Preliminary results of treatment of chronic hepatitis C with recombinant interferon alpha in renal transplant patients

Chronic hepatitis C is a common cause of viral liver disease in kidney transplant recipients. To assess the efficacy and the safety of therapy with interferon alpha (IFN alpha) in such a population we conducted a prospective study where 16 kidney transplant recipients with chronic hepatitis C received recombinant IFN alpha 3 million units three times weekly scheduled for 24 consecutive weeks. All the patients had stable renal function for at least 1 year (mean serum creatinine 125.4 +/- 41 mumol/l). Fifteen patients had a positive HCV viraemia at the beginning of the study. In 15 patients serum alanine aminotransferase (ALT) levels decreased rapidly and normalized (48 +/- 44 vs 98.5 +/- 46 IU/l; P = 0.0044). ALT remained in the normal range as long as IFN alpha was continued. Serum levels of gamma glutamyl transpeptidase decreased from 129.75 +/- 111.2 to 88 +/- 85 IU/l; P = 0.012). After discontinuation of IFN alpha therapy seven responders relapsed within 1-9 weeks. HCV viraemia assessed 1 month after the end of IFN alpha therapy remained positive in all the patients who scored positive at the beginning, i.e. 15. Side effects of IFN alpha (fatigue, anorexia, weight loss) were frequent leading to four patients dropping out of the study. The haematological tolerance was moderate. The major concern was the increase in serum creatinine (162.5 +/- 57.6 vs 125.4 +/- 41 mumol/l; P < 0.05). In fact only six patients experienced renal failure occurring 45-168 days after the beginning of IFN alpha. Kidney transplant biopsies showed oedema, scarce scattered interstitial inflammatory cellular infiltration and moderate mesangial hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal functional reserve in calcium channel blocker-treated hypertensive recipients of kidney transplant

Renal functional reserve during infusion of an amino acid solution was examined in 12 cyclosporin-treated kidney recipients at 1 (T1) and 8 months (T2) after transplantation. Patients were retrospectively divided into six normotensive (NT) and six hypertensive recipients (HT) maintained on monotherapy with a calcium channel blocker. Baseline glomerular filtration rates (GFR) were similar in NT and HT at T1 and T2. Renal functional reserve was identical in NT and HT at T1 (15 +/- 7 vs 18 +/- 13 ml/min/1.73 m2) but significantly greater in HT at T2 (11 +/- 5 vs 23 +/- 10 ml/min/1.73 m2; P < 0.05). At T2, baseline proximal tubule outflow (lithium clearance) was greater in HT (26 +/- 8 vs 16 +/- 3 ml/min/1.73 m2; P < 0.05), whereas fractional proximal reabsorption was less (54 +/- 11% vs 67 +/- 5%; P < 0.05). These results indicate that: (i) hypertensive recipients on calcium channel blocker therapy do not exhibit permanent glomerular hyperfiltration until 8 months after transplantation, and have a reduced proximal reabsorption; (ii) measurement of amino acid-stimulated GFR and renal functional reserve is a more sensitive method than that of baseline GFR for evaluating renal function and the effects of therapy in kidney recipients.

[Stenosis of the renal artery of the transplant: comparison between interventional and medical treatment]

In a retrospective analysis of 542 renal transplantations performed over a 10 years period, we diagnosed 25 cases of renal allograft artery stenosis that is a prevalence of 4.6%. The reason for angiography was persistent hypertension and/or renal insufficiency. An interventional procedure was performed in 16 patients (group 1): surgery in 5 and transluminal angioplasty (PTA) in 11. Nine other patients were medically treated (group 2). PTA or surgery was undertaken when a significant stenosis (> 70%) was found and when hypertension was severe (mean PAM = 123 +/- 11 mmHg). PTA was primarily performed when the anatomical situation of the stenosis was judged suitable. Medical treatment was chosen because the stenosis was assesses as not being severe enough or because was considered unsuitable for correction. Interventional treatment was successful in 77%. Long term results are shown in the table: in both 2 groups blood pressure decreased significantly at mean follow-up; the number of antihypertensive drugs decreased non significantly but are still necessary in the group 1. Mean serum creatinine is not significantly modified after treatment, there is no degradation of renal function in group 2 and no amelioration in group 1.

