P092 NICE biologics pathways for inflammatory arthritis exhibit regional variability due to modification by CCG’s: results from a national survey of pathways in England

Background/Aims 

NICE publishes guidance underpinned by act of Parliament and legally enforceable, on the use of biological therapies in the treatment of rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) which should allow harmonisation of access independent of region. However, sufficient guidance is not provided on the use of sequential biologics nor is a numerical cap placed on the number of biologics a patient can attempt if they have had an inadequate response. We have previously reported that in a limited sample, Clinical Commissioning Groups (CCGs) interpret NICE guidance variably and restrict access to NICE approved treatments depending on geography, the so-called “postcode lottery”. We determined the variability of biologics pathways in all CCG’s in England to examine whether a potentially unfair postcode lottery exists for sequential biologics use.

Methods 

All 135 England CCGs covering over 55 million people, were sent Freedom of Information requests, for their biologic pathways for RA, PsA and AS. Where CCGs did not have this information, the relevant acute trusts were contacted, with responses recorded under that CCG. For every CCG the local biologics pathways were examined for detail on the number and type of biologics commissioned before an Individual Funding Request was needed. “No Cap” was recorded if CCG’s responded with no restriction on the number of biologics.

Results 

Responses were obtained from 124/135 CCG’s for RA, 122/135 for PsA and AS, all covering an estimated population in excess of 45 million people. For RA, 55% CCG’s had no cap on the number of commissioned RA biologics. 45% had a variable cap from 3 to 6 commissioned biologics. For PsA, the figures were 54% with no cap and 46% with variable capping between 2-5 biologics allowed, for AS the figures were 51% and 49% respectively. In total this represented 41 different local pathways for RA, 29 different pathways for PsA and in AS where fewer biologics choices exist, 25 different pathways depending on CCG and location.

Conclusion 

There is wide regional variation in the interpretation of NICE guidance by CCG’s resulting in many different local pathways depending on geography. Approximately 50% of pathways restricted biologics prescribing by mandating the type and sequence of biologics used, potentially compromising patient care and delaying treatment by requiring an IFR for a NICE approved biologic. Moreover, pathways varied as to which biologics could be used at any point of management by region as well. As exemplars of good practice, approximately 50% of CCG’s had no cap, allowing clinical freedom to prescribe the most appropriate biologic. The results of this national study demonstrate the variability of biologics pathways in many areas of England ensuring a postcode lottery still exists in many regions.

Disclosure 

J. Mistry: None. D. Hill: None. A. Bosworth: None. A. Kaul: None.

Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy

INTRODUCTION

The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment.

METHODS

All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP.

RESULTS

Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7-16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications.

CONCLUSIONS

This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.

SAT0143 A PHASE 1 STUDY IN HEALTHY VOLUNTEERS EXPLORING THE SAFETY, PHARMACOKINETICS AND PHARMACODYNAMICS OF ATI-450: A NOVEL ORAL MK2 INHIBITOR

Background:

ATI-450, is an investigational small molecule inhibitor of the MAPK-activated protein kinase 2 (MK2) signaling pathway. This pathway drives the expression of multiple cytokines including TNFα, IL-1α and β, and IL-6.

Objectives:

We evaluated the safety and tolerability of ATI-450 in healthy volunteers as well as pharmacokinetics (PK) and pharmacodynamics (PD). Here we present data from single and multiple ascending dose cohorts. The aim was to select a dose for evaluation in phase 2 in patients with rheumatoid arthritis.

Methods:

Safety, PK and PD were assessed in a randomized, observer-blind, placebo-controlled, phase 1 study in male and female healthy subjects aged 18-55 (n=77).

Safety and tolerability of ATI-450 was evaluated based on adverse events, clinical laboratory, vital signs, 12-lead ECG, Holter monitoring, and physical examination. Blood was drawn for PK analysis at 0.5, 1, 2, 4, 6, 8, 12 hours, 24, 36, and 48 hours post dose in the SAD cohort and on day 7 of the MAD cohort. PD of ATI-450 were explored by investigating the inhibition of a target biomarker, phospho-HSP27 (pHSP27) and proinflammatory cytokines, TNFα, IL1β, IL6 and IL8 inex-vivoLPS-stimulated blood samples collected 4 and 12 hours post dose on day 7 from subjects in the MAD cohorts.

