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Aim Cyclosporine (CsA), dosed to achieve C2 targets, has been shown to provide safe and efficacious immunosuppression when used with a mycophenolate and steroids for de novo kidney transplant recipients. This study examined whether use of enteric-coated mycophenolate sodium (EC-MPS) together with basiliximab and steroids would enable use of CsA dosed to reduced C2 targets in order to achieve improved graft function. Methods Twelve-month, prospective, randomized, open-label trial in de novo kidney transplant recipients in Australia. Seventy-five patients were randomized to receive either usual exposure (n = 33) or reduced exposure (n = 42) CsA, EC-MPS 720 mg twice daily, basiliximab and corticosteroids. Results There was no significant difference in mean Cockcroft-Gault CrCl (creatinine clearance) (60.2 ± 17.6 mL/min per 1.73 m2 vs 63.2 ± 24.3, P = 0.64 for usual versus reduced exposure respectively) at 6 months. There was no significant difference between treatment groups in the incidence of treatment failure defined as biopsy proven acute rejection, graft loss or death (secondary endpoint: 30.3% full exposure vs 35.7% reduced exposure). At 12 months the incidence of overall adverse events was the same in both groups. Conclusion This exploratory study suggests de novo renal transplant patients can safely receive a treatment regimen of either full or reduced exposure CsA in combination with EC-MPS, corticosteroids and basiliximab, with no apparent difference in efficacy or graft function during the first year after transplant.

SUMMARY: The enzyme 11β hydroxysteroid dehydrogenase type 2 (11βHSD2) converts glucocorticoids to their 11-keto metabolites, permitting binding of aldosterone to the non-selective mineralocorticoid receptor. Recent studies have suggested that 11βHSD deficiency may be implicated in essential hypertension and renal disease. Using an antibody against a peptide deduced from the cDNA sequence, the renal expression of 11βHSD2 was examined in patients with advanced stages of renal disease and associated hypertension, patients with primary hypertension resulting in renal damage, and patients with preserved or mildly damaged renal architecture without concomitant hypertension. Despite variable degrees of tubulointerstitial damage, 11βHSD2 was expressed in distal convoluted tubules and collecting ducts in all patient groups. Collapsed tubules retained strong immunoreactivity, but decreased staining was apparent in dilated tubules. There was weak staining of the thick ascending limb of Henle. Variable glomerular expression of 11βHSD2 was observed. Our results therefore suggest that absence of renal 11βHSD2 is not a prominent feature of hypertensive nephrosclerosis, or primary renal disease associated with hypertension.

Investigation into the contribution of the immune system and inflammatory cascade to acute rejection (AR) and cardiac allograft vasculopathy (CAV) has implicated vascular endothelial growth factor (VEGF). The endomyocardial biopsy (EB) has proved invaluable in the diagnosis of AR, and in providing information concerning the biological processes occurring following transplantation. The association between VEGF and AR and the development of CAV was examined in endomyocardial biopsies (EBs) from a cohort of 76 heart transplant recipients. VEGF mRNA levels were quantified through real time RT-PCR in 712 EBs, obtained at routine intervals during post-operative monitoring. VEGF and leukocyte and endothelial markers were assessed in a subset of biopsies through immunohistochemistry. The results of generalised linear modelling, adjusting for covariates, revealed VEGF mRNA expression was 19% greater during severe AR as compared to no rejection (p=0.007). Immunohistochemical results supported these findings. Mean VEGF mRNA levels were not significant predictors for the development of CAV (p=0.554). However the risk of cardiac related death increased 9-fold for a 1 unit increase in mean VEGF expression (p=0.006). Similarly, a single unit increase in mean AR severity equated to a 10-fold increase in the risk of cardiac related death (p0.005). Our data suggest that increased VEGF expression is strongly associated with severe AR and cardiac related death.

