Dynamic challenges inhibiting optimal adoption of kidney paired donation: findings of a consensus conference

While kidney paired donation (KPD) enables the utilization of living donor kidneys from healthy and willing donors incompatible with their intended recipients, the strategy poses complex challenges that have limited its adoption in United States and Canada. A consensus conference was convened March 29-30, 2012 to address the dynamic challenges and complexities of KPD that inhibit optimal implementation. Stakeholders considered donor evaluation and care, histocompatibility testing, allocation algorithms, financing, geographic challenges and implementation strategies with the goal to safely maximize KPD at every transplant center. Best practices, knowledge gaps and research goals were identified and summarized in this document.

Inhibiting periapical lesions through AAV-RNAi silencing of cathepsin K

Dental caries, one of the most prevalent infectious diseases worldwide, affects approximately 80% of children and the majority of adults. Dental caries may result in endodontic disease, leading to dental pulp necrosis, periapical inflammation and bone resorption, severe pain, and tooth loss. Periapical inflammation may also increase inflammation in other parts of the body. Although many studies have attempted to develop therapies for this disease, there is still an urgent need for effective treatments. In this study, we applied a novel gene therapeutic approach using recombinant adeno-associated virus (AAV)-mediated RNAi knockdown of Cathepsin K (Ctsk) gene expression, to target osteoclasts and periapical bone resorption in a mouse model. We found that AAV-sh-Cathepsin K (AAV-sh-Ctsk) impaired osteoclast function in vivo and furthermore reduced bacterial infection-stimulated bone resorption by 88%. Reduced periapical lesion size was accompanied by decreases in mononuclear leukocyte infiltration and inflammatory cytokine expression. Our study shows that AAV-RNAi silencing of Cathepsin K in periapical tissues can significantly reduce endodontic disease development, bone destruction, and inflammation in the periapical lesion. This is the first demonstration that AAV-mediated RNAi knockdown gene therapy may significantly reduce the severity of endodontic disease.

Simultaneous liver-kidney transplantation summit: current state and future directions

Although previous consensus recommendations have helped define patients who would benefit from simultaneous liver-kidney transplantation (SLK), there is a current need to reassess published guidelines for SLK because of continuing increase in proportion of liver transplant candidates with renal dysfunction and ongoing donor organ shortage. The purpose of this consensus meeting was to critically evaluate published and registry data regarding patient and renal outcomes following liver transplantation alone or SLK in liver transplant recipients with renal dysfunction. Modifications to the current guidelines for SLK and a research agenda were proposed.

Diabetes, hypertension and hyperlipidemia: prevalence over time and impact on long-term survival after liver transplantation

With increasing short-term survival, the transplant community has turned its focus to delineating the impact of medical comorbidities on long-term outcomes. Unfortunately, conditions such as diabetes, hypertension and hyperlipidemia are difficult to track and often managed outside of the transplant center by primary care providers. We collaborated with Kaiser Permanente Northern California to create a database of 598 liver transplant recipients, which incorporates diagnostic codes along with laboratory and pharmacy data. Specifically, we determined the prevalence of diabetes, hypertension and hyperlipidemia both before and after transplant and evaluated the influence of disease duration as a time-dependent covariate on posttransplant survival. The prevalence of these comorbidities increased steadily from the time of transplant to 7 years after transplant. The estimated risk for all-cause mortality (hazard ratio = 1.07 per year increment, 95% CI 1.01-1.13, p < 0.02) and mortality secondary to cardiovascular events, infection/multisystem organ failure and allograft failure (hazard ratio = 1.08 per year increment, 95% CI 1.00-1.16, p = 0.05) increased for each additional year of diabetes. No associations were found for duration of hypertension and hyperlipidemia. Greater attention to management of diabetes may mitigate its negative impact on long-term survival in liver transplant recipients.

The comparative study of former and latest FIGO staging of vulva cancer

AIM

By means of comparing the 2009 staging with the 1994 staging for vulva carcinoma on prognostic predicting, the essay aims to investigate the alterations of clinical decision due to the staging changing.

METHODS

A retrospective analysis was adopted which involves 100 patients with primary squamous cell carcinoma of the vulva treated at Sun Yat-sen University Cancer Center from January 1980 to December 2005. Meanwhile, survival rate was calculated by life table method. In addition, Kaplan-Meirer method was used to evaluate the prognostic factors in univariate analysis. And the independent prognostic factors were provided through COX regression model.

