Angiotensin II mediates epithelial-to-mesenchymal transformation in tubular cells by ANG 1-7/MAS-1-dependent pathways

Epithelial-to-mesenchymal transformation (EMT) of tubular cells into a myofibroblastic phenotype is an important mediator of renal scarring in chronic nephropathy. This study examines the role of the renin-angiotensin system (RAS) in this process. NRK-52E cells were exposed to angiotensin (ANG) II and ANG 1-7 in the presence or absence of inhibitors and agonists of RAS signaling. EMT was assessed at 3 days by expression of alpha-smooth muscle actin (alpha-SMA) and E-cadherin and the induction of a myofibroblastic phenotype. Expression of fibrogenic growth factors and matrix proteins was assessed by RT-PCR and immunofluorescence microscopy. To confirm findings in vivo, rats were also infused with ANG 1-7 (24 microg*kg(-1)*h(-1)) or saline via an osmotic minipump for 10 days, and renal fibrogenesis was then assessed. Treatment of NRK-52E cells with ANG II induced characteristic changes of EMT. Selective blockade of the AT(1) receptor or the AT(2) receptor failed to inhibit ANG II-induced EMT. However, blockade of the ANG 1-7 receptor, Mas-1, was able to prevent ANG II-dependent EMT. To confirm these findings, both ANG 1-7 and the selective Mas receptor agonist, AVE-0991, were able to induce NRK-52E cells in a dose-dependent manner. Exposing cells to recombinant ACE2 was also able to induce EMT. In addition, an infusion of ANG 1-7 induced the tubular expression of alpha-SMA and the expression of matrix proteins in the kidney. ANG II is a potent stimulus for EMT, but not through conventional pathways. This study points to the possible limitations of conventional RAS blockade, which not only fails to antagonize this pathway, but also may enhance it via augmenting the synthesis of ANG 1-7.

Downregulation of cystine transporter xc by irinotecan in human head and neck cancer FaDu xenografts

BACKGROUND

The purpose of this study was: (1) to document the critical requirement of cystine for growth of human tumor cells in vitro, and (2) to determine the effect of the anticancer agent irinotecan on the cystine transporter x(c)(-) in head and neck FaDu xenografts.

METHODS

Cell growth was measured by sulforhodamine B assay. xCT protein, glutathione (GSH) and DNA damage were determined using Western blot, spectrophotometry, and immunohistochemistry, respectively.

RESULTS

Depletion of cystine from the medium inhibited tumor cell growth. Treatment of FaDu tumor with a therapeutic dose of irinotecan resulted in depression of xCT protein levels, leading to tumor growth retardation and downregulation of GSH with increased reactive oxygen species (ROS). The accumulation of ROS correlated with increased DNA damage as evidenced by increased H2AX.

CONCLUSION

Depression of xCT protein by irinotecan resulted in downregulation of GSH and increase in ROS, which could be the other possible mechanisms of DNA damage by irinotecan.

First aid provision in nightclubs and other entertainment venues

This article discusses the role and responsibilities of the registered nurse in providing first aid in challenging environments, such as crowded nightclubs. Basic assistance for common emergencies, including substance misuse, wounds, choking and anaphylaxis, are discussed. This article emphasises the importance of risk assessment and reminds readers of the need to maintain personal safety.

Introduction to the nurse's role in providing first aid

This article, the first in an eight-part series, discusses the importance of a considered, responsible approach to first aid. The article describes the challenges of working outside one's clinical environment and describes the legal background to undertaking first aid.

400 cGy TBI with fludarabine for reduced-intensity conditioning allogeneic hematopoietic stem cell transplantation

Fludarabine and 200 cGy TBI are commonly used for reduced-intensity conditioning preceding allogeneic hematopoietic SCT (HSCT). However, graft rejection and disease relapse are significant causes of treatment failure with this regimen. We modified this regimen by escalating the TBI dose to 400 cGy in 40 patients with hematologic malignancies. Thirty-four patients achieved complete donor T-cell chimerism at a median of 40 days following HSCT. The incidences of grades II-IV and III-IV acute GVHD were 40 and 15%, respectively, whereas that of limited and extensive chronic GVHD were 12 and 20%, respectively. Two patients rejected their grafts and 12 relapsed. The 100-day mortality was 18%, 2-year transplant-related mortality 20% and overall survival was 58% at a median follow-up of 16 months. There were no significant survival differences between patients with lymphoid compared to myeloid malignancies. A dose of 400 cGy TBI administered with fludarabine is well tolerated and further study is needed to determine whether outcomes are superior to those with 200 cGy TBI.