Results:

ATI-450 was generally well tolerated. No serious adverse events or severe adverse events were reported, and no adverse events led to discontinuation of the study medication. The most common adverse events (reported by 2 or more subjects who received ATI-450) observed during the trial were dizziness, headache, upper respiratory tract infection, constipation, nausea, and abdominal pain. All adverse events were mild. A trend of a decrease in absolute neutrophil count (ANC) was observed without correlated clinical sequelae.

ATI-450 had dose proportional PK with a terminal half-life (t½) of 9-12 hours in the MAD cohort on day 7. A dose and concentration dependent inhibition ofex vivostimulated cytokines and target biomarker was observed. On day 7, patients in the 50mg BID dose (the dose with the highest degree of inhibition) recorded mean trough drug levels (12 hours post dose) that were 1.4, 2.5, 2.5 and 2.4 times greater than the IC80for TNFα, IL1β, IL8 and pHSP27 respectively. Mean Cmax drug levels (4 hours post dose) were 3.6, 6.4, 6.2 and 6.0 times greater than the IC80for TNFα, IL1β, IL8 and pHSP27 respectively. IL6 levels were inhibited by more than 50% for part of the dosing interval.

Conclusion:

Oral ATI-450 was generally well tolerated at all doses with dose proportional PK. The t½ suggests that once or twice daily oral dosing may be possible. At the 50mg BID dose, marked inhibition of TNFα, IL1β and IL8, IL6 and pHSP27 was observed. ATI-450 has the potential to be an oral, small molecule drug which can target multiple cytokines. Exploration of its benefit to risk profile in patients with rheumatoid arthritis is warranted.

Disclosure of Interests:

Judy Schnyder Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Joe Monahan Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Walter Smith Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Heidi Hope Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, Deborah Kelly Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, David Burt Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, E Huff Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, A Kaul Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, A Hildebrand Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, B Burnette Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, N Klug Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics, M Bangs Shareholder of: Aclaris Therapeutics, Employee of: Aclaris Therapeutics, David Gordon Shareholder of: aclaris therapeutics, Employee of: aclaris therapeutics

P87 CCG biologics pathways: re-introduction of the postcode lottery by stealth

Background

NICE guidance approves pathways for inflammatory arthritis biologic therapies. Locally, CCG's commission pathways based on their interpretation of NICE guidance. For patients to have equal access to biologics, CCG pathways in different areas must be uniform. We examined whether CCG biologics pathways complied with this standard.

Methods

Using Freedom of Information requests, direct requests and internet searches, we found 21 approved biologics pathways in England for rheumatoid arthritis, 12 for psoriatic arthritis and 11 for ankylosing spondylitis. This covered 22.8 million people in England for RA (2017 population estimates). CCG Pathways were compared to NICE guidance with respect to restrictions and number of therapies allowed before an Individual Funding Request (IFR) was needed.

Results

We studied NICE guidance and determined an 'ideal' pathway for patients requiring &gt; 1 biologic. All CCG pathways followed NICE guidance for 1st line biologics but there was significant variation for biologic failures. 18/21 CCG RA pathways indicated the maximum number of drugs that the CCG would commission without the clinician needing IFR. 7/18 allowed 1-3 biologics serially, 10/18 allowed 4-6 and 1/18 was unrestricted. Rituximab is NICE approved in RA in inadequate responders/intolerance to DMARDs/anti-TNF-α. 17/21 RA pathways allowed rituximab 1stline for haematological or treated solid malignancies, 4/21 did not. 6/21 CCG’s allowed rituximab 5 years after solid organ malignancy, 5/21 after 10 years, 10/21 did not specify or allow this usage. NICE guidelines for RA approve 11 biologics. 14/21 RA pathways allowed all 11 biologics, 7/21 pathways excluded sarilumab, tofacitinib or baricitinib or all three. NICE guidelines for PsA recommend the least expensive drug used first of the injected biologics or JAK inhibitors. IFR was required after 3 drugs in 9/12 pathways with 1/12 allowing 4 lines of therapy. For AS, 5/11 allowed 2 lines of therapy, the remainder 3 or 4 lines. Again, many pathways pre-specified which biologics could be used and excluded other NICE approved drugs at specific stages.