Chronic renal disease is characterized by declining renal function, loss of intrinsic renal cells, and their replacement with fibrotic tissue. This study investigates apoptosis and its regulation in the context of chronic renal disease. RNA was extracted from renal biopsies from patients with various forms of chronic renal disease. Expression of genes of the Bcl-2 family, death receptor pathway, and growth factors were measured by reverse-transcription real-time polymerase chain reaction. Apoptosis was detected by the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end-labeling technique. Tubulointerstitial apoptosis was positively associated with tubulointerstitial injury and renal dysfunction and increased 2.3-fold per unit (U) increase in transforming growth factor beta(1) (TGFbeta(1)) mRNA (P0.05). Conversely, a 1 U increase in epidermal growth factor (EGF) mRNA was associated with a 47% decrease in tubulointerstitial apoptosis (P0.05). Tubulointerstitial injury was correlated with increased TGFbeta(1) and tumour necrosis factor alpha (TNFalpha) mRNA (P0.005) and decreased EGF mRNA (P0.05). Additionally, for a 10 U decrease in the glomerular filtration rate there was an estimated increase of 5 and 10% in TGFbeta(1) and TNFalpha mRNA, respectively (P0.05), whereas EGF mRNA decreased by an estimated 15% (P0.005). Therefore dysregulation of cytokine/growth factor expression plays a central role in the progression of chronic renal disease through contribution to renal cell loss, tubulointerstitial injury, and renal dysfunction.

Background Survival after lung transplantation has improved, but with the consequence that long-term toxicities of treatment are of growing importance. In particular, renal impairment is common, has many causes, and carries with it increased morbidity and mortality. Methods We retrospectively analyzed clinical and laboratory data of 136 patients who underwent lung and heart–lung transplantation at our institution between 1990 and 2004 inclusive. Using multivariate analysis we considered the impact of age, gender, pulmonary diagnosis, transplant type (single lung, double lung, heart–lung), hypertension, diabetes mellitus, cigarette smoking, current immunosuppression, duration of calcineurin inhibitor (CNI) exposure and pre-existing renal impairment on renal function. Results At transplantation, creatinine clearance (CrCl) for the patient population was 108 ± 3.28 (mean ± SEM) ml/min/1.73 m2. At end of follow-up (6 ± 0.32 years) there was a significant decline in glomerular filtration rate (GFR) to 56.7 ± 1.78 ml/min/1.73 m2 (p < 0.001). Five of 136 patients (3.7%) developed end-stage renal failure (ESRF). On multivariate analysis, factors most strongly associated with this decline included (in order of significance): CrCl at transplantation; pack-years of cigarette smoking; exposure to sirolimus (SLM); CNI exposure; and age at transplantation. The rate of decline in GFR was linked to CrCl and age at the time of transplantation. Conclusions This analysis has demonstrated that patients with a lower baseline CrCl, older age at transplantation, and a smoking history are at high risk for rapid loss of renal function after transplantation. To best preserve kidney function, these patients should be targeted for aggressive risk factor modification as well as minimization of CNI exposure wherever possible.

Background/Aims: Despite the cystic fibrosis gene product, the cystic fibrosis transmembrane conductance regulator, being widely expressed throughout the kidney, there is no clearly defined renal phenotype in patients with cystic fibrosis. As patients with cystic fibrosis survive longer progressive pancreatic destruction may lead to abnormal glucose tolerance and diabetes mellitus, which in the kidney may be associated with the characteristic changes of nodular glomerulosclerosis. Methods: The adult cystic fibrosis service at the Alfred hospital consists of a cohort of 200 patients. We describe 3 cystic fibrosis patients with impaired renal function who had renal biopsies performed as part of their diagnostic work-up. All patients had fasting plasma glucose levels, oral glucose tolerance tests and measurements of HbA1c performed to assess for the presence of cystic fibrosis-related diabetes mellitus. Results: The renal biopsies of all 3 patients showed histological changes characteristic of diabetic nephropathy. In all cases described characteristic Kimmelstiel-Wilson nodules were present. However, in all 3 patients the presence of impaired glucose tolerance and diabetes mellitus was excluded using standard biochemical diagnostic criteria. Conclusion: We describe 3 adult CF patients, who on renal biopsy had histological evidence of nodular glomerulosclerosis in the absence of abnormal glucose metabolism. We speculate that the pro-inflammatory cytokine profile, typical of cystic fibrosis, predisposes to the lesions described.

SUMMARY: Background and Aim: Tubular atrophy is a major feature of most renal diseases and is closely associated with the loss of renal function. The present study sought to investigate whether Fas/FasL-induced tubular epithelial cell apoptosis was a feature of experimental diabetic nephropathy. The effects of renoprotective therapy with blockade of the renin-angiotensin (RAS) system were also examined. Method: Six-week-old female Ren-2 rats were injected with streptozotocin and maintained diabetic for 12 weeks. Further groups of diabetic rats were treated with the angiotensin-converting enzyme inhibitor, perindopril, for 12 weeks. Results: Widespread apoptosis, identified by using mediated Terminal dUTP nick-end labelling (TUNEL) staining was noted in the tubules of diabetic Ren-2 rats. These changes were associated with an increase in both Fas mRNA and Fas L (ligand) within the tubules (P

