Systemic mycoses during prophylactical use of liposomal amphotericin B (Ambisome) after liver transplantation

We investigated the prophylactical administration of liposomal amphotericin B (Ambisome) in the early phase after liver transplantation (LTx). Fifty-eight patients received Ambisome prophylactically after LTx. Ambisome (1 mg kg-1 day-1) was given intravenously for 7 days after LTx. Immunosuppressive prophylaxis was cyclosporin A (CsA) based in 11 patients. Forty-seven patients had a tacrolimus-based immunosuppressive regimen. CsA and tacrolimus dosages were adjusted to trough levels of 150-250 ng ml-1 (EMIT) and 5-15 ng ml-1 (MEIA II) respectively. Three patients died from sepsis due to Aspergillus fumigatus infection. Reasons for a fatal outcome were foudroyant Aspergillus pneumonia in a patient transplanted for fulminant hepatic failure on post-operative day (pod) 8; Aspergillus sepsis with severe endocardidtis in a patient with two retransplantations for graft non/dysfunction on pod 24; and disseminated aspergillosis due to Aspergillus fumigatus in a patient retransplanted for primary non-function (pod 19). All three patients underwent haemofiltration for renal failure. One patient with Candida albicans sepsis (pod 4) recovered under increased dosage of Ambisome (3 mg kg-1 per day). Ambisome (1 mg kg-1 per day) seems to be beneficial against systemic Candida infections. However, the onset of systemic Aspergillus infections could not be prevented. Obviously, higher Ambisome doses appear to be necessary against Aspergillus. We recommend the use of Ambisome (3 mg kg-1 per day) for patients with risk factors such as graft dys-/non-function, retransplantation, haemofiltration and complicated acute liver failure to prevent invasive aspergillosis.

Identification of glucoside and carboxyl-linked glucuronide conjugates of mycophenolic acid in plasma of transplant recipients treated with mycophenolate mofetil

1. Mycophenolic acid (MPA), is primarily metabolized in the liver to 7-O-MPA-beta-glucuronide (MPAG). Using RP-h.p.l.c. we observed three further MPA metabolites, M-1, M-2, M-3, in plasma of transplant recipients on MMF therapy. To obtain information on the structure and source of these metabolites: (A) h.p.l.c. fractions containing either metabolite or MPA were collected and analysed by tandem mass spectrometry; (B) the metabolism of MPA was studied in human liver microsomes in the presence of UDP-glucuronic acid, UDP-glucose or NADPH; (C) hydrolysis of metabolites was investigated using beta-glucosidase, beta-glucuronidase or NaOH; (D) cross-reactivity of each metabolite was tested in an immunoassay for MPA (EMIT). 2. Mass spectrometry of M-1, M-2, MPA and MPAG in the negative ion mode revealed molecular ions of m/z 481, m/z 495, m/z 319 and m/z 495 respectively. 3. Incubation of microsomes with MPA and UDP-glucose produced M-1, with MPA and UDP-glucuronic acid MPAG and M-2 were formed, while with MPA and NADPH, M-3 was observed. 4. Beta-Glucosidase hydrolysed M-1 completely. Beta-Glucuronidase treatment led to a complete disappearance of MPAG whereas the amount of M-2 was reduced by approximately 30%. Only M-2 was labile to alkaline treatment. 5. M-2 and MPA but not M-1 and MPAG cross-reacted in the EMIT assay. 6. These results suggest that: (i) M-1 is the 7-OH glucose conjugate of MPA; (ii) M-2 is the acyl glucuronide conjugate of MPA; (iii) M-3 is derived from the hepatic CYP450 system.

Ribosomes inhibit an RNase E cleavage which induces the decay of the rpsO mRNA of Escherichia coli

The hypothesis generally proposed to explain the stabilizing effect of translation on many bacterial mRNAs is that ribosomes mask endoribonuclease sites which control the mRNA decay rate. We present the first demonstration that ribosomes interfere with a particular RNase E processing event responsible for mRNA decay. These experiments used an rpsO mRNA deleted of the translational operator where ribosomal protein S15 autoregulates its synthesis. We demonstrate that ribosomes inhibit the RNase E cleavage, 10 nucleotides downstream of the rpsO coding sequence, responsible for triggering the exonucleolytic decay of the message mediated by polynucleotide phosphorylase. Early termination codons and insertions which increase the length of ribosome-free mRNA between the UAA termination codon and this RNase E site destabilize the translated mRNA and facilitate RNase E cleavage, suggesting that ribosomes sterically inhibit RNase E access to the processing site. Accordingly, a mutation which reduces the distance between these two sites stabilizes the mRNA. Moreover, an experiment showing that a 10 nucleotide insertion which destabilizes the untranslated mRNA does not affect mRNA stability when it is inserted in the coding sequence of a translated mRNA demonstrates that ribosomes can mask an RNA feature, 10-20 nucleotides upstream of the processing site, which contributes to the RNase E cleavage efficiency.

Situs inversus of donor or recipient in liver transplantation

Situs inversus is a rare anatomical abnormality that is often associated with multiple, complex malformations. In the past, patients with situs inversus were considered unsuitable candidates for transplantation or organ donation because associated visceral, and especially vascular, anomalies pose special technical difficulties. Recently, several cases of successful liver transplantation in recipients with situs inversus have been published using modified surgical techniques. This report reviews the literature and describes our own experience, including two liver graft recipients with complete and incomplete situs inversus, and one patient who underwent successful transplantation using a liver from a donor with situs inversus.

