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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

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.

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.

Background. Improvements in cardiac transplant practice and immunosuppressive treatment have done much to curb the incidence of acute cellular rejection (ACR); however, antibody-mediated rejection (AMR) and cardiac allograft vasculopathy (CAV) remain prevalent. Recent studies have shown that allograft rejection is governed by both allogeneic and nonallogeneic factors such as inflammation. Initial studies have suggested that vascular endothelial growth factor (VEGF), a leukocyte mitogen produced by activated endothelial cells and leukocytes, may play a specific role in not only leukocyte trafficking, but also in the augmentation of ACR and development of CAV. Methods. We investigated the localization of VEGF protein using immunohistochemistry in a cohort of 76 heart transplant patients during periods of ACR and AMR and assessed the development of CAV. Results. We showed a significant correlation between lymphocytic localization of VEGF protein and severe ACR (P

Infiltration of the kidney is commonly found in lymphoma, but acute renal failure arising from bilateral renal infiltration is uncommon. Primary renal lymphoma may occur and is usually of B-cell lineage. It is rare for patients with lymphoma to develop acute renal failure as their initial clinical presentation. Recently, an association between primary renal lymphoma and a second primary malignancy has been reported. We describe the first case of a renal T-cell-rich B-cell lymphoma presenting as acute renal failure, which was associated with a second primary pulmonary malignancy.

Background. The induction of operational tolerance is the holy grail of clinical transplantation. However, in animal models with operational tolerance, long- term grafts still develop chronic damage. The elucidation of the impact of allogenic versus nonallogeneic factors in such a model is important. This study examined the effect of a clinically relevant combination of warm ischemia and cold preservation in the absence of allogeneic response (isografts) and in the context of operational tolerance. Methods. Dark Agouti (DA) rat kidneys were transplanted into DA recipients (isografts) or Albino Surgery recipients (allografts) tolerized by two transfusions of DA blood, under cover of cyclosporin A. Grafts were subjected to minimal cold preservation or to 30 mins warm ischemia followed by 24 hrs cold preservation. Results. After an initial peak of renal dysfunction, serum creatinine concentration returned to normal in isografts and nonischemic allografts, but remained significantly elevated in ischemic allografts (P

The increasing array of strategies and models for improving clinical practice and patient outcomes can be confusing for clinicians. The Clinical Support Systems (CSS) model has proved to be effective in local environments because it demystifies the design and implementation of evidence-based practice improvement projects. The CSS model is simple and has a wide scope. It provides a broad framework with minimalist specifications, enabling clinicians to design their own systems of care that cut across fragmented organisational structures. Implementing simple rules can be an effective strategy for change in complex care systems. These rules do not impose solutions on clinicians, but rather, help them to find creative solutions that have meaning for them and are contextually relevant.

Background The pathogenetic mechanisms responsible for progressive renal impairment of diabetic nephropathy are still poorly understood, despite its growing incidence. Increasing evidence suggests that growth factors may contribute to the initiation and progressive fibrosis of diabetic nephropathy. In this study, the gene expression and protein distribution of platelet-derived growth factor-A and -B (PDGF-A and PDGF-B) in human diabetic nephropathy were examined. Methods PDGF-A and PDGF-B mRNA levels in surplus renal biopsy tissue from seven patients with overt diabetic nephropathy and six nephrectomy samples were examined using quantitative reverse transcription-polymerase chain reaction (RT-PCR). In addition, each sample was also examined immunohistochemically to quantify and localize peptide expression of each PDGF isoform. Results Gene expression of PDGF-A and PDGF-B mRNA were increased 22- and 6-fold, respectively, in biopsies from patients with diabetic nephropathy compared with control tissue. Immunostaining also demonstrated increased peptide expression of both PDGF-A and PDGF-B in diabetic nephropathy, with each isoform showing a specific pattern of tissue distribution. Conclusions The findings of increased gene and protein expression of PDGF in renal biopsies from patients with diabetic nephropathy imply a potential role for this prosclerotic growth factor in the development of the progressive fibrosis that characterizes human diabetic kidney disease.

