Summary of FDA workshop on ischemia reperfusion injury in kidney transplantation

The Food and Drug Administration (FDA) held an open public workshop in September 2011 to discuss the current state of science related to the effects of ischemia reperfusion injury (IRI) on outcomes in kidney transplantation. Topics included the development of IRI and delayed graft function (DGF), histology and biomarkers, donor factors, recipient factors, organ quality and organ preservation by means of cold storage solutions or machine perfusion. Various mechanisms of injury and maladaptive response to IRI were discussed as potential targets of intervention. Animal models evaluating specific pathophysiological pathways were presented, as were the limitations of extrapolating animal results to humans. Clinical trials of various drug products administered in the peri-transplant period were summarized; a few demonstrated early improvements in DGF, but none demonstrated an improvement in late graft function. Clinical trial design for IRI and DGF were also discussed.

Nodal involvement evaluation in advanced cervical cancer: a single institutional experience

PURPOSE

To assess the usefulness of different imaging techniques in the detection of nodal involvement in patients with advanced cervical carcinoma. Moreover, to analyze the correlation between the presurgical (FIGO) and postsurgical (pTNM) staging classifications.

MATERIALS AND METHODS

All patients diagnosed with advanced cervical cancer (FIGO Stages IIB-IV) from 2005 to 2012 were selected. The medical charts of 51 patients that underwent presurgical assessment with posterior surgical staging by means of para-aortic lymphadenectomy, were reviewed. Nodal status assessment by computed tomography scan (CT scan), magnetic resonance imaging (MRI), positron emission tomography (PET), and sonography was compared, as well as the size given in imaging techniques compared to the final pathologic report information.

RESULTS

Presurgical analysis by CT scan, MRI, PET, and sonography showed pelvic nodal involvement in 51.3% of patients, and para-aortic involvement in 30.8% of cases. CT scan showed positive pelvic nodes in 35% of cases, but pathologic confirmation was observed in just 17.6% of cases. However, MRI resulted in higher rates of up to 48.8% of cases. Concerning para-aortic nodal involvement, CT scan showed positive nodes in 25% of cases, MRI in 3.2% of cases, and the pathologic report in 15.6% of cases. The authors found significant differences between staging groups among both classifications (FIGO vs. pTNM; p < 0.001). Eight cases (15.7%) were understaged by FIGO classification.

CONCLUSIONS

Despite all imaging techniques available, none has demonstrated to be efficient enough to avoid the systematic study of para-aortic nodal status by means of surgical evaluation.

[Central diabetes insipidus: diagnosis and management]

Central diabetes insipidus (CDI) is caused by deficient secretion of antidiuretic hormone (ADH) due to different conditions that can affect the hypothalamic neurons. It results in an inability to retain normal quantities of free water, which leads to polyuria, including at night, and polydipsia. In adults, it is mostly due to the "idiopathic" form or present after pituitary surgery or a traumatic brain injury. In rare cases, an underlying systemic disease is found. The diagnosis of CDI is based on the water deprivation test. Pituitary MRI and specific clinical and biological work-up are recommended to precise etiology. Treatment of choice is desmopressin, a synthetic analogue of the endogenous ADH hormone. A multidisciplinary team generally provides management and monitoring of CDI.

Reduction in porphyrin excretion as a sensitive indicator of lead toxicity in primary cultures of adult rat hepatocytes

Alterations of specific metabolic pathways can be used as sensitive indicators of toxicity by chemicals and can give valuable information on the mechanism(s) involved. Short-term effects of lead on hepatic haem biosynthesis were studied in an in vitro system. Primary cultures of adult rat hepatocytes were exposed for 24-48 hr to lead (0.024-3.6 mm), and excreted and intracellular porphyrins were measured in untreated and lead-treated cultures. Cytotoxicity, as estimated by enzyme leakage, and morphological alterations were also evaluated. Control hepatocytes produced porphyrins at a rate of 387 pmol/mg cellular protein/day. Most of the released and intracellular porphyrins were protoporphyrins, although uro- and coproporphyrins were also detected in lower amounts. After 24 hr of exposure to 0.1-3.6 mm Pb(2+) , excreted porphyrins decreased by 24-92% and intracellular porphyrins by 36-60%, while 48 hr of exposure to 0.024-3.6 mm Pb(2+) caused a progressive reduction of 77-97% in porphyrin excretion and of 49-67% in intracellular porphyrins. Lead exposure also produced a differential decrease of proto-, copro- and uro-porphyrin excretion. These lead effects can be explained mainly by inhibition of the enzyme 5-aminolaevulinate dehydratase, resulting in a decreased monopyrrole supply for porphyrin biosynthesis, and probably by inhibition of the enzyme uroporphyrinogen decarboxylase. Morphological alterations and enzyme leakage were detected only after 24 hr of exposure to 2.4 mm and 48 hr of exposure to 3.6 mm Pb(2+), respectively. The results show that changes in porphyrin production, and particularly in their excretion, in cultured rat hepatocytes are useful indicators of lead toxicity, since they are more sensitive than enzyme leakage and can give preliminary information on the enzyme(s) that could be affected. They also suggest the potential benefits of the use of this method for the evaluation of compounds that alter haem biosynthesis.

Metagenomics and antibiotics

Most of the bacterial species that form part of the biosphere have never been cultivated. In this situation, a comprehensive study of bacterial communities requires the utilization of non-culture-based methods, which have been named metagenomics. In this paper we review the use of different metagenomic techniques for understanding the effect of antibiotics on microbial communities, to synthesize new antimicrobial compounds and to analyse the distribution of antibiotic resistance genes in different ecosystems. These techniques include functional metagenomics, which serves to find new antibiotics or new antibiotic resistance genes, and descriptive metagenomics, which serves to analyse changes in the composition of the microbiota and to track the presence and abundance of already known antibiotic resistance genes in different ecosystems.

[Arterial blood pressure circadian rhythm: significance and clinical implications]

Arterial blood pressure circadian rhythm: significance and clinical implications Arterial blood pressure exhibits a circadian rhythm characterized by a decrease during the sleep period and a steep increase in the early morning hours that can be characterized by 24 h ambulatory blood pressure monitoring (ABPM). The absence of a nocturnal dipping or an excessive morning surge, commonly observed in hypertensive patients, is associated with an increased cardiovascular and renal risk. Numerous studies show that a better control of nocturnal blood pressure can be obtained by the administration of anti-hypertensive medication at the evening time, improving microalbuminuria, left heart hypertrophy, or arterial intima-media thickness, but only one study has so far demonstrated a decrease of major cardiovascular events. In this context, the decision on restoring or not the nocturnal dipping should be left to the judgement of the clinician, and applied in an individual manner to each patient.

[Is ABPM an extension of a well done physical examination?]

Hypertension is a key risk factor for developing cardiovascular and renal diseases and one of the most important causes of morbidity and mortality worldwide. Iterative measurement of the clinical blood pressure is the method proposed by international and national organizations to establish the diagnosis of hypertension. However, current data suggest that neither in-hospital nor self home blood pressure measurement is sensitive and specific enough for one to recommend them as the sole diagnostic test. More accurate diagnosis of hypertension would allow a significant cost saving by reducing both cardiovascular and renal complication burden, and costs induced by erroneously diagnosing normal subjects as hypertensives. Therefore, 24h ABPM is increasingly becoming the gold standard for diagnosing hypertension.