Conclusion

NICE specify the least expensive drug should be used for injected biologics with variation for administration mode/dosage. CCG’ s commission variably restrictive pathways potentially against NICE guidance, both with number and type of therapies before IFR submission is required. Some pathways allowed little scope to use therapies from earlier pathway points without breaching CCG limits. The IFR process for NICE approved therapies can exhibit wide variation in our experience with different outcomes for similar cases, and is time consuming with CCG decision making being opaque, despite NICE approval being legally enforceable. CCG biologic pathways introduce wide regional variation and potential unfairness in their interpretation of NICE guidance. This may disadvantage the worst affected patients who fail several therapies and prevent access to life changing therapy depending on geographical location.

Disclosures

J. Mistry None. D. Hill None. A. Kaul None.

P184 Developing a pathway for tocilizumab treatment in giant cell arteritis: a South London regional experience

Background

Tocilizumab is now approved by the National Institute of Health and Care Excellence (NICE) for up to a year in relapsing or refractory giant cell arteritis (GCA). The practicalities of developing a pathway for referral using a hub and spoke model were previously unknown. Here we discuss our novel experiences utilising tocilizumab for GCA in its first year of licensing, after the introduction of a new regional multi-disciplinary team referral pathway.

Methods

We assessed all patients started on tocilizumab for GCA between August 2018-May 2019. The central assessing hub is St George’s University Hospitals NHS Foundation Trust, a large tertiary rheumatology department in the South of England, serving a population of 1.3 million.

Results

As per Table 1 below. A total of 9 patients were identified: 6 female and 3 male, with an average age of 74.2 (range 63-80). 5 patients were referred internally from clinicians at St George’s Hospital, with the remainder from local district general hospitals. Steroid protocols between patients were varied, and two-thirds required a 3-day IV methylprednisolone course, including all 4 patients with visual symptoms. A third of patients were on concurrent methotrexate, a disease-modifying antirheumatic drug. 8 of 9 patients were on alendronate, vitamin D/calcium, and a gastroprotective agent, and 7 were on aspirin. Reported side effects from steroids were common, with weight gain, increased appetite and osteoporosis noted. All our 9 patients continue their tocilizumab injections, with one individual having a 3-month break for a routine hip operation, and another a 1-month hiatus due to temporary derangement in liver function tests. Tocilizumab proffered improved disease control and few side effects were noted. 3 patients have now been on tocilizumab for 12 months and raise interesting discussions about ongoing funding and treatment efficacy.

Conclusion

Our case series shows the development and delivery of an effective hub and spoke referral pathway for tocilizumab treatment in GCA. We show that steroid dosing could be reduced with tocilizumab, and that all subjects received full funding for treatment. Our referral pathway has encouraged the uptake of the IL-6 monoclonal antibody treatment for GCA and compliance with NICE guidelines.

Disclosures

P. Saha None. V. Sandhu None. H. Robinson None. A. Ezeonyeji None. I. Al-Shakarchi None. S. Chander None. R. Suresh None. A. Kaul None. N. Sofat None.

X chromosome aneuploidy and micronuclei in fertile mares

Abnormalities of chromosomes are an important and well documented cause of disorders of sexual development, fertility problems and congenital anomalies in mammals. Detection of low-level 63,X/64,XX mosaicism during routine cytogenetic evaluation is a challenge because its clinical significance is not yet fully clear. This study describes the prevalence and levels of 63,X mosaicism for a cohort of fertile mares and compares the results with eight problem mares for which no clinical cause of sub-fertility was found. The study design allowed for the analysis of micronuclei which are biomarkers of genomic instability and can disturb cell divisions, drive cancer development or cause congenital diseases. Although 27% of the fertile mares were identified to be 63,X mosaics, the results showed that the rates of abnormal cells were very low (1-3%). Levels of abnormal cells in problem mares with 63,X mosaicism were similar or higher. The average rate of micronuclei in the blood of the fertile mares was ∼1%, well below the baseline (5%) which was proposed for peripheral blood of normal healthy humans. We found weak to modest, but not significant, correlations between the age of fertile mares and 63,X cells (Kendall's tau b = 0.2905; p > 0.05) as well as the rate of micronuclei (Kendall's tau b = 0.1896; p > 0.05). Likewise, the correlation between presence of a 63,X cell line and micronuclei rate was not significant (Kendall's tau b = 0.3201; p > 0.05). The presence of 63,X cells in rates greater than 3% may indeed indicate a higher risk for sub-fertility and eventually for associated health problems in such mares. Detection and elimination of mares with high level of X aneuploidies from breeding may have a positive effect on the fertility within the general horse population. This data may support the evaluation of problem mares with mosaic karyotypes involving the X chromosome.