Nicolaides-Baraitser syndrome (NCBRS) is an intellectual disability (ID)/multiple congenital anomalies syndrome caused by non-truncating mutations in the ATPase region of SMARCA2, which codes for one of the two alternative catalytic subunits of the BAF chromatin remodeling complex. We analyzed 61 molecularly confirmed cases, including all previously reported patients (n = 47) and 14 additional unpublished individuals. NCBRS is clinically and genetically homogeneous. The cardinal features (ID, short stature, microcephaly, typical face, sparse hair, brachydactyly, prominent interphalangeal joints, behavioral problems and seizures), are almost universally present. There is variability however, as ID can range from severe to mild, and sparse hair may be present only in certain age groups. There may be a correlation between the severity of the ID and presence of seizures, absent speech, short stature and microcephaly. SMARCA2 mutations causing NCBRS are likely to act through a dominant-negative effect. There may be some genotype-phenotype correlations (mutations at domain VI with severe ID and seizures; mutations affecting residues Pro883, Leu946, and Ala1201 with mild phenotypes) but numbers are still too small to draw definitive conclusions.

The purpose of this study was to investigate the antitumor effects of a combination of metronomic doses of a novel delivery vehicle, PLGA-PRINT nanoparticles containing docetaxel, and anti-angiogenic mEZH2 siRNA incorporated into chitosan nanoparticles. In vivo dose-finding studies and therapeutic experiments were conducted in well-established orthotopic mouse models of epithelial ovarian cancer. Antitumor effects were determined on the basis of reduction in mean tumor weight and number of metastatic tumor nodules in the animals. The tumor tissues from these in vivo studies were stained to evaluate the proliferation index (Ki67), apoptosis index (cleaved caspase 3), and microvessel density (CD31). The lowest dose of metronomic regimen (0.5 mg/kg) resulted in significant reduction in tumor growth. The combination of PLGA-PRINT-docetaxel and CH-mEZH2 siRNA showed significant antitumor effects in the HeyA8 and SKOV3ip1 tumor models (p

Cyclosporine nephropathy (CyAN) is a major limiting factor in the otherwise successful widespread use of cyclosporine in solid organ transplant. Transforming growth factor-beta1 (TGF-beta1) has been implicated as an important fibrogenic cytokine in the development of this disease. TGF-beta-inducible gene-H3 (beta(ig)-H3) is a TGF-beta1- induced gene product, which acts as a marker for biologically active TGF-beta1. This study reports TGF-beta1 gene expression and beta(ig)-H3 tissue distribution in non-renal allograft CyAN. Renal tissue from nine patients who had developed CyAN after successful heart or heart-lung transplantation and from four kidneys removed for tumour were analyzed for TGF-beta1 gene expression beta(ig)-H3 protein with reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry, respectively. TGF-beta1 gene expression was increased in CyAN compared to nephrectomy (P

SUMMARY Platelet-derived growth factor (PDGF) is a pleiotropic cytokine synthesized by various resident renal cells and infiltrating cells. Its best-studied role in the kidney is in the mediation of glomerular mesangial cell proliferation. The relationship between expression of PDGFA, PDGFB and the receptor β (PDGFRβ) in human renal biopsies of immunoglobulin A nephropathy (IgAN), a disease characterized by mesangial cell proliferation, and thin membrane nephropathy (TMN), a non-proliferative glomerulopathy, was studied. Using competitive reverse transcriptase-polymerase chain reaction (RT-PCR), the quantity of mRNA molecules of each growth factor and the receptor was determined in renal biopsies from 20 patients with IgAN and 16 with TMN. In addition, eight nephrectomy samples with paired cortical and medullary samples were studied. There was no significant difference between the disease groups for PDGFA (TMN, 1409 ± 475 copy number/microgram RNA; IgAN, 691 ± 133, P = 0.35), PDGFB (TMN, 2280 ± 467; IgAN, 1465 ± 197, P = 0.10) or PDGFRβ (TMN, 1387 ± 273; IgAN, 1402 ± 344, P = 0.68). Analysis of nephrectomy samples showed higher constitutive expression of PDGFA and PDFGB in the medulla as compared with the cortex. However, further analysis of cortical samples in the IgAN group again failed to show a significant difference compared with TMN. We conclude that whole tissue analysis may have masked upregulation at glomerular level although it should reflect mRNA expression in the tubulointerstitial compartment.

