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Abstract
Mycophenolate mofetil (MMF) has been reproducibly shown to inhibit lymphocyte adhesion and penetration of endothelial cell surfaces. The mechanism is not yet elucidated. In vitro studies on the effects of MMF on cell adhesion molecules (CAM) using human umbilical vein endothelial cells (HUVEC) have shown conflicting results. Different studies have independently shown that MMF increased, decreased or had no effect on intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule (VCAM-1). Several studies suggest MMF may reduce the endothelial expression of E-selectin. Recent studies have been unable to replicate initial work, which suggested that MMF impaired glycosylation of lymphocyte CAM. The same studies concluded that MMF had no effect on the surface expression of lymphocyte CAM, but altered the binding ability of these molecules. ICAM-1/LFA-1 (lymphocyte function-associated antigen-1), VCAM-1/VLA-4 (very late antigen-4) and P-selectin/PSGL-1 (P-selectin glycoprotein ligand-1) ligand pairs are most likely to be involved. Few in vivo and no conclusive human studies have been carried out. The literature relevant to cell adhesion molecules in systemic lupus erythematosus (SLE) is reviewed in detail.
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Affiliation(s)
- MJ Lewis
- Lupus Research Unit, The Rayne Institute, St Thomas’ Hospital, London, UK
| | - D D'cruz
- Lupus Research Unit, The Rayne Institute, St Thomas’ Hospital, London, UK
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2
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Abstract
Mycophenolate mofetil (MMF) has been reproducibly shown to inhibit lymphocyte adhesion and penetration of endothelial cell surfaces. The mechanism is not yet elucidated. In vitro studies on the effects of MMF on cell adhesion molecules (CAM) using human umbilical vein endothelial cells (HUVEC) have shown conflicting results. Different studies have independently shown that MMF increased, decreased or had no effect on intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule (VCAM-1). Several studies suggest MMF may reduce the endothelial expression of E-selectin. Recent studies have been unable to replicate initial work, which suggested that MMF impaired glycosylation of lymphocyte CAM. The same studies concluded that MMF had no effect on the surface expression of lymphocyte CAM, but altered the binding ability of these molecules. ICAM-1/LFA-1 (lymphocyte function-associated antigen-1), VCAM-1/VLA-4 (very late antigen-4) and P-selectin/PSGL-1 (P-selectin glycoprotein ligand-1) ligand pairs are most likely to be involved. Few in vivo and no conclusive human studies have been carried out. The literature relevant to cell adhesion molecules in systemic lupus erythematosus (SLE) is reviewed in detail.
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Affiliation(s)
- M J Lewis
- The Rayne Institute, St Thomas' Hospital, London, UK.
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3
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Gibson WT, Hayden MR. Mycophenolate mofetil and animal models. Lupus 2016. [DOI: 10.1177/0961203306071675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Mycophenolate mofetil (MMF), is the morpholinoethyl ester of mycophenolic acid (MPA). Though initially developed as an anti-rejection treatment, MMF is beginning to find application in more common immune-mediated diseases. MMF has been shown to be effective against transplant-associated vascular disease, lupus and other inflammatory diseases via multiple mechanisms in several animal models. MMF treatment blocks the proliferation of T cells and B cells, attenuates the production of autoreactive IgG and IgM, diminishes complement deposition, and reduces the production of multiple proinflammatory cytokines including TNF-α, IFN-γ, IL-2, IL-3, IL-4, IL-5, IL-6 and IL-12. It also increases production of the anti-inflammatory mediator IL-10. In addition, MMF reduces the infiltration of immune cells into sites of inflammation by interfering with the expression of cell-surface molecules critical for this process, including MHC class II, CD40, CD80, CD86, I-A, and ICAM-1. Additional mechanisms involving mannosylation and N-linked glycosylation of cell-surface molecules are only beginning to be investigated. This article will focus on the contribution of animal models of disease as investigational tools in the development of MMF as an immunomodulatory drug. The use of mice, rats, rabbits, monkeys, baboons and interspecific xenografts will be discussed.
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Affiliation(s)
- WT Gibson
- Centre for Molecular Medicine and Therapeutics, Child and Family Research Institute, Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - MR Hayden
- Centre for Molecular Medicine and Therapeutics, Child and Family Research Institute, Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
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4
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Caterson EJ, Lopez J, Medina M, Pomahac B, Tullius SG. Ischemia-reperfusion injury in vascularized composite allotransplantation. J Craniofac Surg 2014; 24:51-6. [PMID: 23321872 DOI: 10.1097/scs.0b013e31827104e1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Vascularized composite allotransplantation may now be considered a viable treatment option in patients with complex craniofacial and limb defects. However, the field is still in its infancy, and challenges continue to exist. These challenges, most notably the adverse effects of lifelong immunosuppression, must be weighed against the benefits of the procedure. Improvements in this risk-benefit ratio can be achieved by achieving tolerance and preventing rejection. Five decades after Dr. Joseph E. Murray introduced the field of transplantation to the world, we now have a better understanding of the immunologic factors that may contribute to rejection and inhibit tolerance. In this article, we review emerging evidence that suggests that "danger signals" associated with ischemia-reperfusion injury contribute to innate immune activation, promoting rejection, and inhibiting tolerance. Based on this understanding, we also describe several strategies that may ameliorate the damaging effects of ischemia-reperfusion and the clinical implications of ischemia-reperfusion on the vascularized composite tissue allotransplantation outcome.
