-9 induced gelatin degradation was only increased in BOS compared to control (p<0.01). ConclusionWe demonstrated increased levels of immunoglobulins and complement proteins dominantly present in rCLAD. This leads to the belief that antibodies and AMR might play a more important role in rCLAD compared to BOS. Therefore, anti B-cell therapy could offer beneficial therapeutic effects in patients diagnosed with rCLAD, which needs further research.

Immunologic evaluation of the endometrium with a levonorgestrel intrauterine device in solid organ transplant women and healthy controls

ObjectiveThe objective was to describe the endometrial milieu of stable transplant patients and healthy women before and after levonorgestrel intrauterine system (LNG-IUS) insertion. Study designWomen between 18 and 45 years of age desiring LNG-IUS insertion were enrolled with a 2:1 ratio of healthy to stable solid organ transplant patients. The first visit entailed a blood draw, uterine lavage and endometrial biopsy followed by LNG-IUS insertion. Follow-up visit involved a repeat serum draw, uterine lavage and endometrial biopsy. Cytokine levels were measured in the uterine lavage and serum by quantifying inflammatory biomarkers. Immunohistochemistry staining was performed on the endometrial tissue to measure macrophage levels. Statistical analysis included a nonparametric analysis that compared medians of the marker levels before and after intrauterine device (IUD) insertion within the group and between the two groups. ResultsSixteen participants completed the study: 5 solid organ transplant patients and 11 healthy patients. For the serum, there were no marked changes in the cytokines or soluble receptor levels in either group after IUD insertion. However, in the uterine lavage, there was an increase in cytokine levels post-IUD insertion for both healthy and transplant women. For the endometrial tissue, there was evidence of macrophage activity in both groups after device insertion. ConclusionsThis pilot study investigated the uterine environment of the transplant patient population. Findings have pointed to the strong local inflammatory response following LNG-IUS insertion for the transplant recipients. In addition, these preliminary findings will help power a larger study that can investigate the safety and effectiveness of the IUD in this patient population. ImplicationsFindings from this pilot study suggest that the IUD is inducing a local inflammatory reaction in the uterus of the transplant patient as in the healthy control. A larger study can build on these preliminary results to pursue the efficacy and safety of IUD use among solid organ transplant patients.

Serum MicroRNA-99a Helps Detect Acute Rejection in Renal Transplantation

BackgroundMicroRNAs (miRNAs) are short, single-stranded, non-coding RNAs, and they are becoming increasingly known as potential biomarkers for a variety of pathologies. However, the significance of circulating miRNAs in renal transplantation patients needs further studies. Materials and MethodsAn miRNA array was used to profile the serum miRNAs of stable transplantation patients and transplantation patients with acute rejection (AR). We performed quantitative real-time polymerase chain reaction with the serum samples from 12 patients with AR, 11 control transplantation patients without rejection, and 15 transplantation patients with delayed graft function (DGF) for validation. Receiver operator characteristic analysis was used to assess the diagnostic capacity of serum miRNA. ResultsThe miR-99a, miR-100, miR-151a, let-7a, let-7c, and let-7f were deregulated in the serum of the patients with AR. In the validation set, only miR-99a and miR-100 were upregulated in the AR group. We further evaluated the expression levels of miR-99a and miR-100 in the DGF group. Only miR-99a was observed with the potent diagnostic value in discriminating AR patients from stable patients (area under the curve [AUC] = 0.750, 95% confidence interval [CI] = 0.529–0.971, P = .042) and DGF patients (AUC = 0.811, 95% CI = 0.600–1.000, P = .006). ConclusionSerum miR-99a may serve as a biomarker of AR in renal transplantation patients. Further studies are required to confirm the results.

Prophylactic platelet transfusions: should they be a treatment of the past?

For decades, prophylactic platelet transfusions have been a standard practice for treatment-related thrombocytopenia in patients with hematologic malignancies, although evidence supporting this practice was limited. Two recent randomized controlled studies were carried out to challenge this practice by comparing prophylactic to therapeutic-only platelet transfusion strategies. This review compares and contrasts the study findings to provide further insight into the study conclusions and their application to practice. Past studies exploring platelet transfusion in this patient population focused on identifying the optimal platelet threshold for transfusions and the minimum effective dose to achieve hemostasis. Balancing increased demand with limited supply has further necessitated determining if a therapeutic-only approach is as efficacious. This is especially pertinent given improved prognosis of hematologic malignancies because of novel therapies and better diagnostic technologies. Two large randomized controlled studies showed that therapeutic-only strategy reduces platelet utilization, but possibly at an increased risk of high-grade bleeding in certain patient groups. The majority of this adult patient population should continue to receive prophylactic platelet transfusions to prevent high-grade bleeding. Stable autologous stem cell transplant patients appear to be at a lower risk of thrombocytopenia-related bleeding and are candidates for therapeutic-only platelet transfusions in expert centers with careful monitoring.