Hydrothermal epitaxy growth of self-organized vanadium dioxide 3D structures with metal–insulator transition and THz transmission switch properties

The hydrothermal method is an effective approach for the synthesis of VO₂ films with unique crystallites morphology and sharp electrical and optical switch properties.

Vasculitis and vasculopathy in Lupus Nephritis: Clinical variability, outcome, and new insight into treatment

More than 50% of patients with systemic lupus erythematosus (SLE) have renal involvement at presentation or during their illness. Lupus nephritis (LN) encompasses several patterns of renal disease, including glomerular, tubulointerstitial, and vascular pathologies. The presence and significance of renal vascular lesions (VLs) are often overlooked. VLs in LN are not rare with an incidence of 10%-40% on renal biopsies from various studies and their presence is often labeled as poor prognostic markers. The current treatment protocol for LN is mainly based on the glomerular pathology, and no guidelines/consensus exists for treatment of LN with VLs. We describe the clinical presentation, course, response to therapy, and outcomes in five patients with SLE with histological evidence of renal VLs.

A non-randomised single centre cohort study, comparing standard and modified bowel preparations, in adults with cystic fibrosis requiring colonoscopy

BACKGROUND

Adults with cystic fibrosis (CF) have been reported to be at five to ten-fold risk (25 to 30 fold risk after solid organ transplant) of colorectal cancer (CRC) than the general population. Limited publications to date have reported on practical aspects of achieving adequate colonic cleanse producing good visualisation. In this study, we compared two bowel preparation regimens, standard bowel preparation and a modified CF bowel preparation.

METHODS

A non-randomised study of adults with CF attending a single centre, requiring colonoscopy investigation were selected. Between 2001 and 2015, 485 adults with CF attended the clinic; 70 adults with CF had an initial colonoscopy procedure. After five exclusions, standard bowel preparation was prescribed for 27 patients, and modified CF bowel preparation for 38 patients. Demographic and clinical data were collected for all consenting patients.

RESULTS

There was a significant difference between modified CF bowel preparation group and standard bowel preparation group in bowel visualisation outcomes, with the modified CF bowel preparation group having a higher proportion of "excellent/good" GI visualisation cleanse (50.0% versus 25.9%) and lower rates of "poor" visualisation cleanse (10.5% versus 44.5%) than standard bowel preparation (p = 0.006). Rates of "fair" GI cleanse visualisation were similar between the two groups (39.4% versus 29.6%) (Additional file 1: Table S1). Detection rates of adenomatous polyps at initial colonoscopy was higher in modified CF bowel preparation cohort than with standard preparation group (50.0% versus 18.5%, p < 0.01). Positive adenomatous polyp detection rate in patient's age > 40 years of age was higher (62.5%) than those < 40 years of age (24.3%) (p = 0.003). Colonic adenocarcinoma diagnosis was similar in both groups.

CONCLUSION

This study primarily highlights that standard colonoscopy bowel preparation is often inadequate in patients with CF, and that colonic lavage using modified CF bowel preparation is required to obtain good colonic visualisation. A higher rate of polyps in patients over 40 years of age (versus less than 40 years) was evident. These results support adults with CF considered for colonoscopy screening at 40 years of age, or prior to this if symptomatic; which is earlier than CRC screening in the non-CF Australian population.

Changing hospitalization trends for systemic lupus erythematosus and rheumatoid arthritis in England

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic, multisystemic, immune-mediated disorder associated with a substantial hospitalization risk. As a comparatively rare disease, there is a sparsity of research examining the burden of hospital admission in the contemporary era. We aim to describe national trends in hospitalization rates in England between 1998 and 2015 for SLE, using rheumatoid arthritis (RA) and general population rates as comparison cohorts for benchmarking.