RESULTS

Univariate analysis indicated that the prognostic factors of vulva squamous cell carcinoma were: age (P=0.018), lymph node metastasis (P=0.010), the 1988 staging (P=0.031), the 2009 staging (P=0.001), the number of positive lymphnodes (P<0.001), treatment method (P=0.011), recurrence site (P=0.024). COX regression model indicated that the independent prognostic factor was: the number of positive lymph nodes (P<0.001). Here was not significant difference in overall survival rate (P=0.454) between unilateral or bilateral lymph node metastasis. Also, lesion diameter was not an independent prognostic factor (P=0.380).

CONCLUSION

Compared with the 1994 staging, the 2009 staging made some modifications in lesion size, extension, lymph node status and so on. The 2009 staging is better than the 1994 staging on prognostic predicting and, which could guide the clinical treatment more accurately.

Patient, center and geographic characteristics of nationally placed livers

Once a liver offer has been refused locally and regionally, it is offered nationally. We characterized nationally (n = 1567) versus locally (n = 19 893) placed grafts from adult, nonfulminant, deceased donor liver transplants (LT) from 2/1/05 to 1/31/10. Donors of nationally versus locally placed livers differed by age (50 vs. 42 years), positive HCV antibody (11 vs. 2%) and death from stroke (51 vs. 42%) (p < 0.001 for all). Recipients of nationally versus locally placed livers differed by LT-MELD (20 vs. 24), rates of ascites (35 vs. 37%), encephalopathy (12 vs. 15%), hepatocellular (17 vs. 24%) and nonhepatocellular exceptions (6 vs. 11%) (p ≤ 0.03 for all). Six (5%) centers utilized 64% of the nationally placed grafts while 43 (38%) centers accepted zero during the 5-year period; all high volume centers used ≥1. Compared to local distribution, transplantation with a nationally placed liver was associated with a similar adjusted risk of graft (HR, 0.99; 95% CI, 0.86-1.14) and patient (HR, 0.98; 95% CI, 0.84-1.14; p = 0.77) survival. In conclusion, utilization of nationally placed livers is highly concentrated in very few centers, with no increased adjusted risk of graft loss. These findings provide the foundation for a more informed discussion about changing our current liver allocation and distribution policies.

Octreotide for the treatment of systemic lupus erythematosus: clinical effects and an in vitro study on its therapeutic mechanism

Increased serum growth hormone (GH), together with high expression of growth hormone receptor on peripheral blood mononuclear cells (PBMCs), correlates with systemic lupus erythematosus (SLE) activity, suggesting that modulation of GH signaling may affect SLE activity. We explored the effects of octreotide (OCT), an analog of somatostatin that suppresses the release of GH, in SLE. The objectives of the study were to investigate effects of OCT on the proliferative capacity and cytokine expression of PBMCs from patients with SLE and to investigate therapeutic effects of OCT in patients with SLE. PBMCs from 13 active/inactive SLE patients and 11 controls were pretreated with or without GH and cultured with OCT. The proliferation of PBMCs was assessed by MTT assay and cytokines were quantified by ELISA. We compared the clinical response of 12 patients with SLE treated with OCT (100 µg twice daily) with 12 patients treated with prednisone over three months. OCT inhibited PBMC proliferation in a dose-dependent manner and decreased the secretion of interleukin-6 (IL-6), interleukin-10 (IL-10), and interferon-gamma (IFN-γ). Patients treated with OCT demonstrated improvements in SLEDAI, dsDNA titer, complement levels, and erythrocyte sedimentation rate (ESR). OCT inhibited PBMC proliferation and PBMC secretion of IL-6, IL-10 and IFN-γ stimulated by GH. Treatment of patients with OCT resulted in clinical improvement in SLE.