Loss of glucocorticoid receptor from pro-inflammatory T cells after lung transplant

Pro-inflammatory cytokines in T and natural killer T (NKT)-like cells increase with time post-transplant in otherwise stable patients, suggesting that some patients become relatively resistant to immunosuppressants such as glucocorticoids (GC). We hypothesized that GC receptor (GCR) would be down-regulated in peripheral blood pro-inflammatory T and NKT-like cells after lung transplantation and loss of GCR would correlate with time post-transplant. Blood was collected from 17 stable lung transplant patients and 17 healthy, aged-matched controls. Intracellular GCR expression and pro-inflammatory cytokines were determined using flow cytometry. There was a loss of GCR in CD8(+) and CD8(-) T and NKT-like cells in transplant patients compared with control subjects (transplants 37 ± 9%, controls 47 ± 12%; GCR(+)CD8(+) and CD8(-) T cells: transplants 39 ± 13%, controls 58 ± 13%). Loss of GCR was associated with a greater percentage of T cells producing interferon-gamma (IFN-γ) and tumor necrosis factor-alpha (TNF-α) but not NKT-like cells. There was a correlation between the percentage of GCR-negative T cells with months post-transplant (R = 0.519, p = 0.033) and dose of prednisolone (R = 0.775, p = 0.038). Time post-transplant and prednisolone dose correlate with loss of GCR in pro-inflammatory T cells in stable transplant patients, suggesting the need for reassessment of the long-term use of steroids after lung transplant in view of their attendant significant side effects.

Refrigerated Platelets for the Treatment of Acute Bleeding

This review is a synopsis of the decisions that shaped global policy on platelet (PLT) storage temperature and a focused appraisal of the literature on which those discussions were based. We hypothesize that choices were centered on optimization of preventive PLT transfusion strategies, possibly to the detriment of the therapeutic needs of acutely bleeding patients. Refrigerated PLTs are a better hemostatic product, and they are safer in that they are less prone to bacterial contamination. They were abandoned during the 1970s because of the belief that clinically effective PLTs should both be hemostatically functional and survive in circulation for several days as indicated for prophylactic transfusion; however, clinical practice may be changing. Data from two randomized controlled trials bring into question the concept that stable autologous stem cell transplant patients with hypoproliferative thrombocytopenia should continue to receive prophylactic transfusions. At the same time, new findings regarding the efficacy of cold PLTs and their potential role in treating acute bleeding have revived the debate regarding optimal PLT storage temperature. In summary, a "one-size-fits-all" strategy for PLT storage may not be adequate, and a reexamination of whether cold-stored PLTs should be offered as a widely available therapeutic product may be indicated.

PD30-09 TRANSURETHRAL RESECTION OR INCISION OF THE PROSTATE AFTER RENAL TRANSPLANTATION: IS THERE A SAFE TIME FOR THE PROCEDURE?

improvements in graft survival following kidney transplantation. However, there are no non-invasive diagnostic parameters available that enable early and reliable detection of acute rejection. The objective of our study was to establish a urinary protein profile suitable to determine rejectionspecific changes following kidney transplantation and to predict early acute rejection at a postoperative stage. Furthermore, we focused on identification of candidate proteins for the use as biomarkers in clinical practice for diagnosis of acute rejection. METHODS: Urine samples of 116 kidney recipients were included. Rejection was proven by biopsy (n1⁄458) and stable transplant function was monitored for at least 2 years (n1⁄458). Postoperative urine samples were collected between 3rd and 10th day following transplantation. Urinary protein profiles were analyzed by SELDI-TOF-MS. Multiplex-Fluorescence-2DE and Peptide Mass Fingerprinting were used for identification of candidate proteins. Urinary concentration of candidate proteins was validated by ELISA. RESULTS: A protein signature including 4 masses differentiated acute rejection from stable transplant patients at the postoperative stage with 73% sensitivity and 88% specificity. Alpha-1-microglobulin (A1MG) and Haptoglobin (Hp) were identified as putative biomarkers for acute rejection. Protein levels were significantly higher in postoperative urine samples from patients with upcoming rejection than in stable transplant patients (A1MG: 29.13 mg/ml vs. 22.06 mg/ml, p1⁄40.001; Hp: 628.34 ng/ml vs. 248.57 ng/ml, p1⁄40.003). The combination of both proteins enabled the diagnosis of early rejection with 85% sensitivity and 80% specificity. CONCLUSIONS: Protein profiling using mass spectrometry is suitable for non-invasive detection of rejection-specific changes following kidney transplantation. A specific protein profile enables prediction of early acute allograft rejection in the immediate postoperative period. A1MG and Hp appear to be reliable rejection biomarkers. Further analyses have to show if early diagnosis is possible for patients with allograft rejection that occurs several month after transplantation by analyzing changes in urine protein pattern in regular intervals.