METHODS

Hospital admission rates, emergency and day-case admission rates, length of stay and bed days used were calculated using finished consultant episodes from Hospital Episode Statistics data. Cochran-Armitage tests and linear regression quantified the significance and magnitude of change over time.

RESULTS

SLE admissions increased from 8.97 to 9.04 per 100,000 (p < 0.001) between 1998 and 2015. By comparison, RA admissions rose from 71.0 to 171.6 per 100,000 (p < 0.001) and all-cause admissions rose from 24,500 to 34,500 per 100,000 (p < 0.001). Emergency admissions decreased both for SLE (2.6 to 1.2 per 100,000) and RA (12.8 to 4.4 per 100,000) despite all-cause emergency admissions increasing from 9400 to 10,300 per 100,000. SLE and RA day cases increased, whilst median length of stay decreased. Despite increasing admissions, total bed days for SLE and RA fell by 60% and 90%, respectively.

CONCLUSIONS

Whilst all-cause emergency admissions rose in the general population, those for SLE fell. Length of stay and bed days reduced and day cases increased, probably reflecting changing therapeutic strategies. This potentially large reduction in resource utilization warrants consideration when assessing the impact of new therapies.

Utility of Oxford Classification in Post-Transplant Immunoglobulin A Nephropathy

BACKGROUND

With increasing graft survival, post-transplant immunoglobulin A nephropathy (IgAN) has emerged as an important cause of chronic graft dysfunction in renal allograft recipients. We studied the clinico-pathological features of post-transplant IgAN regardless of the primary disease. The aim was to study the usefulness of the Oxford classification in predicting survival.

METHODS

Indication graft biopsy specimens (n = 915) were received during a 10-year period; 27 biopsy specimens from 22 patients were diagnosed as IgAN.

RESULTS

Post-transplant IgAN was seen in 2.6% of biopsy specimens. Mean time to occurrence was 71.6 ± 47.6 months (range, 6.8 months to 16 years), occurring most commonly 4 to 8 years after transplant. Associated rejection was present in 4 biopsies; 72.7% (16/22), 91% (20/22), and 31.8% (7/22) presented with rise in serum creatinine, proteinuria, and hematuria, respectively. Four (21%) patients had nephrotic range proteinuria. Mesangial hypercelullarity (M1), endocapillary hypercelullarity (E1), segmental glomerulosclerosis (S1), and tubulo-interstitial fibrosis (T1-2) was present in 36.6%, 22.7%, 54.5%, and 31.8% biopsies, respectively. The most frequent Haas class was III (n = 7; 29.1%), followed by classes IV and I (n = 5; 20.8% each). The 2- and 5-year graft survival rates were 75% and 56%, respectively. High serum creatinine, low estimated glomerular filtration rate, E1 and T lesions, and degree of interstitial inflammation predicted graft survival. Interestingly, percentage (>25%) of segmentally sclerosed glomeruli and not S1 correlated with graft outcome.

CONCLUSIONS

The Oxford MEST scheme is useful in predicting graft survival in post-transplant IgAN. The degree of interstitial inflammation is also an important feature for determining graft outcomes in post-transplant IgAN.

Optimization of treatment modality in elderly end-stage renal disease population: Peritoneal dialysis versus transplant

Despite kidney transplantation (KT) being considered as the best treatment modality for end-stage renal disease (ESRD), patient and graft survival in the elderly population is poorer than younger individuals. Many authors argue that prolonged life expectancy outweighs the risk of remaining on dialysis, but few studies had compared the treatment modalities, especially with peritoneal dialysis (PD). A retrospective study was conducted at a tertiary care institute to compare outcome of elderly ESRD patients, who received KT with those continued on PD; and to evaluate the predictors of patient survival. Patient survival at 1 year was (76.2% vs. 91.1%); 5 years (53.7% vs. 21.8%); and 10 years (35.6% vs. 0.00%) among KT and PD population, respectively. Infection was the most common cause of death among KT group (35 [41.2%] vs. 34 [28.2%]) while cardiovascular mortality in PD group (55 [46.2%] vs. 7 [8.2%]). Technique survival at 1, 5, and 10 years in PD group was 92.8%, 58.5%, and 0%, respectively. Similarly, graft survival at 1, 5, and 10 years in KT group was 98.7%, 90.2%, and 90.2%, respectively. Multivariate analysis showed body mass index (BMI) (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.82–0.93, p < 0.001), and albumin (HR 0.55, 95% CI 0.37–0.80, p = 0.002) were significant predictors of survival. In the 1^st year, patient survival was better in PD than KT, but after adjustment for BMI and albumin, both short-term and long-term survival in elderly KT group was better than that of PD. Hence, elderly ESRD patients should not be barred from KT just because of age.