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Affiliation(s)
- Edward J Caterson
- Divisions of Plastic Surgery and Transplant Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
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5
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Cicora F, Lausada N, Vasquez DN, Cicora P, Guerrieri D, Gonzalez P, Zalazar G, Stringa P, Raimondi C. Protective effect of immunosuppressive treatment before orthotopic kidney autotransplantation. Transpl Immunol 2011; 24:107-12. [DOI: 10.1016/j.trim.2010.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 10/12/2010] [Accepted: 10/19/2010] [Indexed: 12/27/2022]
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6
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Sabbatini M, Uccello F, Serio V, Troncone G, Varone V, Andreucci M, Faga T, Pisani A. Effects of mycophenolate mofetil on acute ischaemia-reperfusion injury in rats and its consequences in the long term. Nephrol Dial Transplant 2009; 25:1443-50. [DOI: 10.1093/ndt/gfp710] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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7
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Donor preconditioning with a calcineurin inhibitor improves outcome in rat syngeneic kidney transplantation. Transplantation 2009; 87:326-9. [PMID: 19202436 DOI: 10.1097/tp.0b013e3181945332] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ischemia-reperfusion injury (IRI) in the early posttransplant period affects immediate graft function and late allograft dysfunction. This study determines the influence of pharmacologic preconditioning with a calcineurin inhibitor on IRI in a syngeneic F344 rat kidney transplant model. Donor rats were pretreated with one dose of cyclosporine (10 mg/kg) or tacrolimus (1 mg/kg) administered at 24 hr or 7 days before being subjected to 2 hr of cold ischemia and then transplanted. Pharmacologic preconditioning significantly improved renal function, as assessed by serum creatinine and inulin clearance, and histologic score versus vehicle-treated rats. There were no differences between cyclosporine and tacrolimus in the measured outcomes. This renoprotective effect, although not complete, was seen with only one dose of calcineurin inhibitor, and the effect was sustained for at least 7 days before IRI. This approach may represent a viable pharmacologic intervention to decrease IRI at the time of organ transplantation.
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Pradeau D, Stocco J, Chaumeil JC. [Solutions for organ preservation and other cardioplegic liquid formulations. Role of the hospital pharmacist]. ANNALES PHARMACEUTIQUES FRANÇAISES 2008; 66:1-18. [PMID: 18435981 DOI: 10.1016/j.pharma.2007.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2007] [Indexed: 11/19/2022]
Abstract
Solid organ transplantation is an increasing need and a well-established activity which requires maintaining the quality of the transplant from procurement through the entire, storage, transport and graft procedure. Solutions for organ preservation play a key role in this procedure, by minimizing the deleterious effects of both ischemia and reperfusion. As such, their qualitative and quantitative compositions have to be optimized and validated. The development strategy and formulations proposed for these solutions are analyzed in this review as well as the results of the clinical studies which have set up the relevant pharmacological and physicochemical criteria. The French regulatory status of these products is also discussed. A clear distinction has to be made between solutions for organ preservation which are classified as produits thérapeutiques annexes (therapeutic ancillary products) and cardioplegic liquid formulations which are considered as medicinal products and are subject to marketing approval. Finally, the roles of the hospital pharmacist in the evaluation, selection, purchase and proper use of these products are described.
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Affiliation(s)
- D Pradeau
- Laboratoire de développement analytique et galénique, Ageps, 7, rue du Fer à Moulin, 75221 Paris cedex 05, France.
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9
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Huang Y, Rabb H, Womer KL. Ischemia-reperfusion and immediate T cell responses. Cell Immunol 2007; 248:4-11. [PMID: 17942086 DOI: 10.1016/j.cellimm.2007.03.009] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 03/30/2007] [Indexed: 12/12/2022]
Abstract
The pathogenesis of ischemia-reperfusion injury (IRI) is complex and not well understood. Inflammation plays an important role in IRI, with involvement of leukocytes, adhesion molecules, chemokines and cytokines. Emerging data suggest a role of T cells as mediators of IRI both in renal and extra-renal organs. Divergent roles of T cell subsets have also been elucidated, suggesting a more complicated role of T cells in the different phases of IRI. This review presents recent evidence from various animal models that advances our understanding of the role T cells play in IRI. These findings entertain the possibility of using immunotherapeutic agents for the prevention and treatment of IRI.
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Affiliation(s)
- Yanfei Huang
- Division of Nephrology, Johns Hopkins University School of Medicine, Ross 965, 720 Rutland Avenue, Baltimore, MD 21205, USA
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10
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Gibson WT, Hayden MR. Mycophenolate Mofetil and Atherosclerosis: Results of Animal and Human Studies. Ann N Y Acad Sci 2007; 1110:209-21. [PMID: 17911436 DOI: 10.1196/annals.1423.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The immunosuppressive agent mycophenolate mofetil (MMF) has beneficial effects in cardiac transplant patients beyond the suppression of tissue rejection. Patients with regimens containing MMF experience diminished intimal thickening and cardiac allograft vasculopathy compared to patients treated with azathioprine. Studies have shown that diet-induced atherosclerosis (a related vasculopathy) is a chronic inflammatory process, and so MMF has also been used to reduce atherosclerosis in a rabbit model of hyperlipidemia. These data hold out the intriguing possibility that MMF might be a viable primary or secondary preventive agent in people at significant risk for atherosclerosis.