Decreased risk of graft failure with maternal liver transplantation in patients with biliary atresia

The presence of maternal cells in offspring may promote tolerance to noninherited maternal antigens (NIMAs). Children with biliary atresia (BA) have increased maternal cells in their livers, which may impact tolerance. We hypothesized that patients with BA would have improved outcomes when receiving a maternal liver. We reviewed all pediatric liver transplants recorded in the SRTR database from 1996 to 2010 and compared BA and non-BA recipients of maternal livers with recipients of paternal livers for the incidences of graft failure and retransplantation. Rejection episodes after parental liver transplantation were examined for patients transplanted at our institution. BA patients receiving a maternal graft had lower rates of graft failure compared to those receiving a paternal graft (3.7% vs. 10.5%, p = 0.02) and, consequently, fewer episodes of retransplantation (2.7% vs. 7.5%, p = 0.04). These differences were not seen among non-BA patients or among BA patients who received female deceased donor grafts. In patients transplanted at our institution, paternal liver transplantation was associated with an increased incidence of refractory rejection compared to maternal liver transplantation only in BA. Our data support the concept that maternal cells in BA recipients promote tolerance to NIMAs and may be important in counseling BA patients who require liver transplantation.

P1-08-22: Treatment Patterns and Clinical Outcomes in Elderly Patients with HER2−Positive Metastatic Breast Cancer from the registHER Observational Study

Background: Data are lacking regarding treatment patterns and outcomes in elderly patients (pts) with HER2−positive (HER2+) metastatic breast cancer (MBC).

Methods: registHER is a large, observational cohort of pts with HER2+ MBC diagnosed within 6 months of enrollment. Pts (N=1,001) were followed until death, disenrollment, or June 2009 (median follow-up 27 months). In these analyses, pts were stratified into three groups based on age at MBC diagnosis: younger (&lt;65 years), older (65-74 years), elderly (≥75 years). For Progression Free Survival (PFS) and Overall Survival (OS) analyses of 1st-line trastuzumab (T) vs. no T, older and elderly pts were combined due to small number of events in elderly. Hierarchical multivariate analyses were adjusted for baseline characteristics and treatments.

Results: ER/PR status was similar across age groups (Table 1). Elderly pts with HER2+ MBC had higher rates of underlying cardiovascular disease (CVD) than younger or older pts. In pts receiving T-based 1st-line treatment, elderly pts were less likely to receive chemotherapy (C), and more likely to receive T alone or combined with hormone therapy (HT). Central nervous system (CNS) events decreased with increasing age. In T-treated pts, incidence of left ventricular dysfunction (grade ≥3) was higher in elderly pts (3/63 [4.8%]) than in younger (21/746 [2.8%]) or older pts (2/134 [1.5%]). Across age groups, unadjusted median PFS (months) was significantly higher for pts treated with T in 1st-line than those who were not (&lt;65 years T: 11.0; &lt;65 years no T: 3.4; ≥65 years T: 11.7; ≥65 years no T: 4.8). In pts &lt;65 years, unadjusted median OS (months) was significantly higher in T-treated pts; in pts ≥65 years, median OS was similar (&lt;65 years T: 40.4, &lt;65 years no T: 25.9; ≥65 years T: 31.2, ≥65 years no T: 28.5). In multivariate analyses, T in 1st-line was associated with significant improvement in PFS across age (Table 2). In OS, significant improvement was observed for pts &lt;65 years; results were suggestive for pts ≥65 years.

Conclusions: Elderly pts (≥75 years) with HER2+ MBC in registHER had higher rates of underlying CVD than younger counterparts and received less aggressive treatment, including less 1st-line T. These population-based, real-world data suggest improved PFS with T as 1st-line therapy across all age groups.

Survival time of cardiac allografts prolonged by isogeneic BMT in mice

To find an approach to prolong the survival time of cardiac allografts in a BALB/c-to-C57/BL6 heterotopic heart transplant model and to try to figure out related chemokines and cytokines, isogeneic and allogeneic BM cells were obtained from pregnant C57/BL6 (♀C57/BL6 × ♂BALB/c) and regular BALB/c mice and injected to the half lethally irradiated C57/BL6 mice 1 day before heart transplantation. Recipients were treated with CsA or phosphate-buffered saline for 7 days. Isogeneic BMT (iBMT) from pregnant C57/BL6 mice was observed to significantly prolong the survival of BALB/c allografts and reduce the lymphocyte infiltration. Allogeneic BMT (aBMT) and iBMT both exhibited signicantly less T-cell proliferation reactivity and the similar degree of chimerism. There was no significant difference in these groups of IFN-γ and IL-4 production. The level of chemokine MIG (CXCL9) dramatically decreased in aBMT and iBMT groups compared with the control group. But there were no significant differences between aBMT and iBMT group. IL-17 and RORγ(t) (receptor-related orphan receptor) production were downregulated in iBMT recipients. These results indicate that iBMT can prolong the survival of cardiac allografts. IL-17 production downregulated in iBMT recipients. This means that iBMT may have important therapeutic implications.