Efficacy and Safety of Cyclosporine versus Tacrolimus in Steroid and Cyclophosphamide Resistant Nephrotic Syndrome: A Prospective Study

Calcineurin inhibitors (CNIs) are the preferred drugs for treatment of childhood steroid-resistant nephrotic syndrome (SRNS) who are also resistant to cyclophosphamide (CYC). Although few studies have shown a benefit of one over the other, efficacy and safety of either CNIs (tacrolimus [TAC] or cyclosporine [CSA]) in this special population remained to be assessed in long-term studies. Forty-five children with SRNS who were also resistant to CYC (CYC-SRNS) from January 2006 to June 2011, were included in the study. Patients were treated with CNI either TAC or CSA based on 1:1 allocations and were prospectively observed. Patients who were nonresponsive to CNIs had been treated with mycophenolate mofetil. Outcomes were measured in terms of remission of NS, adverse effects of drugs, and progression of disease. After 6 months of treatment, 16/23 (69.5%) patients on CSA achieved remission and 18/22 (81.8%) on TAC achieved remission (P = 0.3). The side effects hypertrichosis, and gum hyperplasia were significantly less in TAC group as compared to CSA group (P < 0.001). The 1-, 2-, 3-, 4-, and 5-year estimated renal survival (doubling of serum creatinine as event) in CSA group was 96%, 91%, 85%, 54%, and 33% and in TAC group was 96%, 95%, 90%, 89%, and 79%, respectively (P = 0.02). Although TAC and CSA are equally efficacious, TAC has significantly less side effects. The long-term outcome of renal function was significantly better in patients who were treated with TAC as compared to CSA.

Neutrophil Gelatinase-associated Lipocalin: As a Predictor of Early Diabetic Nephropathy in Type 2 Diabetes Mellitus

This study was carried out to look for diagnostic and prognostic role of neutrophil gelatinase-associated lipocalin (NGAL) in early diabetic nephropathy (DN) in type 2 diabetes individuals. NGAL was measured in both urinary and serum sample of 144 type 2 diabetes individuals stratified into three categories based on urinary albumin-creatinine ratio and 54 control populations with estimated glomerular filtration rate >60 mL/min/1.73 m² and serum creatinine <1.2 mg/dl. The serum NGAL (sNGAL), urine NGAL (uNGAL), and uNGAL/urine creatinine were significantly higher in diabetic individuals than in the control populations with significant difference in between the groups (P < 0.05). Difference of above values between control value and normoalbuminuria was also statistically significant (P < 0.05). Again, sNGAL and uNGAL correlate positively with albuminuria (P < 0.05). Tubular injury may precede glomerular injury in diabetic individuals, and NGAL can be used as a biomarker to diagnose DN even earlier to incipient nephropathy. Both sNGAL and uNGAL can predict albuminuria and be used as a noninvasive tool for diagnosis, staging, and progression of DN.

Direct-acting Antiviral Agents in Hepatitis C Virus-infected Renal Allograft Recipients: Treatment and Outcome Experience from Single Center

Hepatitis C virus (HCV) infection in renal allograft recipient is associated with increased morbidity and mortality. At present, only few studies related to treatment and outcomes of HCV-infected renal allograft recipients with DAAs have been published. We aimed the study to assess the efficacy and safety of sofosbuvir-based regimens in HCV-infected renal allograft recipients. We analyzed data of 22 eligible HCV-infected renal allograft recipients (14 genotype-3, 6 genotype-1, one each genotype-2 and 4) who were treated with DAAs at our institute. DAA regimen included sofosbuvir and ribavirin with or without ledipasvir or daclatasvir for 12–24 weeks. Patients were followed up for 24 weeks after completion of treatment. A rapid viral response of 91%, end of therapy response of 100%, and sustained viral response at 12 and 24 weeks of 100% with rapid normalization of liver enzymes were observed. Therapy was well tolerated except for ribavirin-related anemia. A significant decrease in tacrolimus trough levels was observed and most patients required increase in tacrolimus dose during the study. Treatment with newer DAAs is effective and safe for the treatment of HCV-infected renal allograft recipients.