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Affiliation(s)
- William Thomas Gibson
- Centre for Molecular Medicine and Therapeutics, Child and Family Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, BC, Canada V5Z 4H4
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11
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Rook M, Postma DS, van der Jagt EJ, van Minnen CA, van der Heide JJH, Ploeg RJ, van Son WJ. Mycophenolate Mofetil and Bronchiectasis in Kidney Transplant Patients: A Possible Relationship. Transplantation 2006; 81:287-9. [PMID: 16436974 DOI: 10.1097/01.tp.0000188638.28003.96] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Bronchiectasis is a rare acquired condition, generally resulting from long-term chronic pulmonary inflammation. Mycophenolate mofetil (in short, mofetil) is a commonly used immunosuppressant in kidney transplantation. In the literature, there is no report of a relationship between mofetil use and development of bronchiectasis. Five kidney transplant patients developed complaints of cough, dyspnea, and abundant sputum production without apparent cause. Pulmonary complaints started at a range of 0-20 months after the start of mofetil treatment. Lesions were classified as bronchiectasis(-like), based on clinical presentation, chest x-ray, and computed tomography scan. Withdrawal of mofetil greatly relieved pulmonary complaints. Since the first kidney transplantation in our center in 1968, we have had no diagnosis of bronchiectasis in over 1,500 patients without mofetil treatment. These cases suggest an association between mofetil and development of bronchiectasis. Converting mofetil to another immunosuppressive drug should be considered when unexplained pulmonary complaints develop in patients receiving mofetil.
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Affiliation(s)
- Mieneke Rook
- Department of Medicine, Division of Nephrology, Renal Transplant Unit, University Medical Center Groningen, Groningen, The Netherlands.
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12
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Schwarze ML, Houser SL, Muniappan A, Allan JS, Menard MT, McMorrow I, Maloney ME, Madsen JC. Effects of Mycophenolate Mofetil on Cardiac Allograft Survival and Cardiac Allograft Vasculopathy in Miniature Swine. Ann Thorac Surg 2005; 80:1787-93. [PMID: 16242456 DOI: 10.1016/j.athoracsur.2005.04.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Revised: 04/25/2005] [Accepted: 04/26/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic rejection, as manifested by cardiac allograft vasculopathy, remains the leading cause of late graft failure in heart transplant recipients. Despite recent clinical trials, the efficacy of mycophenolate mofetil in preventing human cardiac allograft vasculopathy remains controversial. We investigated whether mycophenolate mofetil would prevent cardiac allograft vasculopathy and prolong cardiac allograft survival in our well-established miniature swine model of heart transplantation. METHODS Hearts disparate at the major histocompatibility complex class I locus were heterotopically transplanted into miniature swine recipients treated with a 12-day course of mycophenolate mofetil (n = 3) or cyclosporine A (n = 3). Allograft survival, acute rejection, and chronic rejection were monitored in the two groups. RESULTS Hearts transplanted with 12 days of cyclosporine were rejected between 46 and 61 days, whereas two of the three hearts transplanted with mycophenolate mofetil remained beating beyond 120 days (p = 0.02). At necropsy, there was a 4.9% mean prevalence of cardiac allograft vasculopathy in the mycophenolate mofetil group as compared with 16.6% in the cyclosporine group (p = 0.03). Cardiac allograft rejection and vasculopathy in the cyclosporine-treated group was associated with prominent myocardial interferon-gamma gene expression, a finding absent in two thirds of the mycophenolate mofetil-treated swine. Moreover, the mycophenolate mofetil-treated swine failed to develop IgM or IgG alloantibodies. CONCLUSIONS A short course of mycophenolate mofetil resulted in a longer allograft survival than a similar course of cyclosporine. Moreover, mycophenolate mofetil reduced the prevalence of cardiac allograft vasculopathy as compared with cyclosporine-treated controls. The salutary effect of mycophenolate mofetil may be related to its ability to decrease interferon-gamma expression in the myocardium and prevent the generation of alloantibodies.
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Affiliation(s)
- Margaret L Schwarze
- Transplantation Biology Research Center, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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13
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Treska V, Molacek J, Kuntscher V, Liska V, Kobr J, Racek J, Kormunda S. Immunosuppresive agents have an influence on ischemia-reperfusion injury in kidneys procured from a non-heart-beating donor: experimental study. Transplant Proc 2005; 36:2931-4. [PMID: 15686663 DOI: 10.1016/j.transproceed.2004.10.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ischemic-reperfusion injury (IRI) has a considerable influence on the function of kidneys from non-heart-beating donors (NHBD) after transplantation. IRI is accompanied by a marked inflammatory reaction with the production of reactive oxygen species and of the proinflammatory cytokine tumor necrosis factor alpha. The effect on the development of ischemic-reperfusion injury of early treatment of the donor with mycophenolate mofetil and tacrolimus was monitored in an animal model of a NHBD. The study demonstrated that the combination of the two immunosuppressives reduced the production in the NHBD kidney of tumor necrosis factor alpha, an indicator of the degree of inflammatory reaction after reperfusion, to a considerable extent but not of malondialdehyde or reduced glutathione. Pre-treatment of marginal donors with these immunosuppressants may improve the immediate function of transplanted kidneys by reducing cytokine production.
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Affiliation(s)
- V Treska
- Department of Surgery, University Hospital, Plzen, Czech Republic.
