Tacrolimus monitoring in hair samples of kidney transplant recipients

Background

Calcineurin inhibitors, including tacrolimus, remain a cornerstone of immunosuppressive therapy after kidney transplantation. However, the therapeutic window is narrow, and nephrotoxic side effects occur with overdose, while the risk of alloimmunization and graft rejection increases with underdose. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) allows quantification of tacrolimus in biological samples from patients. This study investigates the feasibility of quantifying tacrolimus in scalp hair from kidney transplant (KT) recipients and correlates hair tacrolimus concentrations with tacrolimus dosage and blood trough levels. The aim was to provide proof-of-principle for hair tacrolimus drug monitoring in KT recipients.

Method

Single-center prospective study between September 9, 2021 and December 4, 2021, including KT recipients under tacrolimus. Minors, patients with active skin or hair diseases, and patients with scalp hair shorter than 4 cm were excluded from participation. Scalp hair was collected from the posterior vertex of patients, cut into segments, and analyzed for tacrolimus by LC-MS/MS. Patients filled out a questionnaire on hair treatments and washing habits. In parallel, tacrolimus trough levels were measured in whole blood and correlated with hair tacrolimus concentrations.

Results

In total, 39 consenting KT recipients were included, and hair samples were collected at 53 visits. Tacrolimus was detected in 98% of hair samples from patients exposed to the drug. Tacrolimus hair levels and whole blood trough levels were correlated with a beta coefficient of 0.42 (95% CI: -0.22-1.1, p = n.s.). Age and dark hair affected hair tacrolimus measurements, while different tacrolimus formulations (immediate release vs. extended release), hair washes, and permanent coloring did not. Longitudinal measurements in a subgroup of patients indicate that long-term measurement of hair tacrolimus levels is feasible.

Conclusion

Measuring tacrolimus in hair is a potentially reliable method to monitor drug exposure in KT patients. Rapid wash-in effects and consistent concentrations over time indicate that tacrolimus is incorporated into the hair matrix, allowing temporal resolution in the analysis of recent exposure and exposure history. This method provides a simple and low-risk alternative to regular blood sampling, sparing patients from frequent hospital visits through the self-collection of hair samples.

Trajectories of humoral and cellular immunity and responses to a third dose of mRNA vaccines against SARS-CoV-2 in patients with a history of anti-CD20 therapy

BACKGROUND

The majority of patients with B-cell-depleting therapies show compromised vaccination-induced immune responses. Herein, we report on the trajectories of anti-SARS-CoV-2 immune responses in patients of the RituxiVac study compared with healthy volunteers and investigate the immunogenicity of a third vaccination in previously humoral non-responding patients.

METHODS

We investigated the humoral and cell-mediated immune response after SARS-CoV-2 messanger RNA vaccination in patients with a history with anti-CD20 therapies. Coprimary outcomes were antispike and SARS-CoV-2-stimulated interferon-γ concentrations in vaccine responders 4.3 months (median; IQR: 3.6-4.8 months) after first evaluation, and humoral and cell-mediated immunity (CMI) after a third vaccine dose in previous humoral non-responders. Immunity decay rates were compared using analysis of covariance in linear regression.

RESULTS

5.6 months (IQR: 5.1-6.7) after the second vaccination, we detected antispike IgG in 88% (29/33) and CMI in 44% (14/32) of patients with a humoral response after two-dose vaccination compared with 92% (24/26) healthy volunteers with antispike IgG and 69% (11/16) with CMI 6.8 months after the second vaccination (IQR: 6.0-7.1). Decay rates of antibody concentrations were comparable between patients and controls (p=0.70). In two-dose non-responders, a third SARS-CoV-2 vaccine elicited humoral responses in 19% (6/32) and CMI in 32% (10/31) participants.

CONCLUSION

This study reveals comparable immunity decay rates between patients with anti-CD20 treatments and healthy volunteers, but inefficient humoral or CMI after a third SARS-CoV-2 vaccine in most two-dose humoral non-responders calling for individually tailored vaccination strategies in this population.Trial registration numberNCT04877496; ClinicalTrials.gov number.

Humoral and cellular immune responses on SARS-CoV-2 vaccines in patients with anti-CD20 therapies: a systematic review and meta-analysis of 1342 patients

BACKGROUND

Immune responses on SARS-CoV-2 vaccination in patients receiving anti-CD20 therapies are impaired but vary considerably. We conducted a systematic review and meta-analysis of the literature on SARS-CoV-2 vaccine induced humoral and cell-mediated immune response in patients previously treated with anti-CD20 antibodies.