Influence of killer immunoglobulin-like receptor/HLA ligand matching on achievement of T-cell complete donor chimerism in related donor nonmyeloablative allogeneic hematopoietic stem cell transplantation

Achievement of complete donor chimerism (CDC) after allogeneic nonmyeloablative hematopoietic stem cell transplantation (NMHSCT) is important for preventing graft rejection and for generating a graft-vs-malignancy effect. The alloreactivity of NK cells and some T-cell subsets is mediated through the interaction of their killer immunoglobulin-like receptors (KIRs) with target cell HLA/KIR ligands. The influence of KIR matching on the achievement of T-cell CDC after NMHSCT has not been previously described. We analyzed 31 patients undergoing T-cell replete related donor NMHSCT following fludarabine and 200 cGy TBI. Recipient inhibitory KIR genotype and donor HLA/KIR ligand matches were used to generate an inhibitory KIR score from 1 to 4 based upon the potential number of recipient inhibitory KIRs that could be engaged with donor HLA/KIR ligands. Patients with a score of 1 were less likely to achieve T-cell CDC (P=0.016) and more likely to develop graft rejection (P=0.011) than those with scores greater than 1. Thus, patients with lower inhibitory KIR scores may have more active anti-donor immune effector cells that may reduce donor chimerism. Conversely, patients with greater inhibitory KIR scores may have less active NK cell and T-cell populations, which may make them more likely to achieve CDC.

Effect of prior rituximab on high-dose therapy and autologous stem cell transplantation in follicular lymphoma

Autologous stem-cell transplantation (ASCT) has been used in follicular lymphoma (FL) to achieve durable responses in first remission or in the relapsed or refractory settings. Addition of rituximab to chemotherapy for FL has been shown to improve survival. The impact of prior therapy with rituximab upon the effectiveness of high-dose therapy (HDT) and ASCT in patients with FL is unknown. We retrospectively reviewed consecutive patients with FL who underwent HDT and ASCT. Patients were categorized according to prior therapy with rituximab. Outcomes were compared between groups in all patients and in a well-matched subset. In all 35 patients received prior rituximab and 71 rituximab-naive patients were analyzed. The rituximab-naive group had a median overall survival (OS) that was not reached during follow-up, with a median relapse-free (RFS) survival of 49.9 months. The prior rituximab group also did not reach median OS and had a median RFS of 24.6 months. Survivals were not significantly different in this group or in the well-matched subset. In conclusion, these results suggest that the use of rituximab-based regimens for the treatment of FL does not compromise the effectiveness of HDT and ASCT as a salvage strategy in patients with FL.

Elevated lactate dehydrogenase is an adverse predictor of outcome in HLA-matched sibling bone marrow transplant for acute myelogenous leukemia

Prognostic factors for survival following allogeneic BMT for AML include age, disease status and cytogenetic risk classification. Lactate dehydrogenase (LDH) levels have not been studied as a potential risk factor. We reviewed our experience with BMT for AML and included LDH at the time of admission in an analysis of prognostic factors for survival. We found that LDH >330 U/l (1.5 times the upper limit of normal at our institution), older age, active disease, peripheral stem cell graft and male-to-male transplant were significant adverse predictors of survival. After accounting for LDH, other factors such as disease status and cytogenetics were not significantly associated with the outcome of BMT. All but one patient with an LDH >330 U/l had active disease. However, when patients in CR were excluded, LDH >330 U/l remained a significant adverse predictor of overall survival (hazard ratio 2.70, 95% confidence interval 1.41-5.16, P=0.003). We conclude that LDH is an important adverse risk factor for survival and should be included in future studies of risk performed on larger patient cohorts.

Patients mobilizing large numbers of CD34+ cells (‘super mobilizers’) have improved survival in autologous stem cell transplantation for lymphoid malignancies

The cellular composition of an autologous graft may influence autologous stem cell transplantation (ASCT) outcome. Etoposide (VP) plus filgrastim (G) frequently mobilizes high numbers of CD34+ cells for autologous transplantation. We investigated whether patients collecting high numbers of CD34+ cells ('super mobilizers') have a better outcome than other patients. We reviewed 350 consecutive adult patients with NHL or Hodgkin's lymphoma receiving an ASCT from January 1994 to December 2005, mobilized with VP+G. Super mobilizers were defined as collecting a minimum of 8 x 10(6) CD34+ cells/kg. Two hundred and three patients were super mobilizers, while 147 collected between 2.0 and 7.95 CD34+ cells/kg. Super mobilizers were younger and more likely to have received two or fewer prior chemotherapy regimens (80 versus 63%, P<0.001). Median CD34+ cell dose for the super mobilizing group was 13.7 x 10(6) versus 4.4 x 10(6)/kg in the standard collecting group. The super mobilizer group had a superior overall survival (P=0.006). In multivariable analysis, favorable disease status and younger age at transplant, and super mobilization were associated with improved survival. We conclude that patients had an improved ASCT outcome if large numbers of CD34+ cells were mobilized and infused. The explanation for this observation is unknown.

