Selective corticosteroid and calcineurin-inhibitor withdrawal after pancreas-kidney transplantation utilizing thymoglobulin induction and sirolimus maintenance therapy

Of 25 simultaneous pancreas-kidney transplant (SPK) recipients treated with thymoglobulin induction, sirolimus and reduced-dose cyclosporine (CsA), 18 low-immune responders (non-African-Americans, PRA < 30%) were withdrawn from prednisone on post-transplant day 5, whereas seven high-immune responders continued on prednisone. Most high- and low-immune responder recipients were converted from CsA to mycophenolic acid (MPA) at six months post-transplantation. At a mean follow-up of 28 +/- 10 months, two pancreas grafts were lost to pancreatitis. There were no patient or kidney graft losses, but one acute rejection episode. At 28 +/- 11 months, all 18 low-responder recipients remain steroid-free. Twenty recipients (14 low and six high-immune responders) were converted from CsA to MPA. During conversion, immune response was monitored by Flow-PRA and T-cell stimulation (Cylex) assays. Nineteen of 20 recipients displayed a post-conversion PRA of 0%, whereas one highly sensitized patient expressed a post-conversion PRA of 67%. Fifty-eight percent of individual T-cell stimulation scores were in the hypo-responsive range. Twelve of 18 low-immune responders are both steroid and CsA-free at a mean follow-up of 17 +/- 13 months, whereas five of seven high-immune responders remain CsA-free at a mean follow-up of 11 +/- 10 months. These data suggest that thymoglobulin induction with combined sirolimus and CsA maintenance therapy permits immunosuppression minimization in selected SPK recipients.

An in vivo model for studying adherence of intestinal pathogens

A new method for preparing an isolated colonic loop in a living rabbit is described. The loop with its intact neurovascular supply can be used as as a "living test tube" to study the adherence of microorganisms to intestinal mucosa. Moreover, the clear colonic mucus produced by the loop can be used to study its physiochemical nature and protecting properties in health and disease.

Racial/ethnic differences in adequacy of information and peer support for women with breast cancer

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Background: Existing disparities in quality of care for women with breast cancer suggest the need to explore the adequacy of information and care support provided to patients. This study investigated whether racial/ethnic variation existed in receipt and usefulness of cancer-related information and availability of peer support. Methods: 2,030 women diagnosed with non-metastatic breast cancer and reported to the Los Angeles County, Surveillance Epidemiologic and End Results registry between 8/05–5/06, were identified and mailed a survey shortly after initial treatment. Latina and African American (AA) women were oversampled. Outcomes included self-reported receipt and perceived usefulness of treatment-related (recovery from surgery, radiation, chemotherapy) and survivorship-related (sexual functioning, relationships, nutrition, anxiety) information and experiences with other women with breast cancer. We report results on a 50% respondent sample (N=742) that will be updated based on a final sample of 1,400 women (projected response rate, 72%). Results: More women received information and found it useful regarding treatment than survivorship issues. After adjusting for age and education, a higher percentage of Latina women, compared to white and AA women, desired more information on treatment-related issues and survivorship-related issues (p<.01). A higher percentage of Latina women also reported having no contact with other women with breast cancer, either through the health care system or a family/friend (p<.001), and reported a desire for more contact as compared to white or AA women (42%, vs. 15% and 29%, respectively). Overall, women rated the benefit of talking to other women high, particularly in helping with emotional issues and few endorsed potentially negative consequences. Conclusions: Women with breast cancer expressed the need for more useful information and care support, especially about managing survivorship concerns. Particular focus is warranted with Latina women to provide desired information and greater opportunities for peer contact.

No significant financial relationships to disclose.

Modulation of ERK 1/2 and p38 MAPK signaling pathways by ATP in osteoblasts: involvement of mechanical stress-activated calcium influx, PKC and Src activation

There is evidence that extracellular nucleotides, acting through multiple P2 receptors, may play an important role in the regulation of bone metabolism by activating intracellular signaling cascades. We have studied the modulation of mitogen-activated protein kinase (MAPK) signaling pathways and its relationship to changes in intracellular calcium concentration ([Ca(2+)](i)) induced by ATP in ROS-A 17/2.8 osteoblastic cells. ATP and UTP (10 microM) increased [Ca(2+)](i) by cation release from intracellular stores. We have found that when the cells are subsequently subjected to mechanical stress (medium perturbation), a transient calcium influx occurs. This mechanical stress-activated calcium influx (MSACI) was not observed after ADP stimulation, indicating that P2Y(2) receptor activation is required for MSACI. In addition, ERK 1/2 and p38 MAPK were activated by ATP in a dose- and time-dependent manner. This activation was almost completely blocked using neomycin (2.5mM), an inhibitor of phosphoinositide-phospholipase C (PI-PLC), Ro 318220 (1 microM), a protein kinase C (PKC) inhibitor, and PP1 (50 microM), a potent and selective inhibitor of the Src-family tyrosine kinases. Ca(2+)-free extracellular medium (containing 0.5mM EGTA) and the use of gadolinium (5 microM), which suppressed MSACI, prevented ERK 1/2 and p38 phosphorylation by ATP. Altogether, these results represent the first evidence to date suggesting that P2Y(2) receptor stimulation by ATP in osteoblasts sensitizes mechanical stress activated calcium channels leading to calcium influx and a fast activation of the ERK 1/2 and p38 MAPK pathways. This effect also involves upstream mediators such as PI-PLC, PKC and Src family kinases.

