The effects of glucocorticoid therapy

Patient and Graft Survival Outcomes During 2 Eras of Immunosuppression Protocols in Kidney Transplantation: Indiana University Retrospective Cohort Experience

BACKGROUND

Since 1964 when Indiana University performed its first kidney transplant, immunosuppression protocol was steroid-based until 2004 when steroid-free immunosuppression protocol was adopted. We describe clinical outcomes on our patients administered early steroid withdrawal (ESW) protocol (5 days) compared with our historical cohort (HC), who were on chronic steroid-based immunosuppression.

METHODS

We performed a retrospective study evaluating kidney transplant recipients between 1993 and 2003 (HC, n = 1689) and between 2005 and 2016 (ESW cohort, n = 2097) at the Indiana University program, with a median follow-up of 10.5 years and 6.1 years, respectively. Primary outcomes were patient and death-censored graft survival at 1, 3, and 5 years in both study cohorts. Secondary outcomes were 1-year rates of biopsy-proven acute rejection; graft function at 1, 3, and 5 years; and risk of post-transplant infection (BK virus and cytomegalovirus) in the ESW cohort. Cox proportional model and Kaplan-Meier estimates were used to estimate survival probabilities. Fisher exact tests were used to compare episodes of acute rejection in the ESW cohort.

RESULTS

No difference was observed in patient survival between the ESW and HC cohorts (P = .13). Compared with the ESW cohort, death-censored graft survival was significantly worse in the HC (5 year: 86.4% vs 90.6%, log-rank P < .001). One-year acute rejection reported in the ESW cohort alone was 15.7% and significantly worse in Black patients and younger patients (P < .05).

CONCLUSIONS

In this sizeable single-center cohort study with significant ethnic diversity, ESW is a viable alternative to steroid-based immunosuppression protocol in kidney transplant recipients.

Immunoexpression of calcitonin and glucocorticoid receptors in central giant cell lesions of the jaws

BACKGROUND

This study analyzed the immunoexpression of calcitonin receptor (CTR) and glucocorticoid receptor (GR) in central giant cell lesions (CGCLs) and verified potential associations with patient's response to clinical treatment with intralesional injection of triamcinolone.

MATERIALS AND METHODS

Fifty-four cases of CGCLs, including 22 non-aggressive, and 32 aggressive, were investigated by immunohistochemistry.

RESULTS

Surgery was the therapeutic choice for 53.1% of the aggressive CGCLs, and 46.9% were submitted to the conservative treatment with intralesional triamcinolone injections. Among patients submitted to conservative treatment, 60% (n = 9) showed favorable response. CTR expression was observed in 68.51%, and GR in 94.44% of the total sample. There were no differences in the expression of CTR, neither GR in mononucleated stromal cells (MSCs) or multinucleated giant cells (MGCs), in relation to aggressiveness, treatment performed for and the response to conservative treatment. Both markers showed a positive correlation between their expression in MSCs and MGCs in the total sample (P < 0.0001). CTR expression on MSCs showed a positive correlation with MGCs in the aggressive and non-aggressive groups (P < 0.0001).

CONCLUSIONS

Calcitonin receptor and GR expression were diffuse and similar in non-aggressive and aggressive cases, and it did not influence the response to clinical treatment with triamcinolone in the sample studied.

Venous Thromboembolism and Malignant Brain Tumors: A Review

The incidence of venous thromboembolism (VTE) in patients with primary brain tumors varies be tween 1 and 60%. This variability in incidence is due to study differences in (a) methods of diagnosis of VTE— i.e., diagnosis at autopsy or clinical diagnosis; (b) amount of time from surgery to VTE diagnosis; (c) proportion of patients receiving deep venous thrombosis (DVT) pro phylaxis ; (d) clinical risk factors associated with VTE, such as paresis, prior thrombotic disease, and chemother apy; and (e) tumor location and histology. The etiology of VTE in patients with primary brain tumors is unknown. The preoperative hemostatic abnormalities noted in clin ical studies have been most consistent with compensated disseminated intravascular coagulation (DIC). These ab normalities, however, appear to be of little predictive value for the subsequent development of VTE. Studies involving brain tumor tissue or cell cultures have impli cated factors released by the tumor or surrounding neural tissue that activate the coagulation system or inhibit fi brinolysis. Recommendations for VTE prophylaxis in clude (a) earliest possible ambulation; (b) intermittent pneumatic compression in all nonambulatory patients preoperatively and postoperatively; and (c) s.c. heparin in high-risk patients. The role of low-molecular-weight heparin in VTE prophylaxis has not been established. Patients with malignant brain tumors can be safely anti coagulated with heparin and warfarin if these agents are carefully monitored. Of 197 patients in seven series who received anticoagulants, only 5 (2.5%) had intracranial bleeding. Vena caval filters and thrombectomy are rarely required. Thrombolytic therapy is contraindicated. Key Words: Venous thromboembolism—Deep venous throm bosis—Malignant brain tumors.