METHODS

We searched PubMed, Embase, Medrxiv and SSRN using variations of search terms 'anti-CD20', 'vaccine' and 'COVID' and included original studies up to 21 August 2021. We excluded studies with missing data on humoral or cell-mediated immune response, unspecified methodology of response testing, unspecified timeframes between vaccination and blood sampling or low number of participants (≤3). We excluded individual patients with prior COVID-19 or incomplete vaccine courses. Primary endpoints were humoral and cell-mediated immune response rates. Subgroup analyses included time since anti-CD20 therapy, B cell depletion and indication for anti-CD20 therapy. We used random-effects models of proportions.

FINDINGS

Ninety studies were assessed. Inclusion criteria were met by 23 studies comprising 1342 patients. Overall rate of humoral response was 0.40 (95% CI 0.35 to 0.47). Overall rate of cell-mediated immune responses was 0.71 (95% CI 0.57 to 0.87). A time interval >6 months since last anti-CD20 therapy was associated with higher humoral response rates with 0.63 (95% CI 0.53 to 0.72) versus <6 months 0.2 (95% CI 0.03 to 0.43); p=0<01. Similarly, patients with circulating B cells more frequently showed humoral responses. Anti-CD20-treated kidney transplant recipients showed lower humoral response rates than patients with haematological malignancies or autoimmune disease.

INTERPRETATION

Patients on anti-CD20 therapies can develop humoral and cell-mediated immune responses after SARS-CoV-2 vaccination, but subgroups such as kidney transplant recipients or those with very recent therapy and depleted B cell are at high risk for non-seroconversion and should be individually assessed for personalised SARS-CoV-2 vaccination strategies. Potential limitations are small patient numbers and heterogeneity of studies included.

FUNDING

This study was funded by Bern University Hospital.

[Care counselling - the client's expectations]

The amendment of legal care consultations in the context of the long-term care insurance law (2008) has broadened recent consulting practice within the action range of the nursing care insurance in Germany. The informational needs and consulting requests of the clients were not investigated so far. Our aim was to examine information needs and consulting requests of those in need of care and their informal carers.The consulting requests of visitors of 2 open citizen events were documented by the use of a semi-structured questionnaire. Content analysis following Mayring (2008) was used for data analysis.158 consulting discussions were documented, from which 177 consulting requests were formed. The consulting requests can be divided in 4 main categories: (1) inquiry about the care system [56/32%], (2) inquiry about individual access to care offers [43/24%], (3) inquiry about regional care suppliers [43/24%], (4) situation- and disease-specific inquiries [35/20%].Inquiries about local suppliers of care and situation- and disease-specific inquiries outweigh the number of inquiries about the care system in general. Furthermore, our results show that the informational needs of those in need of care do not only refer to the scope of care insurance law, but to additional social security codes.

[What information do people needing care and their care-giving relatives need?]

BACKGROUND

The recent reform of the German Care Insurance Law (2008) was expanded to include independent consultancy for care issues. The goal of this study was to explore the informational needs of people in need of care and their informal caregivers.

METHOD

A semi-structured questionnaire was used to document 89 consultation conversations. The data were analyzed using qualitative content analysis.

RESULTS

The findings identified that information was needed about (1) the German health care insurance system, (2) access to care, (3) local care services, and (4) situation and disease-specific concerns.

CONCLUSION

Consultancy services for people in need of care and informal caregivers require detailed knowledge about local care services and, therefore, should be integrated into the neighborhoods of the users.

[Structures of long-term care facilities: a study in nursing homes in Leipzig]

BACKGROUND

In order to provide guidelines for the organization and design of nursing homes, it is important to evaluate current care facilities. The aim of the study was to describe the structures of nursing homes in the German city of Leipzig.

MATERIALS AND METHODS

As part of a cross-sectional design, 47 nursing homes participated in a written survey.

RESULTS

The majority of nursing homes focus on caring for residents diagnosed with dementia. Only a few special care units exist. A precise description of the structure of nursing homes, concepts and nursing methods, however, is rare. Established concepts exist in a small number of institutions. Approved service offers are largely available, but do not apply specifically to the large group of nursing home residents with dementia.

CONCLUSION

The study showed not only the diversity of the stationary nursing homes in a large city, but also their resources and limitations.