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14
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de Fijter JW. Leendert C. Paul, 1946-2004. Am J Transplant 2004. [DOI: 10.1111/j.1600-6143.2004.00658.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Daha MR, de Fijter JW. In memoriam—Leendert C. Paul, MD, 1946–2004. Transplant Proc 2004. [DOI: 10.1016/j.transproceed.2004.11.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dragun D, Böhler T, Nieminen-Kelhä M, Waiser J, Schneider W, Haller H, Luft FC, Budde K, Neumayer HH. FTY720-induced lymphocyte homing modulates post-transplant preservation/reperfusion injury. Kidney Int 2004; 65:1076-83. [PMID: 14871428 DOI: 10.1111/j.1523-1755.2004.00478.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND A novel immunomodulator, FTY720, modulates lymphocyte migration to injured tissues via enhanced lymphocyte sequestration to secondary lymphoid organs. We tested whether or not single-dose FTY720 (0.5 mg/kg) pretreatment rescues renal grafts from post-transplant preservation/reperfusion injury. METHODS Rat renal grafts were cold-preserved in University of Wisconsin (UW) solution for 4 hours and then transplanted into syngeneic or allogeneic recipients that received a single dose of FTY720 24 hours before transplantation. Flow cytometry analysis of peripheral blood and lymph nodes was performed to confirm the biologic effect of FTY720. Grafts were harvested after 24 hours. Renal sections were examined histologically and stained for intracellular adhesion molecule-1 (ICAM-1), vascular cellular adhesion molecule-1 (VCAM-1), platelet endothelial cellular adhesion molecule-1 (PECAM-1), major histocompatibility complex (MHC) class II, and inflammatory cells. Interleukin-1 (IL-1) production was determined in renal protein extracts. RESULTS FTY720 pretreatment significantly increased CD3+ T-cell sequestration to lymph nodes in the face of peripheral lymphopenia. Isografts and allografts from the FTY720-treated groups did not develop increased creatinine (0.55 +/- 0.12 in isografts and 0.62 +/- 0.08 mg/dL in allografts), compared with vehicle controls (2.28 +/- 0.20 in isografts and 2.24 +/- 0.18 mg/dL in allografts). Kidneys from FTY720-treated groups also showed lower acute tubular damage scores. Furthermore, FTY720 decreased neutrophil influx, although circulating neutrophils were unchanged. FTY720 also prevented postischemic IL-1 intragraft production not affecting infiltration with recipient ED-1+ macrophages and MHC class II-positive cells. Expression of ICAM-1, VCAM-1, and PECAM did not differ among groups. CONCLUSION FTY720 ameliorated morphologic and functional consequences of post-transplant reperfusion injury. Thus, FTY720-induced peripheral T-cell absence may influence intragraft IL-1 production and neutrophil infiltration, despite proadhesive endothelial properties. FTY720 may broaden the utility in renal transplantation as a pretreatment strategy against preservation/reperfusion injury.
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Affiliation(s)
- Duska Dragun
- Department of Nephrology, Medical Faculty of the Charité Campus Mitte, Berlin, Germany.
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17
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Niederkorn JY. Passing of a giant. Transplantation 2004; 78:306-7. [PMID: 15282927 DOI: 10.1097/01.tp.0000135953.57831.c9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Jerry Y Niederkorn
- University of Texas Southwestern Medical School at Dallas, Dallas, TX, USA
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18
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Kieran NE, Rabb H. Immune Responses in Kidney Preservation and Reperfusion Injury. J Investig Med 2004. [DOI: 10.1177/108155890405200530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Organ preservation and reperfusion injury have significant detrimental effects on both short- and long-term organ function. Ischemia reperfusion injury (IRI) underlies organ transplant dysfunction, myocardial infarction, stroke, and shock. Multiple molecular pathways are engaged in reactive oxygen production, apoptosis, signaling, and tissue regeneration. There has been an increased understanding of the important role of immune and inflammatory pathways in IRI, both in humans and in experimental models. Both cellular and soluble components of the immune system are directly activated during IRI, and there is evidence that immune mediators directly contribute to organ dysfunction. Immune activation during IRI likely underlies the enhanced immunogenicity of ischemic organs, with resultant increased rejection and fibrosis. Novel human therapies targeting T and B cells for classic immune diseases can now be considered to prevent and treat IRI. Organ preservation injury and cold ischemia could well have distinct pathophysiology from warm IRI and represent an opportunity to develop improved preservation methods.