Renal functional reserve in cyclosporin-treated recipients of kidney transplant

The aims of this study were to determine whether renal functional reserve (RFR) is still present in cyclosporin-treated renal transplant recipients, and to examine the relationship between RFR and proximal reabsorption. A serial study was carried out in 12 renal allograft recipients (R) with good renal graft function at 20 +/- 2.5 days (S1) and at 7.6 +/- 0.4 months (S2) post-transplantation, and the results were compared to those in eight subjects who had undergone unine-phrectomy (one-kidney controls: UNx.C) and in 12 healthy volunteers (two-kidney controls: 2K.C). R and C were in similar sodium and protein balance and with similar plasma renin and aldosterone levels. R had normal serum creatinine level on moderate doses of cyclosporin (whole blood cyclosporin concentration: 212 +/- 20 and 125 +/- 20 ng/ml at S1 and S2, respectively). Eight one-hour clearance periods were performed prior to, during and following a three-hour i.v. infusion of a mixture of 20 l-amino acids (Azonutril 25, 4.5 mg amino acids/kg/min). Baseline glomerular filtration rate (GFR) was lower in recipients at S1 and S2 (55 +/- 5 and 54 +/- 4 ml/min/1.73 m2, respectively) than in UNx.C and 2K.C (72 +/- 4 and 113 +/- 4 ml/min/1.73 m2, respectively, P < 0.05 and 0.001). Amino acid infusion elicited significant GFR increases in controls as well as in recipients in spite of higher renal vascular resistances (RVR). The greater measured increase in GFR, which represented RFR, was 18 +/- 3 and 28 +/- 2 ml/min/1.73 m2 in UNx.C and 2K.C, respectively (P < 0.001), and 17 +/- 3 ml/min/1.73 m2 in R at both S1 and S2 (P < 0.001). Contrary to both UNx and 2K controls, the acute hyperfiltration in R at S1 and S2 occurred with a significant increase in effective renal plasma flow, no alteration in filtration fraction and a large decrease (approximately 20 and 17%) in RVR while no correlation could be detected between the RFR and baseline GFR. Baseline lithium clearance, used as a marker of overall proximal fluid delivery (CLi), was significantly lower, whereas baseline fractional excretion of lithium (FELi) was significantly higher in R at S1 and S2 and in UNx.C (41 +/- 4, 40 +/- 3 and 38 +/- 3%, respectively) than in 2K.C (31 +/- 2%, P < 0.05). Consistent and significant increase in CLi, FELi and absolute proximal reabsorption occurred both in R at S1 and S2 and in UNx and 2K controls during elicitation of RFR.(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term follow-up of monoclonal gammopathy of undetermined significance in transplant patients

We report the long-term follow-up of 5 patients (4 kidney, 1 heart recipients) having a pretransplant monoclonal gammopathy of undetermined significance (MGUS). The follow-up of MGUS before transplantation was 41.2 +/- 40.7 months (range 2-108). The monoclonal component isotype was IgG-kappa in 3 cases and IgA-lambda in 2. The pretransplant level of the monoclonal component was 11.1 +/- 4.8 g/l (range 4-15.6). The transplant recipients who had MGUS were older than our other transplant patients. All but one of them received ciclosporine A. They did not experience more rejection or infectious complications than the others. Their posttransplant follow-up ranged from 3 to 9 years. The monoclonal component level remained stable in 2 patients but increased in 3 (33-225%). This was not correlated with bone marrow plasmocytosis. Two patients developed smoldering myeloma indicated by bone marrow immunochemistry studies which showed monomorph monoclonal plasma cells; nevertheless, they did not have cytopenia or bone lytic lesions. This percentage is higher than in the Kyle study but we cannot assume that it is due to ciclosporine A since our study sample is too small. In conclusion, MGUS is not a contraindication to organ transplantation.

Pharmacokinetics of carboplatin in a patient suffering from advanced ovarian carcinoma with hemodialysis-dependent renal insufficiency

Pharmacokinetics of carboplatin were determined in a patient suffering from advanced ovarian cancer with total hemodialysis-dependent chronic renal failure undergoing 3 consecutive cycles of chemotherapy. Dosage was adjusted to reach active AUC (area under the plasma concentration versus time curve) of ultrafilterable carboplatin. A hemodialysis, performed 24 h after administration results in a decrease of 20% of ultrafilterable carboplatin AUC. The relative dialysis efficacy of ultrafilterable carboplatin was great: 84 +/- 3%. The chemotherapy regimen consisted of carboplatin-cyclophosphamide combination for 6 cycles every 4 weeks. After treatment completion, the patient showed a complete response and remains disease free 16 months after the end of the treatment. Carboplatin-based chemotherapy can be given to patients undergoing chronic hemodialysis without life-threatening toxicity with a dialysis performed 24 h after the administration and with a dose adjustment of carboplatin to reach a AUC of 6 mg/ml.min for untreated patients. In these conditions, response in platinum-sensitive tumors can be obtained.