Myocardial contractility after infarction and carnitine palmitoyltransferase I inhibition in rats

Inhibition of carnitine palmitoyltransferase I with etomoxir increases sarcoplasmic reticulum Ca(2+)-transport and V(1) isomyosin expression. To test whether etomoxir attenuates contractile dysfunction after myocardial infarction, we compared the contractility of papillary muscles from etomoxir- and placebo-treated rats 6 weeks after infarction. Etomoxir induced cardiac hypertrophy in animals with small infarctions, and enhanced compensatory heart growth at large infarct size. Contractile function of papillary muscles from etomoxir-treated rats was improved particularly in animals with small infarctions. Thus, induction of mild cardiac hypertrophy by etomoxir in rats with small infarctions may be beneficial for myocardial performance.

An association of chronic alcohol consumption with morphological alterations of the laryngeal mucosa in rats

Within the last decades a considerable amount of epidemologic evidence has been built up to implicate chronic alcohol consumption as a major risk factor not only for oral and pharyngeal cancer, but also for laryngeal cancer. The mechanisms that underlie alcohol-related cancers of the larynx have remained largely unclear. Since the epithelium of the glottic region normally has no direct contact with alcoholic beverages, alcohol-related alterations of glottic mucosa have been questioned. In the present study 20 male Wistar rats were fed nutritionally adequate liquid diets containing 36% of the total calories either as ethanol or isocaloric carbohydrates for 6 months. Morphometric analysis of the glottic mucosa in the ethanol-fed rats showed a significant reduction in epithelial thickness of the glottic epithelium of the anterior commissure as well as of the posterior commissure (P < 0.001). Morphometric analysis of the basal cell nuclei of the glottic epithelium did not show any statistically significant differences between ethanol-fed rats and control rats. These findings indicate that chronic ethanol consumption can cause a significant atrophy of the glottic mucosal epithelium in the rat and suggest an enhanced susceptibility toward locally acting chemical carcinogens.

[Multi-local angiosarcoma of the oral mucosa]

A 64-year-old man presented with a bluish, livid swelling in the region of the lateral alveolar processes of all four quadrants. Evaluation and histopathological findings resulted in the diagnosis of an angiosarcoma at multiple sites. A survey of the literature and an epidemiologic review of our own patients prove this to be an extremely rare occurrence. A partial resection of the maxilla and the mandible on both sides was performed in sano. After discharge, however, a sarcoma was detected in the region of the right scapula 5 months after surgery. Therefore radiation treatment was initiated. The patient died 4 weeks later. The course confirms the poor prognosis of this tumor.

Contractile function of papillary muscle from rats with different infarct size after beta-adrenergic blockade and ACE-inhibition

We tested whether ACE-inhibition with ramipril (A), beta-adrenergic blockade with metoprolol (beta) or combined treatment (beta A) for 6 weeks after inducing myocardial infarction in rats by left coronary artery ligation modifies contractile function of hypertrophied papillary muscle from left ventricles with different infarct size (IS) compared to a placebo group (P). At IS<40% of left ventricle, contraction and relaxation were less impaired than at IS>40% compared to sham operated rats (SO). Isometrically developed peak force and calcium sensitivity of myofilaments, measured in skinned fibres, were significantly higher in beta. Treatment with ramipril or metoprolol improved contraction rate and force development, respectively, mainly at IS<40%, but deteriorated relaxation rate. ACE-inhibition and beta-adrenergic blockade had no significant improving effect on the relaxation rate and further characteristics of the contractile function at IS>40%, although combined treatment reduced the infarct size and ramipril treatment suppressed the development of hypertrophy. Post-extrastimulatory potentiation was increased in beta and beta A at IS>40%. Post-rest potentiations were influenced hardly at IS<40% and were significantly smaller in A at IS>40%. The twitch-to-twitch decay of the potentiations was faster at IS>40%. Increase in the degree of post-extrastimulatory potentiation, steeper twitch-dependent decay of the potentiations and loss of rest-dependent potentiation at IS>40% indicate relatively increased trans-sarcolemmal Ca2+ transports via Ca2+ channels and Na+/Ca2+ exchange, partly modified by ramipril and metoprolol. The results demonstrate that ACE-inhibition and beta-adrenergic blockade induce a dissociation between trophic effects and phenotypic effects on contractile function after chronic infarction.