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Affiliation(s)
- Niamh E. Kieran
- Department of Medicine and Therapeutics, Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Hamid Rabb
- Nephrology Division, Johns Hopkins University Hospital, Baltimore, MD
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19
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Bès S, Tatou E, Vandroux D, Tissier C, Rochette L, Athias P. Physiological and metabolic actions of mycophenolate mofetil on cultured newborn rat cardiomyocytes in normoxia and in simulated ischemia. Fundam Clin Pharmacol 2004; 18:287-98. [PMID: 15147280 DOI: 10.1111/j.1472-8206.2004.00237.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Mycophenolate mofetil (MMF) is a new immunosuppressive drug used to reduce acute rejection after heart transplantation. As with other immunosuppressive drugs, MMF therapy is associated with several adverse effects. However, the direct effects of MMF on myocardial tissue has not been yet evaluated. The aim of the work was thus to evaluate the effects of MMF on isolated cardiomyocytes (CM) in normal conditions and in an in vitro model of simulated ischemia (SI; substrate-free hypoxia) and reperfusion (R; reoxygenation). Myocyte-enriched cultures were prepared from newborn rat heart ventricles. The transmembrane potentials were recorded using conventional microelectrodes and the cell contractions were monitored with a photoelectric device. In basal conditions, MMF (10(-6) and 10(-5) M) exerted no significant effects on the survival and on the electrical and contractile activities of CM in culture, even during long-term exposure (up to 48 h). SI per se led to a gradual decrease and then an abortion of the spontaneous automaticity and electromechanical activity of CM. Pretreating CM with either 10(-6) or 10(-5) M MMF was able to reduce the SI-induced cell dysfunctions. The presence of MMF at these concentrations did not hamper the post-SI functional recovery of CM during reoxygenation. At 10(-5) M, MMF applied during reoxygenation only permitted a better recovery of CM. However, the mitochondrial function after reoxygenation, as assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5 diphenyl-tetrazolium bromide (MTT) test, was not significantly influenced by the addition of MMF before as well as after ischemia. Conversely, MMF was able to reduce in this model the postischemic rise in xanthine and hypoxanthine. These data from CM-enriched model show that MMF: (i) had no cytotoxic effect, (ii) displayed a cytoprotective effect during SI, and (iii) exerted its beneficial effect at least partly through the decrease in the xanthine oxidase-dependent free radical production.
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Affiliation(s)
- Sandrine Bès
- Laboratoire de Physiopathologie et Pharmacologie Cardiovasculaires Expèrimentales, Institut de Recherche Cardiovasculaire, Centre Hospitalier Universitaire Le Bocage, 2 Boulevard Maréchal de Lattre de Tassigny, 21034 Dijon, France
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20
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Shihab FS, Bennett WM, Yi H, Choi SO, Andoh TF. Mycophenolate mofetil ameliorates arteriolopathy and decreases transforming growth factor-beta1 in chronic cyclosporine nephrotoxicity. Am J Transplant 2003; 3:1550-9. [PMID: 14629285 DOI: 10.1046/j.1600-6135.2003.00244.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Afferent arteriolopathy is the most characteristic lesion of chronic cyclosporine (CsA) nephrotoxicity. We investigated the effect of therapeutic doses of mycophenolate mofetil (MMF) in a model of chronic CsA nephrotoxicity where transforming growth factor-beta (TGF-beta) was shown to play a central role. Rats treated with vehicle, MMF 10 mg/kg/day, CsA 10 mg/kg/day or CsA + MMF were sacrificed at 7 or 28 days. Physiologic and histologic changes were studied in addition to TGF-beta1 mRNA and protein expressions, and mRNA expression of plasminogen activator inhibitor-1 (PAI-1) and the extracellular matrix (ECM) proteins biglycan and types I and IV collagen. While MMF markedly ameliorated afferent arteriolopathy, it had no significant effect on interstitial fibrosis and tubular atrophy. In addition, MMF treatment reduced both TGF-beta1 mRNA and protein levels by 39% and 32%, respectively (p < 0.05 vs. CsA only). The expression of the ECM proteins followed that of TGF-beta1 and was significantly decreased with MMF; a similar effect was observed with PAI-1, suggesting an increase in ECM degradation. These results suggest that MMF exerts a beneficial effect on CsA arteriolopathy and that it decreases TGF-beta1. While this drug combination may be useful clinically, long-term studies are needed to determine if MMF has a lasting benefit.
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Affiliation(s)
- Fuad S Shihab
- Division of Nephrology, University of Utah School of Medicine, Salt Lake City, USA.
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21
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Reutzel-Selke A, Zschockelt T, Denecke C, Bachmann U, Jurisch A, Pratschke J, Schmidbauer G, Volk HD, Neuhaus P, Tullius SG. Short-term immunosuppressive treatment of the donor ameliorates consequences of ischemia/ reperfusion injury and long-term graft function in renal allografts from older donors. Transplantation 2003; 75:1786-92. [PMID: 12811235 DOI: 10.1097/01.tp.0000063408.97289.89] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Grafts from so-called "marginal donors" are increasingly used for organ transplantation. The combination of reduced organ quality and additional inflammatory damages may be particularly detrimental in these grafts. In a previous study, we showed the beneficial effects on long-term graft outcome of "suboptimal" grafts by the induction of heme oxygenase-1. Here we tested the impact of short-term donor treatment with established immunosuppressants. METHODS Twelve-month-old Fischer 344 donor rats either were treated with prednisolone, mycophenolate mofetil, RAD, or FK506 24 hr and 1 hr before organ harvesting or remained untreated. Renal allografts were perfused with University of Wisconsin solution and kept at 4 degrees C for an ischemic period of 2 hr. Morphologic, immunohistologic, and real time reverse transcriptase-polymerase chain reaction analyses for relevant markers were performed at serial intervals and at the end of the observation period (6 months). RESULTS All animals survived the observation period, although the ischemic time resulted in accelerated chronic graft dysfunction. Grafts from donors treated with prednisolone or FK506 demonstrated significantly improved graft function and structure by 6 months. Mononuclear infiltrates were significantly reduced by the end of the observation period, whereas intragraft mRNA levels of tumor necrosis factor-alpha and interleukin-10 were significantly altered during the early period after transplantation. Minor improvements in graft function and histologic alterations of suboptimal grafts were observed after pretreatment with mycophenolate mofetil and RAD. CONCLUSION Donor treatment with approved immunosuppressants, in particular prednisolone or FK506, represents a novel therapeutic strategy of clinical relevance, most importantly when using grafts from marginal donors.