AIMS/HYPOTHESIS: Proteinuria, reflecting increased glomerular permeability to macromolecules is a characteristic feature of diabetic nephropathy. Nephrin, a 1241-residue transmembrane protein is a key component of the podocyte slit pore membrane and a major contributor of the glomerular filtration barrier. We investigated the expression of nephrin in human kidney tissue from patients with diabetic nephropathy to elucidate its relationship with proteinuria and the effects of anti-proteinuric therapy with angiotensin converting enzyme inhibition. METHODS: Renal biopsies were examined from 14 patients with Type II (non-insulin-dependent) diabetes mellitus and proteinuria who had been randomised to receive treatment with the ACE inhibitor, perindopril (4 mg/day) or placebo for the preceding 2 years. These specimens were compared with control human tissue sections, obtained from areas of normal renal cortex following nephrectomy for malignancy. Proteinuria was measured, specimens were examined histologically for injury and the expression of nephrin messenger RNA was assessed by quantitative in situ hybridisation. RESULTS: Glomeruli from placebo-treated patients with diabetic nephropathy, showed a 62% reduction in nephrin expression compared with control subjects (p=0.0003). In contrast, nephrin RNA in glomeruli from perindopril treated patients was similar to that in the non-diabetic control group. In both placebo and perindopril treated patients, a close inverse correlation was noted between the magnitude of nephrin gene expression and the degree of proteinuria (placebo: r=0.86, p=0.013, perindopril: r=0.91, p=0.004). CONCLUSION/INTERPRETATION: Modulation in nephrin expression is related to the extent of proteinuria in diabetic nephropathy. These changes define, at a molecular level alterations in the glomerulus that occur in relation to proteinuria in diabetes and the effects of anti-proteinuric treatment with ACE inhibition.

The purpose of this study was to investigate signaling and regulatory mechanisms of apoptosis in a model of focal and segmental glomerulosclerosis. Sprague-Dawley rats received two doses of puromycin aminonucleoside (PAN) (day 0 and week 3) and a uninephrectomy (PAN model). Apoptosis was detected with the use of the terminal deoxynucleotidyl transferase mediated dUTP nick end labeling technique. Bax, Bcl-2, Fas, and Fas ligand expression was analyzed by competitive reverse transcription-PCR. Bax, Bcl-2, and Fas mRNA were localized by in situ hybridization. Renal function was transiently impaired after the first PAN dose. After the second PAN dose, further progressive renal impairment, tubular atrophy, interstitial fibrosis, and glomerulosclerosis were evident. Eighteen percent of PAN samples demonstrated up to 4 apoptotic cells/50 glomeruli, compared with 7% of sham controls (not significant). No consistent significant change in glomerular Bax, Bcl-2, Fas, and Fas ligand mRNA was evident by reverse transcription-PCR, although focal increases in glomerular Bcl-2 mRNA were demonstrated by in situ hybridization. In the tubulointerstitium, apoptosis was increased from weeks 1 to 12 (P < 0.01 PAN versus sham), correlated to renal function and tubulointerstitial injury (P < 0.01). Total renal Bax, Fas, and Fas ligand mRNA were upregulated in the PAN model, peaking at week 17 (P < 0.01 versus sham), whereas Bcl-2 mRNA was not significantly different in PAN versus sham controls. In situ hybridization in the PAN model demonstrated prominent Bax mRNA in dilated tubules and infiltrating leukocytes. Fas mRNA signal was localized to tubular epithelial cells and leukocytes. The results suggest that altered apoptotic signaling and regulatory mechanisms contribute to the tubulointerstitial injury in this model.