Assessment of the hematopoietic cell transplantation comorbidity index in non-Hodgkin lymphoma patients receiving reduced intensity allogeneic hematopoietic cell transplantation

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Background: Several patient-related factors influence outcomes after allogeneic hematopoietic cell transplantation (HCT). The Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI), a weighted index of 17 pre-transplant comorbidities, has been validated in non- myeloablative HCT studies, but it has not been tested in non-Hodgkin's lymphoma (NHL) patients receiving reduced-intensity conditioning (RIC) HCT nor has it been compared with a number of other pre-transplant factors. Methods: We performed an analysis of 63 NHL patients treated with RIC HCT to assess the HCT-CI's impact on overall survival (OS), treatment-related mortality (TRM) and disease-related mortality (DRM). Individual factors, including performance status, single comorbidities, CD34 dose, prior chemotherapy number, pre-transplant induction chemotherapy response, and NHL histology, were also analyzed relative to their impact on OS. Prior to transplant, all patients received an identical induction regimen (EPOCH-fludarabine). All patients received identical RIC (Cy/Flu) and were transplanted from HLA-matched siblings. Results: In univariate analysis, each of the above factors, except for histology and CD34 dose, exhibited a trend toward an association with OS (adjusted p<0.10). The HCT-CI (0–2 comorbidities vs. 3+ comorbidities) demonstrated an association with TRM at 100 days (4.5% vs. 26.3%) and 1 year (13.6% vs. 36.8%) post-transplant, but not DRM. The factor most strongly associated with OS was response to induction chemotherapy (CR/PR/SD vs. PD; p=0.0025). In a Cox model for OS, induction chemotherapy response remained the sole important factor, while the HCT-CI and other pre-transplant factors added little predictive value to the induction chemotherapy response. The HCT-CI was more strongly associated with OS and TRM in a subset analysis restricted to patients in CR/PR following induction chemotherapy. Conclusions: These findings suggest that the HCT-CI may be useful for estimating probabilities of TRM and OS in NHL patients being considered for RIC HCT. The data further suggest that chemotherapy response at transplant may have significant impact on transplant outcomes.

No significant financial relationships to disclose.

The inclusion of high-dose therapy and autologous stem cell transplantation (ASCT) in the treatment of follicular lymphoma (FL) is associated with prolonged overall survival (OS) from diagnosis

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Background: Recent studies have suggested that OS for patients (pts) with FL is improving compared with older reports in which median OS was typically 8 to 10 years. We analyzed outcomes for pts with FL undergoing ASCT at any time in the course of the disease to determine whether this contributes to improved OS. Unlike previously reported transplant series, we calculated OS from the date of diagnosis to determine the potential effect of ASCT on the overall course of the disease. Methods: Between 1/79 and 10/05, 188 pts with FL underwent ASCT at our center. Male/female = 103/85. Median age = 47yrs (20–73). Other pt characteristics are summarized in the table . The International Prognostic Index (IPI) was used since data for the FLIPI were only available for a minority of pts. All pts received chemotherapy-only conditioning regimens, most commonly with busulfan, cyclophosphamide and etoposide (82%). OS was calculated from the date of diagnosis, and survival comparisons were made using the logrank test. Results: 120 pts (64%) are alive at a median follow-up of 8.2 years (0.8–23.7 years). Median follow-up from date of transplant is 5.2 years (0.1–15.3 years). The median OS from the date of diagnosis is 15.2 years. IPI at diagnosis was predictive of OS (low-risk median not reached, low-intermediate = 18.3 yrs, high-intermediate = 4.9yrs) (p = <0.001). Status at transplant (CR/PR1 vs CR/PR2 vs CR/PR3 vs relapsed/refractory) had no effect on OS (p = 0.36). Conclusions: The use of ASCT as part of the overall treatment strategy for pts with FL is associated with prolonged OS and may in part be responsible for the reported improvement in survival for FL reported in recent years. Further prospective evaluation of the role of ASCT in the context of treatment regimens which include monoclonal antibodies is required.

No significant financial relationships to disclose.

[Table: see text]

Autologous hematopoietic stem cell transplantation in peripheral T-cell lymphoma using a uniform high-dose regimen

The role of high-dose therapy and autologous stem cell transplantation (ASCT) for patients with peripheral T-cell lymphoma (PTCL) is poorly defined. Comparisons of outcomes between PTCL and B-cell non-Hodgkin's lymphoma (NHL) have yielded conflicting results, in part due to the rarity and heterogeneity of PTCL. Some retrospective studies have found comparable survival rates for patients with T- and B-cell NHL. In this study, we report our single-center experience of ASCT over one decade using a uniform chemotherapy-only high-dose regimen. Thirty-two patients with PTCL-unspecified (PTCL-u; 11 patients) and anaplastic large-cell lymphoma (21 patients) underwent autologous stem cell transplant, mostly for relapsed or refractory disease. The preparative regimen consisted of busulfan, etoposide and cyclophosphamide. Kaplan-Meier 5-year overall survival (OS) and relapse-free survival (RFS) are 34 and 18%, respectively. These results suggest a poor outcome for patients with PTCL after ASCT, and new therapies for T-cell lymphoma are needed.