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Affiliation(s)
- Anja Reutzel-Selke
- Department of General and Transplantation Surgery, Charite-Campus Virchow Clinic, Berlin, Germany
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22
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Yang CW, Ahn HJ, Kim WY, Li C, Jung JY, Yoon SA, Kim YS, Cha JH, Kim J, Bang BK. Synergistic effects of mycophenolate mofetil and losartan in a model of chronic cyclosporine nephropathy. Transplantation 2003; 75:309-15. [PMID: 12589150 DOI: 10.1097/01.tp.0000045034.48833.51] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Combined treatments of mycophenolate mofetil (MMF) and losartan (LSRT) have synergistic effects on various renal diseases through their hemodynamic and anti-inflammatory effects. This study investigated whether MMF treatment is effective in inhibiting inflammatory processes in chronic cyclosporine A (CsA) nephrotoxicity, and whether combined treatment using MMF and LSRT affords superior protection compared with the respective monotherapies. METHODS Rats on a low-salt diet were given vehicle (VH group, olive oil, 1 mg/kg per day), CsA (15 mg/kg per day), CsA and LSRT (CsA+LSRT group, 100 mg/L per day), CsA and MMF (CsA+MMF group; 40 mg/kg per day), or CsA, LSRT and MMF (CsA+LSRT MMF group). Control groups received each drug without CsA treatment. Renal function, histologic parameters (arteriolopathy, tubulointerstitial fibrosis, and inflammatory cell infiltration), and mediators of CsA-induced nephrotoxicity (angiotensin-II, osteopontin, and transforming growth factor [TGF]-beta1) were studied. RESULTS The CsA-treated rats showed decreased renal function and increased histologic parameters compared with the VH-treated rats. The CsA+MMF treatment significantly improved renal function and histopathologic parameters compared with the CsA group, and combined treatment with MMF and LSRT further improved those parameters compared with the CsA+LSRT and CsA+MMF groups. At a molecular level, increased expression of angiotensin II protein, osteopontin, and TGF-beta1 mRNAs in the CsA group were significantly decreased with MMF, and further decrease was observed with the combined treatment using MMF and LSRT. CONCLUSIONS MMF treatment decreases CsA-induced nephrotoxicity, and combined treatment with LSRT has a synergistic effect in preventing chronic CsA nephrotoxicity.
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Affiliation(s)
- Chul Woo Yang
- Cell Death Disease Research Center, Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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23
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Quiroz Y, Herrera-Acosta J, Johnson RJ, Rodriguez-Iturbe B. Mycophenolate mofetil treatment in conditions different from organ transplantation. Transplant Proc 2002; 34:2523-6. [PMID: 12431510 DOI: 10.1016/s0041-1345(02)03473-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Y Quiroz
- Renal Service and Laboratory, Hospital Universitario and Instituto de Investigaciones Biomédicas, FUNDACITE-Zulia, Maracaibo, Venezuela
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24
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Ventura CG, Coimbra TM, de Campos SB, de Castro I, Yu L, Seguro AC. Mycophenolate mofetil attenuates renal ischemia/reperfusion injury. J Am Soc Nephrol 2002; 13:2524-33. [PMID: 12239241 DOI: 10.1097/01.asn.0000030143.73830.3c] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Immunosuppressive agents may have an impact on ischemia/reperfusion (I/R) injury. The immunosuppressant mycophenolate mofetil (MMF) presents properties that can attenuate such injury. This study investigated the effects of MMF on renal I/R injury. Male Wistar rats received MMF (20 mg/kg per d) or vehicle by gavage beginning 2 d before ischemia and maintained during the entire study. Ischemic injury was induced by bilateral renal arteries occlusion for 60 min. Control rats received MMF and underwent sham operation. At days 1, 2, and 14, post-ischemia renal function was assessed and kidneys were removed for histologic and immunohistochemical studies. MMF given to nonischemic rats did not alter renal function. There was no functional protection at 24 h post-ischemia with MMF. At 2 d, post-ischemia rats pretreated with MMF presented higher inulin clearance compared with untreated rats (0.42 +/- 0.04 versus 0.15 +/- 0.02 ml/min per 100 g; P < 0.001) and attenuated renal blood flow decrease (5.23 +/- 0.28 versus 3.24 +/- 0.37 ml/min; P < 0.01). The immunostaining for intercellular adhesion molecule-1 (ICAM-1) was less intense in rats pretreated with MMF. These rats also presented an earlier decreased infiltrating macrophages/lymphocytes and cell proliferation at day 1 post-ischemia. The functional and immunohistochemical analyses performed at day 14 post-ischemia returned to values similar to controls in both groups of rats. To determine whether mycophenolic acid (MPA) could induce cytoprotection, the effects of MPA on normoxic and hypoxic/reoxygenated (H/R) isolated tubule suspensions were also investigated. MPA was not deleterious to normoxic tubules and it was not protective against H/R tubules. In conclusion, pretreatment with MMF attenuates I/R injury in rats and does not limit the recovery from ischemia. The protective effect of MMF by reducing inflammation precedes the hemodynamic changes and tubular injury.