Our aim was to develop a model of chronic rejection (CR) in small bowel allografts, and to study the changes occurring in these grafts. Small bowel transplantation was performed using the DA to AS rat strain combination. Short-term (5 mg/kg intramuscular, from days -2 to +9), or long-term cyclosporin treatment (5 mg/kg, 3 times a week until day 50) was given to prevent acute rejection. Controls were untreated allografts, DA isografts with and without cyclosporin, and normal DA and AS rats. They were followed for 50 and 100 days after transplantation. Recipients of a syngeneic graft lost weight during the first week after transplantation, but started to regain weight and kept growing thereafter. Histology showed normal bowel architecture with normal mesenteric lymph nodes and Peyers patches. Vigorous acute rejection occurred in the untreated allografts. Animals had persistent weight loss, and were killed between 6-13 days after transplantation. No clinical signs of graft-versus-host disease were seen. Histology showed end-stage acute rejection. In both cyclosporin-treated allografted groups the postoperative course was as in the isografted animals. However, all animals had histologic signs of CR by 50 and 100 days after transplantation. Changes were most prominent in the mesentery. Serositis with increased vascularity, inflammation with sclerosis, and patchy myointimal proliferation with endothelialitis of the mesenteric vessels were found. Changes in the bowel were patchy and included some thickening of the muscle coat, crypt hyperplasia, scattered necrotic cells in the crypts, slight blunting of villi and loss of goblet cells. Infiltrating cells in the mesentery and bowel consisted mainly of CD 4+ cells, CD 8- T-cells and monocytes/macrophages. Lactulose-mannitol urinary excretion ratio was significantly increased in short-term cyclosporin treated allografts at days 50 and 100 posttransplant. Serum albumin levels were significantly lowered in this group at both time points examined. We developed two models in which CR occurs after small bowel transplantation. Long-term cyclosporin treatment delayed the development of CR, since functional abnormalities were only seen in the animals that were treated with short-term cyclosporin.

Long-term survival of intestinal transplants is hampered by chronic rejection (CR). Since transplants with CR demonstrate fibrotic changes, the cytokine basic fibroblast growth factor (bFGF) may be involved in the tissue remodelling of chronic intestinal rejection. The aim of this study was to investigate the bFGF gene and protein expression and distribution in chronically rejecting intestinal allografts. Orthotopic small bowel transplantation was performed in the allogeneic DA-to-AS rat combination. Cyclosporin was administered temporarily to prevent acute rejection. Controls were DA isografts and normal DA. bFGF gene expression was evaluated using reverse transcriptase polymerase chain reaction (RT-PCR) of the ileum RNA and was standardized against Glyceraldehyde-3-phosphate-dehydrogenase (GAP-DH) expression. bFGF protein was determined using immunohistochemistry. To identify the bFGF-positive cell type, sequential sections were stained for cell markers. Allografts showed histological features of CR, whereas isografts preserved normal architecture. bFGF gene expression was present in normal ileum and significantly upregulated in allografts. Immunohistochemical staining showed a significant increase in bFGF protein compared to isografts. Most bFGF-positive cells were localized in the submucosa and muscularis, particularly around the neural plexus. bFGF-positive cells appeared to be ED-2-positive macrophages, strongly suggesting that the site of bFGF production is the activated macrophage. This study demonstrates increased bFGF mRNA and protein in chronically rejecting intestinal allografts that appear to be produced by macrophages.

In the development of a reliable model for chronic rejection in rat renal allografts, the effect of modifying the ureteric anastomosis was tested. Rats, tolerized by pretreatment with two donor blood transfusions under Cyclosporin A, received renal allografts with either sewn or stented ureter. Control groups received isografts or underwent uninephrectomy with insertion of ureteric stents. For the first 6 days after transplantation, serum creatinine and urea values were lower in allograft recipients with stented ureters than in the group with sewn ureters. The method of ureteric anastomosis did not affect the long-term incidence of abnormal function. Allograft morphology was extremely variable from minor to extensive tubular atrophy, interstitial fibrosis, glomerular hypertrophy, focal and segmental glomerulosclerosis as well as vascular changes. Glomerulosclerosis was absent in controls and increased with time in the allografts. Two hundred days after transplantation all allograft recipients with sewn ureters exhibited some glomerulosclerosis, in half of these kidneys more than 25% of glomeruli were affected. Only 33% recipients of allografts with stented ureters exhibited some glomerulosclerosis and less than 20% of glomeruli were affected. The stented ureteric anastomosis provides a reliable method, a reduction of the technical failure rate, a reduction of the incidence of hydronephrosis, allows more accurate assessment of early renal function and may be of importance in reducing the occurrence and prevalence of glomerulosclerosis in the long-term allografts.