A simple fluorescent technique for the location of tumour cells in frozen sections of the head and neck region

Tumour cells possess cell surface proteases referred to as guanidinobenzoatase (GB) which are closely similar to plasminogen activator. Previous studies have demonstrated different isoenzymic forms of GB on tumour cells and normal cells which can be recognised by cytoplasmic protein inhibitors extracted from frozen sections of appropriate tissues. We now show that normal human serum possesses inhibitors which selectively recognise the isoenzymic forms of GB associated with normal cell surfaces but do not recognise the GB on tumour cell surfaces in frozen sections of tissue obtained from the head and neck regions.

[The coexpression of keratin and vimentin in untreated squamous cell carcinoma of the ENT tract]

Forty-four untreated squamous-cell carcinomas of the upper aerodigestive tract were examined immunohistochemically with antibodies against keratin and vimentin. Surprisingly, in 18% of cases, a coexpression of both intermediate filaments was found both in undifferentiated carcinomas and in highly differentiated carcinomas, where it was only possible to observe this phenomenon in the basal cell layer. The tumor-biological relevance of these findings must be the subject of further investigations.

The status of trypsin-like enzymes in squamous-cell carcinoma of the head and neck region

The activity of two proteases associated with tumour cells was studied using frozen sections of squamous-cell carcinoma and fluorescent probes for the enzymes. Four fluorescent probes were used to define the enzymic status of guanidinobenzoatase on the surface of the squamous carcinoma cells. Each of four probes demonstrated the location of cells possessing inactive guanidinobenzoatase, whereas adjacent cells of the same tumour exhibited active enzyme. It was shown that the inactive form of the enzyme was an inhibitor-enzyme complex that could be dissociated. In contrast, all of the squamous carcinoma cells possessed active trypsin-like enzymes that were recognised by fluorescent aprotinin molecules. The observed variation in enzymic status of these two tumour-associated enzyme systems is discussed in the context of a possible biological control mechanism for cell migration.

Activity of the proteolytic enzyme guanidinobenzoatase in human basal cell carcinoma

Basal cell carcinomas exhibit a characteristic pattern of aggressive invasion from the basal layer of skin epithelial cells. These tumour cells possess an enzyme, guanidinobenzoatase (GB), which is known to be associated with cell migration. The enzyme is inhibited by a fluorescent probe, 9-aminoacridine, and this can be used to locate cells possessing active guanidinobenzoatase. All basal cell carcinoma cells in frozen sections were located by their ability to bind 9-aminoacridine. Extracts of most tissues were shown to contain inhibitors of the GB associated with basal cell carcinoma cells. Extracts of skin, however, failed to inhibit this tumour-associated GB. The significance of these results is discussed in terms of the pathophysiology of basal cell carcinomas.

A study on the treatment of arterial hypertension with atenolol/chlorthalidone tablets: preliminary results of a post-marketing surveillance clinical trial on 2449 patients

A post-marketing clinical trial was carried out in ambulatory patients to assess the efficacy and toleration of atenolol (100 mg)/chlorthalidone (25 mg) tablets in the treatment of arterial hypertension. Data are reported on a cut-off at 2449 patients. Analysis of results in the different age groups has shown that after 4 weeks of treatment there was a mean fall of 16-17% in systolic and of 16-18% in diastolic blood pressure. Adequate blood pressure reduction was obtained for all age groups. The frequency of adverse reactions/events was low, these being reported in only 5.7% of cases. As discontinuation of treatment on account of adverse reactions/events occurred in 3.8% of patients, the risk-to-benefit relationship of atenolol/chlorthalidone tablets was very favourable.

Pneumatosis coli: case report documenting time from X-ray appearance to onset of symptoms

Pneumatosis coli was diagnosed in a 66-year-old atopic woman with a 6-month history of chronic cough and intermittent wheeze. A sequence of chest x-rays demonstrated the appearance of gas-filled cysts in the splenic flexure of the colon approximately 2 months before the development of bowel symptoms. The pneumatosis coli and symptoms disappeared in 6 days with the administration of oxygen at a flow rate of 6 liters/min by nasal prongs. The case demonstrates the slow progression of the condition from x-ray recognition to development of symptoms and the simple, effective treatment of the condition with nasal oxygen.

[Radiation therapy of keloids and hemangiomas (author's transl)]

Keloids and hemangiomas of the cavernous type which require treatment respond very reliably to X-rays. Adequate use of this therapeutic possibility offers considerable advantages to the patients in many cases and in addition it is without danger. Treatment of hemangiomas with beta radiation in the form of Sr-90/Y-90 plates for shortterm application to the skin is so safe and at the same time so successful that, in view of the not at all rare unfavorable spontaneous course, it seems rather risky to delay the indication to begin radiation therapy at the earliest possible moment.