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Affiliation(s)
- Carlucci Gualberto Ventura
- Department of Nephrology, Laboratório de Investigação Médica 12, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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25
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Yokota N, Daniels F, Crosson J, Rabb H. Protective effect of T cell depletion in murine renal ischemia-reperfusion injury. Transplantation 2002; 74:759-63. [PMID: 12364852 DOI: 10.1097/00007890-200209270-00005] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Ischemia-reperfusion injury (IRI) is the main cause of acute renal failure in both allograft and native kidney. Studies using T cell knockout mice have established an important role for T cells in renal IRI. T cell depletion strategies are effective in human allograft rejection. However, it is not known whether those are effective in renal IRI. Therefore, the effect of T cell depletion in a murine model of renal IRI using well-characterized antibodies (Abs) that have been effective in preventing experimental allograft rejection was studied. METHODS T cell depleting Abs to CD4 (GK1.5), CD8 (2.43) or pan-T cells (30.H12) were purified from hybridoma culture supernatant. Thymectomized C57BL/6 mice, treated with different combinations of T cell depleting Abs, underwent 30 min of bilateral renal IRI, followed by assessment of renal function, structure, and degree of T cell depletion in spleen, lymph nodes, and peripheral blood by flow cytometry. RESULTS Mice given both GK1.5 and 2.43 had considerable CD4 and CD8 cell depletion but no protection of renal function after ischemia-reperfusion (I/R) as measured by the rise in serum creatinine. However, when GK1.5 and 2.43 was administered combined with 30.H12, which more effectively depleted CD4 T cell numbers, a significant protection of renal function and structure was observed after I/R. Antibody combinations did not significantly alter other leukocyte populations. CONCLUSIONS These data demonstrate that T cell depletion can improve the course of experimental renal IRI. However, more aggressive T cell depletion strategies were required compared with that needed to prevent experimental allograft rejection.
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Affiliation(s)
- Naoko Yokota
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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26
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Yang CW, Ahn HJ, Kim WY, Li C, Kim HW, Choi BS, Cha JH, Kim YS, Kim J, Bang BK. Cyclosporine withdrawal and mycophenolate mofetil treatment effects on the progression of chronic cyclosporine nephrotoxicity. Kidney Int 2002; 62:20-30. [PMID: 12081560 DOI: 10.1046/j.1523-1755.2002.00400.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent clinical trials of mycophenolate mofetil (MMF) in chronic allograft nephropathy (CAN) demonstrated that the dose of cyclosporine A (CsA) is one of the critical factors in determining graft function in CAN, but the effect of MMF on chronic CsA nephropathy is undetermined. We undertook this study to evaluate the effect of MMF on CsA-induced nephrotoxicity in an animal model of chronic CsA nephropathy. METHODS In the first experiment, Sprague-Dawley rats on a low-salt diet were treated with CsA (7.5 mg/kg per day) for 10 weeks, or were treated with CsA for five weeks and then MMF (20 mg/kg per day) was administered five weeks later. In the second experiment, rats were treated with CsA for five weeks, and CsA was then withdrawn for five weeks with or without MMF treatment. Renal function, histologic parameters (tubulointerstitial fibrosis, arteriolopathy, ED-1-positive cells, renin-positive glomeruli, TUNEL-positive cells) and the expression of osteopontin and transforming growth factor (TGF)-beta1 mRNA expressions were compared for different treatment groups. RESULTS CsA-treated rats showed decreased renal function and increased histologic parameters compared with the vehicle (VH)-treated rats. The addition of MMF did not improve these parameters compared with the CsA-treated rats. With CsA withdrawal, renal function and histologic parameters were significantly improved compared with the CsA-treated rats, and MMF treatment after CsA withdrawal further improved the histologic parameters. At the molecular level, the addition of MMF did not decrease the expression of osteopontin and transforming growth factor-beta1 (TGF-beta1) mRNAs, which were increased in the CsA-treated rat kidney. With CsA withdrawal, the expression of both mRNAs was significantly decreased compared with the CsA group, and a further decrease was observed with MMF treatment after CsA was withdrawn. CONCLUSION The combined treatment of CsA and MMF does not prevent the development of chronic CsA nephrotoxicity, but MMF treatment after CsA withdrawal does improve chronic CsA nephrotoxicity. This finding provides a rationale for MMF treatment in chronic CsA nephrotoxicity.
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Affiliation(s)
- Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Kangnam St. Mary's Hospital, The Catholic University of Korea, 505 Banpo-Dong, Seocho-Ku, Seoul 137-040, Korea.
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27
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Affiliation(s)
- Roberto Anaya-Prado
- Borgess Research Institute, Trauma, Surgery Research Scienes, Kalamazoo, MI 49048, USA
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28
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Abstract
The T cell as a bridge between innate and adaptive immune systems: Implications for the kidney. The immune system is classically divided into innate and adaptive components with distinct roles and functions. T cells are major components of the adaptive immune system. T cells are firmly established to mediate various immune-mediated kidney diseases and are current targets for therapy. Ischemic acute renal failure, a major cause of native kidney and allograft dysfunction, is mediated in part by inflammatory components of the innate immune system. However, recent data from experimental models in kidney as well as liver, intestine, brain and heart implicate T cells as important mediators of ischemia reperfusion injury. These data reveal new insights into the pathogenesis of ischemic acute renal failure, as well as identify novel and feasible therapeutic approaches. Furthermore, the identification of T cells as a mediator of early alloantigen-independent tissue injury demonstrates that the functional capacity of T cells spreads beyond adaptive immunity into the realm of the innate immune response.