The high rates of drug-induced acute renal failure, worsening chronic renal dysfunction and systemic toxicity of renally excreted drugs in the elderly can be minimised by carefully assessing renal function, avoiding potentially nephrotoxic drugs as much as possible and closely monitoring drug concentrations and renal function when they must be used. The co-existence of impaired renal function, degenerative vascular disease or cardiac failure in the elderly substantially increases the risk of renal toxicity. When in doubt about potential nephrotoxicity or an increased risk of systemic toxicity from renally excreted drugs in the elderly, the practitioner should consult the numerous published guidelines.

A reproducible animal model is essential for the study of the pathogenesis of chronic rejection. This study investigates: (i) the optimal pre-transplant blood transfusion conditions to induce tolerance in a strongly rejecting rat kidney allograft model (Dark Agouti to Albino-Surgery) and avoiding post-transplant immunosuppression; (ii) the functional and histological changes that occur in long-term surviving kidneys and their similarity to chronic rejection; and (iii) the maintenance of tolerance. Prolonged survival occurred after administration of at least two donor blood transfusions with concomitant cyclosporin A (5 mg/kg per day). The time-span between transfusions appeared to be critical: 4 days was more effective than 2 or 7 days. Ineffective treatment led to death within the first 2 weeks post-transplant with histological evidence of acute graft rejection. Seventy-five per cent of long-term survivors experienced impaired renal function in the first week which improved spontaneously and remained stable in 93% of the surviving animals after 100 days and in 66% after 200 days. The morphology of long-term allografts was extremely variable from minor to extensive tubular atrophy, interstitial fibrosis, glomerular hypertrophy, focal and segmental glomerulosclerosis and vascular changes. Glomerular hypertrophy occurred in uninephrectomized controls and probably denoted a response to uninephrectomy. Glomerulosclerosis increased with time and was absent in controls. Although chronic damage was evident, the rats remained tolerant to fresh donor skin. Replacement of the original kidney allograft with a fresh donor kidney resulted in 70% survival. These second grafts showed less severe renal dysfunction and morphological damage than the original allografts in the long-term follow up.

The aim of this study was to assess the prevalence of human papillomavirus (HPV) DNA in women who had received a renal transplant and to compare this with two control groups. Women who had a functioning renal transplant for greater than 6 months (n = 69) were compared with women on maintenance dialysis (n = 89) and women with impaired renal function (creatinine 0.15-0.39 mmol/l) (n = 22). Women were excluded if they had had a hysterectomy, were older than 65 years, or were not yet sexually active. A questionnaire and cervical scrape were obtained from each participant. The cervical scrape was analysed for HPV DNA using PCR and the L1 consensus primers. The participation rate of transplant patients, dialysis patients and those with impaired renal function ('normal' group) was 69, 68, and 78% respectively. The characteristics of the three groups of women at enrollment were similar. No cytological abnormalities were present in the 'normal' population but 11 of 89 patients on maintenance dialysis and nine of 69 transplant patients had cytological abnormalities of atypia or greater (P = 0.08 and P = 0.07, for 'normal' compared to dialysis and transplant groups respectively). One (4.5%) of the 'normal' women had evidence of HPV DNA, while 18 (20%) of patients on maintenance dialysis and 15 (22%) of transplant patients were positive (P = 0.07 and P = 0.05, for 'normal' compared to dialysis and transplant groups respectively). This study suggests that not only transplant recipients but also dialysis patients may have a higher prevalence of risk factors (cytological abnormalities and HPV DNA) for the development of cervical cancer.