A Pilot Study of Immunosuppression Minimization After Pancreas-Kidney Transplantation Utilizing Thymoglobulin Induction and Sirolimus Maintenance Therapy

AIMS

To determine outcomes utilizing thymoglobulin and sirolimus immunosuppression, with early steroid withdrawal in low-immune responder pancreas-kidney (SPK) recipients, and conversion from cyclosporine (CsA) to mycophenolic acid (MPA) in all recipients at 6 months posttransplantation.

METHODS

SPK recipients received thymoglobulin, sirolimus, and reduced-dose CsA immunosuppression. Low immune responders (non-African-Americans with a pretransplant PRA < 30%) were withdrawn from prednisone on posttransplant day 5 and high immune responders were continued on prednisone. All recipients were converted from CsA to MPA at 6 months posttransplantation. During conversion, recipient immune response was monitored by flow PRA and a T-cell stimulation assay (Cylex).

RESULTS

With a mean follow-up of 9 +/- 4 months, one pancreas was lost to pancreatitis, with no patient or kidney losses and no acute rejection episodes. All eight low immune responder patients were steroid-free at 9 +/- 5 months posttransplantation. Seven patients (five low and two high immune responders) with at least 6-month follow-up were converted from CsA to MPA. One high immune responder with a pretransplant PRA of 43% remained with a PRA of 53% +/- 2% postconversion. The second high immune responder had a pretransplant PRA of 34% and a postconversion PRA of 0%. The five low immune responders had a mean pretransplant PRA of 16% +/- 15% and a postconversion PRA of 0% (P < .01). The Cylex assay resulted in 67% low responsiveness for both high and low immune responders.

CONCLUSION

Thymoglobulin induction with sirolimus maintenance therapy permitted immunosuppression minimization in selected pancreas transplant recipients. Posttransplant evaluation revealed a diminished (regulated) immune response in six of seven patients.

Intention to apply or accept an alternative job among participants of extended employment programs

The research studied 249 people employed in extended employment programs in northern Israel with respect to their intention to apply for an alternative job (an active step) or to accept a new job offer (a passive step). Findings indicated that young, single people who were living with their parents and perceived their level of disability as mild indicated more intention to apply for an alternative job or to accept a new job offer. Furthermore, people with low monthly wages, less satisfaction with their income and with the extended employment program in general, and a lack of participation in non-employment activities expressed a greater inclination to apply for an alternative job or to accept a new job offer. The only difference between people's intentions to apply for an alternative job (an active step) or to accept a job offer (a passive step) was in regard to their perception of their disability. The intention to apply for an alternative job was associated with mild disability, whereas the acceptance of a new job offer was related to mild and moderate disability.

The effect of pancreas transplantation on peripheral vascular disease complications

BACKGROUND

We sought to determine whether pancreas transplantation reduced the incidence of peripheral vascular complications in diabetics with renal insufficiency.

METHODS

A retrospective single-center review was done of 36 kidney-pancreas (KP) and 88 kidney-alone (KA) recipients with a diagnosis of diabetes and end-stage renal disease (ESRD) transplanted between May 1997 and July 2002. Risk factors studied included type of transplant, age, gender, history of smoking, coronary artery disease, hypertension, and peripheral vascular disease (PVD). The endpoint was first peripheral vascular event occurring after transplantation, defined as either an amputation or revascularization procedure.

RESULTS

The mean age of the cohort was 51 +/- 9 years, 64% of patients were of male gender, 20% with a history of smoking, 98% with hypertension, 15% with coronary artery disease (CAD), and 12% with a history of PVD. With a median follow-up of 45 months (12 to 79 months), 3/36 (8%) of KP recipients suffered a PVD complication, compared to 10/88 (11%) of KA recipients (P = NS). Similarly, age, gender, a past history of smoking, CAD, and hypertension were not predictive of PVD complications. Five of 15 patients (33%) with a pretransplant history of PVD suffered a postoperative PVD event compared to only 8 of 109 patients (7%) with no prior history of PVD (P =.008).

CONCLUSIONS

Restoration of normoglycemia by pancreas transplantation did not reduce the risk of PVD complications in diabetics with renal failure. A pretransplant history of PVD was the only risk factor associated with posttransplant PVD events.