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Affiliation(s)
- Hamid Rabb
- Nephrology Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
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29
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Abstract
In parallel with increased clinical demand, less than optimal or so-called marginal kidney grafts are being used for transplantation. In addition to donor age, it appears that several factors may impact negatively on the quality of the graft. Most importantly, a more precise definition of the term 'marginal graft' is needed. The present review analyzes potential risk factors, suggests scoring systems for a more precise definition, and discusses potential treatment options to improve the quality of marginal grafts.
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Affiliation(s)
- Stefan G Tullius
- Department of Surgery, Charité--Campus Virchow Clinic, Berlin, Germany.
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30
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Affiliation(s)
- S G Tullius
- Department of Surgery, Charité-Virchow Clinic, Humboldt University, Augustenburger Platz 1, 13353 Berlin, Germany
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31
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Lui SL, Chan LY, Zhang XH, Zhu W, Chan TM, Fung PC, Lai KN. Effect of mycophenolate mofetil on nitric oxide production and inducible nitric oxide synthase gene expression during renal ischaemia-reperfusion injury. Nephrol Dial Transplant 2001; 16:1577-82. [PMID: 11477158 DOI: 10.1093/ndt/16.8.1577] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Recent animal data suggest that inducible nitric oxide synthase (iNOS) derived nitric oxide (NO) plays an important role in the pathogenesis of renal ischaemia-reperfusion injury (IRI) and that inhibition of iNOS ameliorates IRI. Mycophenolate mofetil (MMF), a lymphocyte selective anti-proliferative agent, has been shown to inhibit NO production in vitro. The aim of this study is to evaluate the effect of MMF on NO production and iNOS gene expression in vivo during renal IRI. METHODS Renal IRI was induced by clamping the left renal pedicle of male BALB/c mice for 30 min, followed by 15 min of reperfusion. The mice received placebo or MMF at 40, 80 or 120 mg/kg/day by oral gavage for 5 days before the operation. Sham-operated mice served as the operation control. The amount of NO produced and the level of iNOS gene expression in the kidney tissue during IRI was assessed by spin trapping electron paramagnetic resonance (EPR) spectroscopy and semi-quantitative reverse transcription polymerase chain reaction (RT-PCR) respectively. RESULTS In the sham-operated kidneys, only low levels of NO and iNOS mRNA were detected. In mice with renal IRI, the amount of NO detected was significantly increased, which was reduced in a dose dependent fashion by pre-treatment with MMF. Pre-treatment with MMF also substantially reduced iNOS gene expression in the kidney tissue. CONCLUSIONS We conclude that pre-treatment with MMF inhibits the production of NO and the induction of iNOS gene expression in the kidney during IRI. These results suggest that MMF might have the potential to ameliorate renal IRI.
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Affiliation(s)
- S L Lui
- Division of Nephrology, University Department of Medicine, Queen Mary Hospital, Hong Kong
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32
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Michael Cecka J, Shoskes DA, Gjertson DW. Clinical impact of delayed graft function for kidney transplantation. Transplant Rev (Orlando) 2001. [DOI: 10.1016/s0955-470x(05)80001-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Reduction of ischemia/reperfusion injury in organ transplants by cytoprotective strategies. Curr Opin Organ Transplant 2001. [DOI: 10.1097/00075200-200103000-00013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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34
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Reutzel-Selke A, Tullius SG, Zschockelt T, Nieminen-Kelhä M, Bachmann U, Jonas S, Pratschke J, Schmidbauer G, Bechstein WO, Volk H, Neuhaus P. Donor pretreatment of grafts from marginal donors improves long-term graft outcome. Transplant Proc 2001; 33:970-1. [PMID: 11267150 DOI: 10.1016/s0041-1345(00)02290-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- A Reutzel-Selke
- Department of Surgery, Charité-Virchow Clinic, Charité, Germany
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35
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Vazquez MA, Jeyarajah DR, Kielar ML, Lu CY. Long-term outcomes of renal transplantation: a result of the original endowment of the donor kidney and the inflammatory response to both alloantigens and injury. Curr Opin Nephrol Hypertens 2000; 9:643-8. [PMID: 11128427 DOI: 10.1097/00041552-200011000-00009] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recent data suggest that long-term allograft survival might be affected by two factors. The first is the endowment of the allograft, which consists of two elements: the nephron mass and the ability of these nephrons to repair injuries sustained during the transplant process. The second factor is renal inflammation. Although inflammation is traditionally ascribed to alloreactivity, recent data have shown that there is also a renal inflammatory response to early injury after transplantation, to brain death in the donor, and as part of the maladaptive response to nephron loss. These two factors contribute to the detrimental effects of delayed graft function or acute rejection on the long-term survival seen in most studies, and the beneficial effects of anti-inflammatory agents on the maladaptive response to nephron loss.
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Affiliation(s)
- M A Vazquez
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75390-8856, USA
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36
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D.H. Koo D, Fuggle SV. Impact of ischemia/reperfusion injury and early inflammatory responses in kidney transplantation. Transplant Rev (Orlando) 2000. [DOI: 10.1053/trre.2000.16754] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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