Fibrin deposition is a common accompaniment of renal allograft rejection, indicating disruption of the normal physiologic balance between procoagulant and anticoagulant pathways. In vitro, tumor necrosis factor (TNF) induces endothelial expression of the procoagulant, tissue factor, and downregulation of thrombomodulin, a key component of the thrombomodulin/protein C (PC)/protein S (PS) pathway, which normally maintains an anticoagulant state by inactivating thrombin, preventing further thrombin formation by degrading factors Va and VIIIa, and decreasing plasminogen activator inhibitor activity. Raised levels of TNF were recently demonstrated within the blood of patients during episodes of renal allograft injection, and may be an early and discriminatory marker of rejection. This led us to investigate prospectively whether monitoring of serum TNF levels was of value clinically, and was associated with effects on circulating PC and PS levels, or alterations in intragraft thrombomodulin expression. Plasma samples (n = 454) were collected three times/week from all patients (n = 25) undergoing renal transplantation during a 9-month consecutive period, and assayed by ELISA and functional assays for TNF, PC, and free PS (FPS). Portions of renal biopsies, taken to evaluate episodes of acute deterioration of renal function, were evaluated by immunoperoxidase labeling for the presence and distribution of TNF, thrombomodulin, PC, PS, thrombin, fibrin, and factors V and VIII. Comparison of 78 plasma samples collected during 26 episodes of biopsy-proven acute cellular rejection with samples collected during periods of stable renal function (n = 349) showed that TNF levels rose significantly (390 +/- 242 pg/ml, p less than 0.01) above background levels 3 days before rising serum creatinine concentrations, and peaked (2,426 +/- 978 pg/ml) on the day of clinical rejection. PC-antigen (Ag) concentrations also decreased 3 days before rejection (68 +/- 13%, p less than 0.05), and were maximally depressed (49% +/- 16%, p less than 0.001) on the day of rejection. FPS levels were normal until the day before rejection (63% +/- 8%, p less than 0.01) and, like PC, were maximally depressed (43 +/- 10%) at rejection. Plasma TNF levels were significantly and inversely correlated with PC-Ag (p less than 0.001) and FPS (p less than 0.005) levels during rejection, regardless of whether such rejection episodes were steroid responsive or required OKT3 monoclonal antibody therapy. TNF, PC, and FPS levels were normal during episodes of cyclosporine toxicity and viral infection.(ABSTRACT TRUNCATED AT 400 WORDS)

There are no accurate noninvasive methods to distinguish renal allograft dysfunction due to rejection or cyclosporine nephrotoxicity. We have studied the value of Tc-99M-DTPA renal scanning in 90 episodes of renal allograft dysfunction occurring in 44 patients subjected to 57 renal biopsies in whom a clear diagnosis could be established. Renal scintigrams were assessed qualitatively and quantitatively by a blinded observer. Rejection was diagnosed when deterioration in perfusion occurred in the presence of maintained or declining radionuclide excretion. The diagnosis of cyclosporine nephrotoxicity was made by exclusion. The final diagnosis was based on the clinical response to therapy and/or the findings on renal biopsy. The scintigraphic diagnosis of rejection had a specificity of 87.9% and significantly contributed to the exclusion of cyclosporine nephrotoxicity (negative predictive value of 90.6%). Furthermore, a scintigraphic diagnosis compatible with cyclosporine nephrotoxicity, in the presence of a drug level above the therapeutic range, indicated a 90.4% probability of true nephrotoxicity. We conclude that, even in cyclosporine-treated renal transplant patients, Tc-99M-DTPA scintigraphy is of clinical value and can be incorporated into an effective diagnostic algorithm for allograft dysfunction.

The body composition of 62 haemodialysis patients (41 males) and 63 controls (30 males) was assessed using anthropometry and in vivo neutron activation analysis of body nitrogen. There was no significant difference between patients and controls in body mass index (BMI) and percentage body fat. Arm muscle circumference was significantly reduced in males. Lean body mass was strongly correlated with body nitrogen in controls (r = 0.951) but less so in patients (r = 0.876). The mean standardised body nitrogen index (NI) was reduced in male patients by 13% (95% confidence interval -9 to -17%) and in females by 4% (95% confidence interval +4 to -12%). Of the 16 patients with a NI below the control range, arm muscle circumference was below the control range in only 3 and BMI less than 18 kg/m2 in 2. NI was correlated negatively with the duration of renal replacement therapy, duration of haemodialysis, the number of previous failed transplants and the total dose of steroids received but not with current energy or protein intakes. Steroid dose was the only significant independent variable. Anthropometry underestimates body protein depletion in haemodialysis patients and the degree of protein loss is related to the cumulative dose of corticosteroids previously received.