Non-allogeneic factors such as increased nephron “workload” may contribute to chronic renal allograft rejection. Reducing dietary protein from 20 % to 8 % was tested in a model of chronic rejection: Dark Agouti kidney to Albino Surgery recipient, “tolerised” by previous donor blood transfusions. Survival, weight gain, serum creatinine concentration and creatinine clearance were similar for both groups at all times. Urinary protein was significantly (P < 0.05) lower in the low-protein (LP) group 1 month after transplantation. After 3 and 6 months, both groups demonstrated mild chronic rejection. After 6 months, tubular atrophy was significantly (P < 0.05) less in the LP group and interstitial fibrosis was marginally reduced. Glomerular hypertrophy, glomerular sclerosis, tubular dilatation, leucocyte infiltration, adhesion molecule expression and TGF-β1 mRNA expression were similarly increased in both groups. Thus, reducing dietary protein to 8 % lowered urinary protein, but did not significantly affect the development of chronic rejection in renal allografts beyond affording a degree of protection from tubulointerstitial damage.

Long-term survival of small bowel transplants ishampered by chronic rejection. Epidermal growth factor(EGF) and transforming growth factor β (TGF-β)have opposing, regulatory roles in normal intestinal physiology and may be involved in thepathogenesis of chronic intestinal rejection. Our aimwas to investigate the expression of EGF andTGF-β1 in chronically rejecting smallbowel transplants. Orthotopic small bowel transplantation was performed inthe allogeneic DA-to-AS rat combination; Cyclosporin wasadministered temporarily to prevent acute rejection.Controls were DA isografts and normal DA rats. PreproEGF and TGF-β1 geneexpression was evaluated by northern blot analysis ofthe ileum RNA and standardized againstglyceraldehyde-3-phosphate-dehydrogenase expression.Allografts demonstrated functional impairment and histological features of chronicrejection, whereas isografts appeared normal. Allograftsdemonstrated a significant reduction of EGF mRNA whencompared to DA isografts. No significant changes were detected in TGF-β1expression in either allogeneic or syngeneic grafts. Inconclusion, this study demonstrates reduced preproEGFand preserved TGF-β1 gene expression inchronically rejecting small bowel transplants.

Altered expression of fibrogenic growth factors in IgA nephropathy and focal and segmental glomerulosclerosis. The profile of fibrogenic growth factor expression was assessed in biopsies from 27 patients with IgA nephropathy (IgAN), 14 focal and segmental glomerulosclerosis (FSGS) patients and 8 controls, by immunohistochemistry. Increased platelet-derived growth factor (PDGF)-A and PDGF-B expression was detected in glomeruli and in vascular structures and collapsed tubules in the interstitium. Computer assisted image analysis demonstrated increased glomerular PDGF-A in IgAN (P < 0.05), but not FSGS patients, compared to controls, suggesting an association with mesangial proliferation. PDGF receptors were prominent in areas of mesangial expansion and intertubular fibrosis. Significant increases in interstitial PDGF Receptor β (PDGFR-β) were detected for both IgAN (P < 0.01) and FSGS (P < 0.05) patients. Interstitial PDGFR-β expression was significantly correlated to monocyte/macrophage infiltrate (P < 0.0001). Increased basic fibroblast growth factor (bFGF) expression was observed segmentally in glomeruli, and in areas of tubulointerstitial damage. Higher proportions of patients with FSGS than IgAN had elevated interstitial bFGF (P < 0.005) and PDGF, reflecting the more severe degree of vascular and tubulointerstitial injury in FSGS patients. This study demonstrates distinct patterns of fibrogenic growth factors in IgAN and FSGS, strongly associated with the severity and type of injury.

Factors involved in "operational" tolerance in animal models induced by recipient pre-treatment with donor-specific blood transfusion (DSBT) need elucidation. This study examined apoptosis, expression of genes of the Bcl-2 family and of TGF-β 1 in isografts, rejecting and tolerant allografts. Methods. Adult inbred Dark Agouti (DA) kidneys were transplanted, with immediate nephrectomy of recipient kidneys, to (1) ALLO, inbred Albino Surgery (AS) rats; (2) DSBT ALLO, AS rats who received two DA blood transfusions under cover of cyclosporine prior to transplantation; or (3) ISO, DA rats. Grafts were retrieved on day 1, 3, or 5. Apoptosis was assessed by TUNEL. RNA was extracted and reverse transcribed to cDNA for quantification by real-time PCR, relative to the 18s housekeeping gene. Results. Apoptosis was negligible in ISO while it increased in allograft groups from day 1. On day 5, apoptosis in ALLO (114.0 ′ 30.6), involved renal tubular cells and leukocytes compared to DSBT ALLO (9.7 ′ 4.0) and ISO (0.9 ′ 0.3) involving leukocytes only. On day 1, DSBT ALLO had higher expression of Bax than ALLO or ISO. On day 3, DSBT ALLO and ALLO had higher TGF-β 1 mRNA than ISO. On day 5, Bcl-2 expression was significantly decreased (P