Formation of acrylamide at temperatures lower than 100°C: the case of prunes and a model study

Acrylamide concentrations in prune products – baby strained prunes (range = 75–265 μg kg⁻⁻¹), baby apple/prune juice (33–61 μg kg⁻⁻¹), prune juice (186–916 μg kg⁻⁻¹) and prunes (58–332 μg kg⁻⁻¹) – on the Canadian market were determined. The formation of acrylamide in a simulated plum juice was also investigated under ‘drying conditions’ in an open vessel at temperatures <100°C for 24 h and under ‘wet conditions’ in a closed vessel at a temperature of 120°C for 1 h. Acrylamide was produced in a simulated plum juice under ‘drying conditions’ in amounts comparable with those found in prunes and prune juices. Acrylamide was not produced in simulated plum juice under ‘wet conditions’ in a closed vessel at temperature of 120°C for 1 h, but under the same condition an authentic prune juice doubled its acrylamide concentration. Formation of acrylamide in prune products was attributed to the presence of asparagine and sugars in the starting materials.

Determination of melamine, ammeline, ammelide and cyanuric acid in infant formula purchased in Canada by liquid chromatography-tandem mass spectrometry

A liquid chromatography-tandem mass spectrometry-based isotope dilution method was developed for the analysis of the triazine compounds melamine (MEL), ammeline (AMN), ammelide (AMD) and cyanuric acid (CYA) in infant formula samples purchased in Canada in 2008 for the purpose of a combined exposure and risk assessment. Infant formula samples were extracted with 1:1 acetonitrile-water, cleaned up on disposable ion-exchange solid-phase extraction cartridges, and analysed by ultra-high-performance liquid chromatography-tandem mass spectrometry. MEL and CYA were detected in almost all infant formula products: the highest concentrations observed were 0.32 mg kg(-1) MEL and 0.45 mg kg(-1) CYA. Samples that were relatively high in MEL in this survey tended to be low in CYA, and vice versa. Concentrations of AMN and AMD were very low in all samples. The total of MEL-related compounds (sum of all four analytes) in all samples was below the interim standard of 0.5 mg kg(-1) for infant formula products established by Health Canada.

Knockdown of HBV surface antigen gene expression by a lentiviral microRNA-based system inhibits HBV replication and HCC growth

Current options for the treatment of hepatitis B virus (HBV) infections, a common liver cancer risk factor, are limited. While RNA interference (RNAi) technologies have been shown to inhibit HBV replication, the consequent effects on hepatocellular carcinoma (HCC) cell growth are not fully understood. The aim of this study was to evaluate the effect of RNAi-mediated decrease in the HBV surface antigen (HBsAg) gene on HBV replication and HCC growth. A lentiviral microRNA-based system expressing siRNAs targeting the HBsAg gene (LVshHBS) was developed and transfected into HepG2.2.15 cells (HBV stably expressing line). We found that LVshHBS significantly inhibited the HBsAg mRNA and protein levels in the HepG2.2.15 cells, while HBsAg secretion into the culture supernatant decreased by 70%. BALB/c (nu/nu) mice were injected with HepG2.2.15 cells transduced with LVshHBS or control vectors to investigate the effect of inhibiting the HBsAg on the development of tumour growth in a human HCC nude mice model. Compared with the control, the tumour growth in nude mice was significantly decreased after injection with LVshHBS. Microarray analysis of tumour-related genes in LVshHBS-transduced HepG2.2.15 cells showed that the expressions of genes involved in cell cycle, differentiation and oncogenesis such as ACP2, BHLHB2, CLK3, CTSC, FOS, NR1D1, PIM1 and SEPT6 genes were downregulated, while that of the E2F3 gene was upregulated. In conclusion, lentiviral microRNA-based RNAi against the HBsAg gene not only inhibits HBV replication but also inhibits the growth of HCC. Downregulation of growth-related genes is implicated in this mechanism of inhibition.