Advances in pharmacotherapy to treat kidney transplant rejection

INTRODUCTION

Current immunosuppressive combination therapy provides excellent prevention of T-cell-mediated rejection following renal transplantation; however, antibody-mediated rejection remains of high concern and accounts for a large number of long-term allograft losses. The recent development of protocol biopsies resulted in the definition of subclinical rejection (SCR), showing histologic evidence for rejection but unremarkable clinical course.

AREAS COVERED

This review describes the current knowledge and evidence of pharmacotherapy to treat kidney allograft rejections and covers SCR treatment options. Each substance is analyzed with regard to its classical indication and further discussed for the treatment of other forms of rejection.

EXPERT OPINION

Despite a lack of randomized trials, early acute T-cell-mediated rejection can be treated effectively in most cases without graft loss. The necessity to treat SCR is currently unclear. Due to a lack of effective therapies, new treatment approaches for antibody-mediated rejection are an urgent medical need to improve long-term outcomes. Future research should aim to better define pathophysiology and histology, stratify risk, and develop rational treatment strategies from randomized controlled trials, in order to establish the value of novel therapies in the arsenal of rejection pharmacotherapy. However, the effective prevention of rejection with minimal side effects still remains the goal in immunosuppression.

Steroids in kidney transplant patients

Any evaluation of steroids in kidney transplantation is hampered by individual variability in metabolism, the lack of clinically available steroid blood levels, and overall little attention to steroid exposure. Many feel that steroids were an essential part of chronic immunosuppression in past decades but may no longer be necessary in low-risk populations when our newer and more potent drugs are used. Potential differences in long-term outcome will be unapparent in short-term antibody induction studies in low-risk patients, particularly with low on steroid doses, as may have happened in the recent, well-done Astellas trial. In many studies, the evidence for the superiority of mycophenolate (MMF) and tacrolimus (TAC) was not as strong as the evidence for the benefit of steroids in the Canadian cyclosporine study. As the practice of steroid withdrawal has increased, we have not seen the improvement in long-term graft survival that many expected with our newer agents. Steroids have immunosuppressive effects even in doses that are low by historic standards, and side effects may not justify their abandonment.

Intralesional injection of triamcinolone hexacetonide as an alternative treatment for central giant-cell granuloma in 21 cases

Central giant-cell granulomas are benign, but occasionally aggressive, lesions that traditionally have been treated surgically. 21 cases of central giant-cell granuloma of the jaw were treated with intralesional injection of corticosteroids. The treatment protocol adopted was intralesional injection of 20mg/ml triamcinolone hexacetonide diluted in an anaesthetic solution of 2% lidocaine/epinephrine 1:200,000 in the proportion 1:1; 1.0ml of the solution was infiltrated for every 1cm(3) of radiolucid area of the lesion, totalling 6 biweekly applications. Ten patients had aggressive lesions and 11 nonaggressive. Two patients showed a negative response to the treatment and underwent surgical resection, 4 showed a moderate response and 15 a good response. 8 of the 19 who had a moderate-to-good response to the drug treatment underwent osteoplasty to reestablish facial aesthetics. In these cases, only mature or dysplastic bone was observed, with the presence or absence of rare giant multinucleated cells. The advantages of this therapy are its less-invasive nature, the probable lower cost to the patient, lower risk and the ability to treat the lesion surgically in the future, if necessary.