Expression and distribution of epidermal growth factor in acute and chronic renal allograft rejection. Epidermal growth factor (EGF) is a fibrogenic cytokine with a possible role in chronic damage. EGF is also involved in tubular regenerative response to injury. This study investigates the expression and distribution of EGF in a rat model of renal allograft rejection. EGF was localised in control kidneys to distal convoluted tubules (DCT) and thick ascending loop of Henle (TAL). Five days post-transplantation EGF was diffusely distributed. In chronic rejection at one, three and six months, damaged areas of allografts demonstrated faint diffuse EGF staining, while well-preserved areas exhibited the normal distribution pattern. PreproEGF mRNA was significantly reduced (P < 0.01) in acute rejection and in chronic rejection at three months to 28% and 51% of normal, respectively. At six months values ranged from 16% to 166% of normal kidneys, and were inversely correlated with tubular damage (P < 0.01). PreproEGF mRNA was localized to DCT and TAL in controls and in well preserved areas of the tissue in chronic rejection. Thus, EGF would not appear to contribute to the development of injury in chronic renal rejection. It may instead exert a protective effect on tubular structures.

It has long been hypothesized that elastic modulus governs the biodistribution and circulation times of particles and cells in blood; however, this notion has never been rigorously tested. We synthesized hydrogel microparticles with tunable elasticity in the physiological range, which resemble red blood cells in size and shape, and tested their behavior in vivo. Decreasing the modulus of these particles altered their biodistribution properties, allowing them to bypass several organs, such as the lung, that entrapped their more rigid counterparts, resulting in increasingly longer circulation times well past those of conventional microparticles. An 8-fold decrease in hydrogel modulus correlated to a greater than 30-fold increase in the elimination phase half-life for these particles. These results demonstrate a critical design parameter for hydrogel microparticles.

A model of chronic renal rejection in the Dark-Agouti to Albino-Surgery rat combination is described. In a number of cases, the original allograft was replaced by a second Dark-Agouti allograft. Seventy-five percent of rats experienced early episodes of rejection that subsided spontaneously. Second allografts had better initial renal function. Variable degrees of tubular atrophy, interstitial fibrosis, vascular damage, glomerulosclerosis, deposition of humoral mediators, and mononuclear leukocyte infiltrate were observed in all long-term allografts. Chronic damage increased with time, and was less severe in second allografts. At 5 days, total interstitial infiltrate was similar to that seen in unmodified rejection, but there was a significant increase in CD4+ cells and a decrease in ED2 and IL-2R expression. Subsequently, the total interstitial infiltrate decreased with time, although it remained significantly higher than in isografts and residual kidneys from uninephrectomized rats. No significant decrease over time was seen in numbers of CD4+ and CD45RC+ cells. The latter had a marked focal distribution after 100 days. Total leukocyte infiltrate was similar in original and second allografts, but there were changes in the proportions of leukocyte subpopulations, including significantly lower numbers of CD45RC+ cells in the latter. The persistence of CD45RC+ cells throughout the course of chronic rejection and their lower numbers in the second allografts favors a role for these cells in the development of chronic injury. The model of chronic renal allograft rejection characterized in this study will be valuable in further studies of the mechanisms of injury in this pathology.

Continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis remains the most common complication of this form of renal replacement therapy and the potential causative organisms are many and varied. Campylobacter bacteria are unusual causes of peritonitis in CAPD patients and we report our experience with eight cases and review those cases reported in the literature. In many episodes, there is a strong association with acute enterocolitis, which may precede the onset of cloudy dialysate by many days. The method of spread of these organisms from the gastrointestinal tract to the peritoneal cavity remains speculative. Bacteremic transfer would appear the most likely route, although it is probable that no single mode of spread explains all episodes. The treatment of choice of Campylobacter peritonitis is with intraperitoneal aminoglycoside in combination with oral erythromycin. An awareness of the potential for Campylobacter to cause CAPD-associated peritonitis, particularly when diarrhea is a prominent feature, has resulted in this organism becoming increasingly isolated in our unit.