Update of current immunosuppressive drugs used in clinical organ transplantation

The outcome of clinical organ transplantations has improved considerably during the last decade, mainly due to the introduction and administration of new drugs for immunosuppression. Our knowledge of basic immune reactions has led to the development of a variety of new immunosuppressants that promise higher selectivity and additive or synergistic drug effects combined with less toxicity. This article gives a brief update of the immunosuppressive currently used in clinical organ transplantation.

Update of current immunosuppressive drugs used in clinical organ transplantation

The outcome of clinical organ transplantations has improved considerably during the last decade, mainly due to the introduction and administration of new drugs for immunosuppression. Our knowledge of basic immune reactions has led to the development of a variety of new immunosuppressants that promise higher selectivity and additive or synergistic drug effects combined with less toxicity. This article gives a brief update of the immunosuppressive currently used in clinical organ transplantation.

Urinary excretion of pyridinium crosslinks and N-terminal crosslinked peptide in preterm and term infants

Urinary excretion of pyridinium crosslinks of collagen, pyridinoline, deoxypyridinoline, and N-terminal crosslinked peptide are now widely used as biochemical markers of bone resorption. In the present cross-sectional study we measured the urinary excretion of total pyridinoline and total deoxypyridinoline by HPLC and N-terminal crosslinked peptide by ELISA in 43 preterm and term newborns in the first 2 months of life. The infants had no history of endocrine or metabolic diseases, bone, chronic heart, or pulmonary diseases. The results were compared by parametric covariance analysis, the HPLC and ELISA results by the Bland-Altman plot. Preterm infants had a statistically higher level of pyridinium crosslinks and N-terminal crosslinked peptide in urine (P < 0.05) than term infants. The very low birthweight infants (gestational age 26-32 weeks) had the highest levels of pyridinoline, deoxypyridinoline and N-terminal crosslinked peptide. Levels of both pyridinium crosslinks and N-terminal crosslinked peptide were independent of sex (P > 0.05). The Bland-Altman plot showed a good agreement between the levels of pyridinium crosslinks and N-terminal crosslinked peptide. Measurement of pyridinium crosslinks and N-terminal crosslinked peptide excretion in small infants gives information about skeletal growth and individual bone turnover, which is dependent on gestational age and birthweight. HPLC and ELISA are reliable methods for the measurement of pyridinium crosslinks and N-terminal crosslinked peptide, respectively.

Effects of soap and detergents on skin surface pH, stratum corneum hydration and fat content in infants

BACKGROUND

In adults the influence of cleansing preparations on the pH, fat content and hydration of the skin is well documented. Studies in newborn and small infants have not been reported.

OBJECTIVE

Our study aimed at examining whether similar effects can be ascertained in infants.

METHODS

Infants without skin disease, aged 2 weeks to 16 months, entered an open, controlled and randomized study. Ten infants each had skin washed with tap water (control group), liquid detergent (pH 5.5), compact detergent (pH 5.5) or alkaline soap (pH 9.5). The pH, fat content and hydration were measured before and 10 min after cleansing. Findings were statistically evaluated by parametric covariance analysis.

RESULTS

The skin pH increased from an average of 6.60 after cleansing in all groups. The smallest increase (+0.19) was observed in the control group, the largest (+0.45) after washing with alkaline soap. After treatment with liquid or compact detergent, the increase of the pH was only 0.09 higher than for the control group. In comparison to the compact and liquid detergents, the alkaline soap group had a significantly higher increase in pH. The fat content (mean starting value: 4.34 micrograms/cm2) decreased after washing in all groups; the smallest effect was observed in the control group (decrease of 0.93 micrograms/cm2), the highest for the alkaline soap group (decrease of 4.81 micrograms/cm2). In comparison to the compact and liquid detergents, the alkaline soap group had a higher decrease in fat content. This difference was significant for compact detergents. No statistically significant differences were observed for hydration before versus after washing.

CONCLUSION

Each cleansing agent, even normal tap water, influences the skin surface. The increase of the skin pH irritates the physiological protective 'acid mantle', changes the composition of the cutaneous bacterial flora and the activity of enzymes in the upper epidermis, which have an acid pH optimum. The dissolution of fat from the skin surface may influence the hydration status leading to a dry and squamous skin.

Pitfalls in monitoring tacrolimus (FK 506)

Tacrolimus (FK 506) is a new, potent immunosuppressive drug for primary and rescue therapy in liver and kidney transplantation. Therapeutic drug monitoring is essential for this drug because of its narrow therapeutic window. Blood levels are monitored routinely by enzyme linked immunoassay (ELISA) or by microparticle enzyme immunoassay (MEIA). In a 13-year-old recipient of a liver transplant who had poor hepatic function during the first postoperative week, the authors observed unusually high tacrolimus blood concentrations using either the ELISA (26.6 to 49.0 microg/l) or MEIA (58.5 to 64.5 microg/l). Parent drug levels measured in the same blood samples by high-performance liquid chromatography/mass spectrometry (HPLC/MS) were up to 10-fold lower (5.1 to 9.0 microg/l). The discrepancies between the immunoassay and HPLC/MS results could not be attributed to any of the known metabolites of tacrolimus.