Avaliação da recuperação do eixo hipotalâmico-hipofisário-adrenal após corticoterapia por meio do cortisol basal

A suspensão da corticoterapia é a causa mais comum de insuficiência supra-renal, e ainda persistem dúvidas quanto à melhor forma de avaliação da inibição e recuperação do eixo hipotalâmico-hipofisário-adrenal (HHA) provocada pelos glicocorticóides. O objetivo deste estudo foi avaliar a utilidade da dosagem do cortisol basal na avaliação desta insuficiência. Foram avaliadas 35 crianças (mediana da idade de 6,9 anos) submetidas ao tratamento preconizado pelo Grupo Brasileiro para o tratamento da Leucemia Linfocítica Aguda (LLA). O teste de estímulo com o hormônio liberador da corticotrofina (CRH 1 mcg/kg) foi realizado antes da introdução da dexametasona (6 mg/m²/dia, por 28 dias), no 8º e no 28º dias do uso do glicocorticóide e 48 horas e um mês após sua retirada. Houve inibição da secreção do cortisol basal e da concentração máxima (após CRH) durante a corticoterapia e 48 horas após sua suspensão, em relação ao valor obtido antes do tratamento (p< 0,01 e p< 0,0001, respectivamente, para os três exames). Um mês após o término da corticoterapia, o valor do cortisol basal e a concentração máxima não apresentavam diferença significativa em relação ao aferido antes do tratamento. Observou-se correlação positiva e significativa entre as concentrações basais e máximas do cortisol em todos os testes realizados. Observou-se, ainda, que ao considerarmos o limite inferior de cortisol basal de 8,5 mcg/dl obtivemos 95% de especificidade para o diagnóstico da insuficiência adrenal. Concluímos que o uso do cortisol basal é de utilidade como marcador da função supra-renal em crianças durante a suspensão do tratamento e após corticoterapia.

Designer glucocorticoids

Glucocorticoids are the most effective anti-inflammatory agents known. However, the use of these powerful molecules is plagued by a host of serious, sometimes life-threatening side-effects. The search for new compounds that maintain the efficacy of the steroids without some of the side-effects has entered a new phase. New approaches are leading to novel kinds of steroidal and non-steroidal compounds with unique profiles that may represent the next generation of safer glucocorticoids.

Cortisolemic indices predict severe infections in Cushing syndrome due to ectopic production of adrenocorticotropin

Because high circulating levels of glucocorticoids impair immunity and predispose to infections, we evaluated whether indices of cortisol (F) production could predict infections in patients with Cushing syndrome (CS) caused by ectopic production of ACTH (EA). Charts of 54 consecutive patients with untreated EA, without underlying diagnosis of small cell carcinoma of the lung, were reviewed, and types of infections, white blood cell (WBC) count, fever, as well as the glucocorticoid indices [0800 h F, daily urine F excretion (UFC), and daily urine 17-hydroxysteroid/g creatinine excretion (17OHS)], were recorded. Thirty-five patients had no or clinically mild infection; the remaining 19 patients had severe, systemic infection (n = 13) and/or sepsis (n = 6), including either bacterial or opportunistic pathogens or both (73.7%, 42.1%, and 13.8%, respectively). The latter group of patients had significantly higher indices of hypercortisolism (F, UFC, and 17OHS) than those with mild or no infections, but these indices did not correlate with temperature or WBC count. Thresholds for identifying severe infection were selected for maximal positive predictive value and were: F, 43.1 microg/dL; UFC, 2000 microg/day; and 17OHS, 35 mg/g creatinine. The most accurate discriminator for severe infection was 17OHS, based on a positive predictive value of 64.7%. Our data strongly suggests that the likelihood for a bacterial or opportunistic infection in CS patients, even without underlying small cell carcinoma of the lung, is greatest in patients with extreme hypercortisolism. The predictive value of total WBC count or the presence of an elevated temperature is not sufficient to identify patients with severe, life-threatening infection.

Ibuprofen inhibits leukocyte migration through endothelial cell monolayers

During inflammation leukocytes are playing a tremendous role in the defense against bacterial infections. Tumor necrosis factor alpha (TNF alpha) increases adhesion of leukocytes to endothelial cells. The non steroidal anti-inflammatory drug ibuprofen is able to reduce inflammatory processes in humans and is a widely used drug. The influence of ibuprofen on TNF-alpha-induced expression of adhesion molecules on endothelial cells is well investigated and has been published recently by our group. For leukocyte migration, leukocytes have to attach and finally migrate through monolayers of endothelial cells. The aim of the current study was to investigate leukocyte migration through endothelial cell monolayers (ECM) under ibuprofen using a migration assay system. Ibuprofen was identified as a potent inhibitor of the leukocyte migration through endothelial cell monolayers in a dose dependent manner. The treatment of either leukocytes (87 +/- 17.6 %; p>0.05) or endothelial cell monolayers (62.5 +/- 9.4 %; p<0.05) showed that the influence is more mediated through endothelial cells, the treatment of both cell types demonstrated an additive effect. In conclusion, the previously published changes of adhesion molecules on endothelial cells could be confirmed with this functional migration test. The inhibition of the leukocyte migration may contribute to the anti-inflammatory actions of the drug.