Renal oncocytoma in transplant patients: report of 2 cases

We report on 2 cases of renal oncocytoma occurring in a liver transplant patient and in a kidney allograft recipient, respectively, during the posttransplant period. This neoplasm has never been reported in transplant patients; its relationship with long-term immunosuppressive therapy is questioned.

[Study of CD45 isoforms on T CD8 lymphocytes, in the peripheral blood and the graft in patients after kidney transplantation]

We report characterization of CD45 isoforms expressed by CD8+ lymphocytes in peripheral blood and in the graft of 40 kidney transplanted patients who underwent kidney biopsy on the basis of clinical signs suggesting rejection. Standard histological examination of the biopsy fragments and three-color cytofluorimetric analysis of lymphocytes extracted from the same fragments by mechanical and enzymatic treatment were performed simultaneously and compared to the peripheral blood lymphocytes. In 14/40 biopsies where lymphocyte extraction succeeded, the predominant subset was CD8 (CD4/CD8 mean ratio was 0.53). Almost all CD8+ cells were activated: among these CD8+ cells, 55 percent were HLA-DR+, and 68 percent CD45RO+, i.e. of a memory cell type with cytotoxic activity. This situation resembles the in vitro observation made during mitogenic stimulation of lymphocytes by phytohemagglutinin, OKT3 or CML ("culture mixte lymphocytaire"). Beside their evident interest for the diagnosis, these data could be useful for our understanding of the physiopathology of the rejection crisis.

[Optimization of renal transplantation]

In 1990, 1,949 renal transplantations were performed in France, with a graft survival rate of 89% at one year and 70% at five years. To improve on these results it would be necessary to pursue a dynamic policy in all fields of transplantation: in view of the ever growing number of patients on the transplantation list, more kidneys should be collected; hyperimmunized recipients should undergo reinforced exchanges to have compatible kidneys; immunosuppression must be optimized: just a using cyclosporin and monoclonal antibodies has resulted in a significant advance, so should the discovery of new drugs, such as FK 506, or of more specific monoclonal antibodies, be a source of progress; the complications of immunosuppression must be controlled: prevention protocols and antiviral treatments have considerably reduced the incidence of viral infections. The emergence of malignant tumours directly related to the degree of immunosuppression can be prevented by a rational use of immunosuppressants and by systematic detection. All these advances make it possible to extend the indications of renal transplantation to subjects at risk, notably patients more than 60 years old, and diabetic patients who can successfully benefit from a dual kidney-pancreas transplantation.

[Influence of angiotensin on the secretion of aldosterone in idiopathic hyperaldosteronism]

The purpose of study was to investigate the role of angiotensin II in idiopathic primary aldosteronism (IPA) and to evaluate the interest of angiotensin converting enzyme inhibitors (ACEI) in its management. The study concerned 10 hypertensive patients, mean 49 +/- 11 years with idiopathic primary aldosteronism due to bilateral adrenal hyperplasia: plasma renin activity (PRA) less than 1.5 ng/ml/h and plasma aldosterone (PA) greater than 25 ng/100 ml. Adrenal venography and adrenal vein aldosterone levels demonstrated bilateral hyperplasia. PRA and PA were evaluated in recumbent position, then after 4 hours in upright posture. The next day, a "captopril screening test" was performed with PA assays before and three hours after a single oral administration of captopril (1 mg/kg). Upright PRA and PA were slightly increased and acute administration of captopril reduced significantly PA levels in all patients. Blood pressure (BP was unmodified under captopril. These hormonal results demonstrated that adrenal glomerulosa remained sensitive to low concentrations of angiotensin II, and underlined the potential interest of ACEI in the management of IPA. Brown R. demonstrated already an increase of adrenal sensitivity to angiotensin II infusions, and isolated an aldosterone-stimulating factor (ASF). Plasma aldosterone levels were related to increased ASF concentrations but there was no link between PRA and ASF. Carey R. suggested that ASF acts through an increase of the sensitivity of aldosterone production to angiotensin II.(ABSTRACT TRUNCATED AT 250 WORDS)