Pregnancy Check Point for Diagnosis of CKD in Developing Countries

Objective

Evidences suggest that females with CKD are associated with high risk of maternal and fetal complications. Early referral in CKD with pregnancy for specialist care may prove useful for maternal and fetal outcome.

Methods

Study looked for assessment of impact of CKD detection at the time of pregnancy and its impact on fetal and maternal outcome.

Results

A total of 465 females were retrospectively evaluated for renal status during their pregnancies, 172 females were unaware about their renal illness at the time of pregnancy, while 208 females were under regular obstetrical and nephrological follow-up during their pregnancy. 44.1% of these females in both groups had GFR < 60 ml/min. Preeclampsia was observed in 17.6% of planned pregnancies, while it was observed in 47.5% of unplanned pregnancies. Worsening of renal failure during and following pregnancy was observed among all stages of CKD, and there was greater decline in GRF with progression to ESRD earlier during or after pregnancy among unplanned pregnancies. Planned pregnancy group had better fetal outcome. Low birth babies weighing < 2500 g in unplanned group were much higher than in planned pregnancies.

Conclusions

Chronic kidney disease is often clinically silent until renal impairment is advanced. Pregnancy can be a check point for detection of renal disease and managed appropriately for better maternal and fetal outcome.

Measured Glomerular Filtration Rate at Dialysis Initiation and Clinical Outcomes of Indian Peritoneal Dialysis Patients

The optimal time for dialysis initiation remains controversial. Studies have failed to show better outcomes with early initiation of hemodialysis; even a few had shown increased adverse outcomes including poorer survival. Few studies have examined the same in patients on peritoneal dialysis (PD). Measured glomerular filtration rate (mGFR) not creatinine-based estimated GFR is recommended as the measure of kidney function in end-stage renal disease (ESRD) patients. The objective of this observational study was to compare the outcomes of Indian patients initiated on PD with different residual renal function (RRF) as measured by 24-h urinary clearance method. A total of 352 incident patients starting on chronic ambulatory PD as the first modality of renal replacement therapy were followed prospectively. Patients were categorized into three groups as per mGFR at the initiation of PD (≤5, >5-10, and >10 ml/min/1.73 m2). Patient survival and technique survival were compared among the three groups. Patients with GFR of ≤5 ml/min/1.73 m2 (hazard ratio [HR] - 3.42, 95% confidence interval [CI] - 1.85-6.30, P = 0.000) and >5-10 ml/min/1.73 m2 (HR - 2.16, 95% CI - 1.26-3.71, P = 0.005) had higher risk of mortality as compared to those with GFR of >10 ml/min/1.73 m2. Each increment of 1 ml/min/1.73 m2 in baseline GFR was associated with 10% reduced risk of death (HR - 0.90, 95% CI - 0.85-0.96, P = 0.002). Technique survival was poor in those with an initial mGFR of ≤5 ml/min/1.73 m2 as compared to other categories. RRF at the initiation was also an important factor predicting nutritional status at 1 year of follow-up. To conclude, initiation of PD at a lower baseline mGFR is associated with poorer patient and technique survival in Indian ESRD patients.

Mapping neuroreceptors with metal-labeled radiopharmaceuticals

The growing epidemiological and economic burden of neurological diseases on society is tremendous. A correct and timely diagnosis can help in lowering the burden and improving the life quality of both the diseased person and the caretaker. Imaging of the brain (neuroimaging) using CT, MRI, and nuclear imaging methods can provide anatomical and functional information. Neuroreceptors are central to neurotransmission and neuromodulation in the CNS. In vivo imaging of receptors in the brain provides powerful tools for the functional study of the central nervous system (CNS) in normal or diseased states. Presently, PET imaging using non-metallic radiotracers dominates the imaging of neuroreceptors. Metal-based probes for SPECT and PET can be economical and logistically easier to use without compromising the information. This review focuses on the development of metallic radiotracers for (99mTc) SPECT and (68Ga) PET along with future directions based on the metallic probes developed for other imaging modalities namely MRI.