Ibuprofen inhibits pyrogen-dependent expression of VCAM-1 and ICAM-1 on human endothelial cells

Leukocyte adhesion and transmigration through the endothelial cell (EC) layer plays a crucial role in inflammation. IL-1 alpha and TNF alpha increase EC-adhesiveness for leukocytes by stimulating surface expression of ICAM-1 (intercellular adhesion molecule 1, CD54), VCAM-1 (vascular cell adhesion molecule 1, CD106) and E-selectin (CD62E). In this study, the effects of ibuprofen on IL-1 alpha and TNF alpha-induced expression of ICAM-1, VCAM-1 and E-selectin on cultured human umbilical vein EC (HUVEC) were analyzed. Exposure to IL-1 alpha or TNF alpha resulted in an increased expression of VCAM-1, ICAM-1, and E-selectin. Ibuprofen was identified as a potent inhibitor of IL-1 alpha and TNF alpha-induced surface expression of VCAM-1 and a less potent inhibitor of pyrogen-induced expression of ICAM-1, whereas no effect on E-selectin was found. The effects of ibuprofen on VCAM-1 expression were dose-dependent (IC50 [IL-1 alpha]: 0.5 mM; IC50 [TNF alpha]: 0.5 mM) and time-dependent with maximum responses observed after 18 h. Moreover, ibuprofen abrogated pyrogen-dependent adhesion of leukocytes to HUVEC. Ibuprofen also inhibited VCAM-1 mRNA expression in pyrogen activated EC. VCAM-1-downregulation on EC by ibuprofen may contribute to the anti-inflammatory actions of the drug.

Review: corticosteroid usage: observations at a community hospital

Corticosteroids have revolutionized the medical treatment of many diseases. However, their value is limited by substantial potential adverse effects. Therefore, the authors reviewed their clinical use at their community medical center by comparing physician decisions about therapeutic management with the indications published in the current medical literature. They retrospectively reviewed 100 consecutive charts of patients from 1993 to 1994 who received corticosteroid therapy during their hospital stay. They found that 36 patients received appropriate corticosteroid intervention, 49 received partially appropriate corticosteroid intervention, and 15 received inappropriate corticosteroid intervention when compared with current medical literature recommendations for patients with the corresponding diagnoses. Ninety-five percent of patients given "partially appropriate" corticosteroid therapy and 73% given "inappropriate" corticosteroid therapy experienced medication-related side effects compared with 19% of patients given appropriate corticosteroid therapy intervention (P < 0.05). No patient records addressed the possibility of steroid-related osteoporosis. There were no significant differences in the clinical course of the three groups of patients treated with corticosteroids. On the basis of these data, the majority of hospitalized patients given corticosteroids did not receive them entirely in accordance with literature recommendations; these patients experienced increased medication toxicity and did not receive prophylaxis for osteoporosis. These limited observations suggest opportunities to improve patient care.

Corticosteroid receptor antagonists: a current perspective

This review aims to highlight a selection of antagonists for the mineralocorticoid and glucocorticoid receptors. Concepts of these receptor systems are described, as is the mechanism of action of these steroids in the brain and periphery. Examples of commonly available and newly synthesized antimineralocorticoids and antiglucocorticoids are given, together with their pharmacological profiles and, when appropriate, clinical and therapeutic applications.

Hemostatic changes in patients with brain tumors

Abnormal hemostasis is a functional property of cancer. Hemostatic abnormalities are common in patients with systemic malignant disease and brain tumors. However, the incidence of thromboembolism is higher in patients with brain tumors than in those with systemic disease. This raises the question of whether or not hemostatic abnormalities found in the blood of the two groups of patients differs, suggesting different pathogeneses. The purpose of this report is to review abnormalities in blood and clinical manifestations of abnormal hemostasis found in brain tumors and cancer patients in an attempt to answer this question. Normal hemostasis, as currently understood, will be considered with an emphasis on features unique to the central nervous system.