On hundred and fifteen renal biopsies performed in 112 patients with mesangial IgA nephropathy were reviewed and the histological disease patterns correlated with the clinical features at the time of initial biopsy. To determine the significance of macroscopic haematuria in this disease, specific comparisons were made between patients with a history of episodes of macroscopic haematuria and those with only microscopic haematuria. The mean age at initial biopsy was 38.3 years (90 males, mean 40.3 years; 22 females, mean 30.2 years). Histological examination showed 9 patients (8%) with class I disease (mesangial matrix expansion alone); 43 patients (38%) with class II disease (diffuse mesangial proliferation); 60 patients (54%) with class III disease (focal and segmental proliferation), including subsets of 20 patients (16%) with segmental sclerosis and/or synechiae and 23 patients (21%) with crescent formation. Class III disease and crescent formation correlated with an increased frequency of capillary loop IgA and glomerular fibrin deposition and with the presence of subendothelial and subepithelial deposits. The degree of renal impairment and the incidence of hypertension were increased in class III disease. Macroscopic haematuria patients were younger (mean 31.1 vs. 43.0 years; p less than 0.001), had less severe renal impairment (mean creatinine 116.2 vs. 213.3 mumol/l; p less than 0.001) and less class III disease (48 vs. 58%; p less than 0.05). The incidence of crescentic disease was equal in macroscopic (17%) and microscopic (23%) haematuria. Eventual progression to end-stage renal failure occurred in 12 patients (11%) and correlated with crescentic disease, renal impairment, hypertension and heavy proteinuria at the time of diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Monoclonal antibodies and a four-layer immunoperoxidase technique were used to analyze and quantitate the various infiltrating cell types found in percutaneous renal biopsies of 25 patients undergoing acute renal allograft rejection. Cell markers included monoclonal antibodies to the human leukocyte-common antigen (PHM 1), mononuclear phagocytes (PHM 2, FMC 32), T cells and T cell subsets (OKT 3, OKT 4, and OKT 8), B cells (7.2), polymorphs (FMC 10, FMC 13), and plasma cells (OKT 10). The proportion of labelled interstitial cells was expressed as a percentage of the total number of infiltrating leukocytes identified with PHM 1, and correlated with the histologically graded intensity of rejection. In mild rejection 32% of the infiltrating cells were T lymphocytes, of which 90% were OKT-8-positive cytotoxic-suppressor cells, and 52% were macrophages. Similarly, in moderate rejection T cells composed 42% of the infiltrate (with 67% of T cells expressing OKT 8 antigen), and macrophages formed 38% of the total cells. By contrast, in severe rejection, the T cell component was decreased to 15% of the cells, of which 78% were OKT-8-positive; these were preponderantly macrophages (60%) and polymorphs (22%). These studies demonstrate that cytotoxic-suppressor T cells and macrophages are the major cells mediating acute interstitial graft rejection.

This paper is a study of 117 patients with endstage renal failure, treated by continuous ambulatory peritoneal dialysis (CAPD) over periods of 1-56 months. The study has shown CAPD to be an effective form of dialysis with a number of advantages over intermittent peritoneal dialysis and hemodialysis (better control of salt and water status, hypertension and anemia, steady state biochemistry and greater ease of self-dialysis). Peritoneal clearance and ultrafiltration have remained adequate in all but a few patients. Hypoproteinemia, poor nutrition, obesity and abdominal herniae have been problems in a small percentage of patients. Hyperlipidemia has developed in half the patients but improved with diet. Peritonitis remains the major barrier to the more widespread use of CAPD, although its incidence can be considerably reduced by use of better connectors, bacterial filters and choice of patients.

Corticosteroid agents have a major role in the treatment of several renal disorders which have an immune basis. They remain the treatment of choice for minimal-change glomerulonephritis, inducing remission in over 90% of patients. The role of corticosteroid therapy in patients with membranous glomerulonephritis remains controversial, although an extensive controlled trial indicated benefit from a two-month course of alternate-day therapy. Intravenously-administered methylprednisolone has been shown to benefit rapidly progressive crescentic glomerulonephritis; the benefit is probably comparable to that which is obtained with immunosuppression and plasma exchange. Corticosteroid therapy has improved dramatically the prognosis of glomerulonephritis that is associated with systemic lupus erythematosus and the various forms of vasculitis (excluding Wegener's granulomatosis), although the concomitant use of immunosuppressive therapy in these disorders reduces the required doses of corticosteroid drugs. For the last 20 years prednisolone and azathioprine have been standard therapy to prevent renal allograft rejection. However, corticosteroid agents are used currently in much lower doses or have been replaced by cyclosporin A.