Sequential administration of anti-complement component C5 eculizumab and type-2 anti-CD20 obinutuzumab for the treatment of early antibody-mediated rejection after kidney transplantation: A proof of concept

Kidney transplant (KT) candidates with donor-specific antibodies (DSA) exhibit exceedingly high antibody-mediated rejection (ABMR) and allograft loss rates. Currently, treatment of ABMR remains an unmet clinical need. We report the use of the anti-C5 eculizumab and the type-2 anti-CD20 obinutuzumab in two patients with early ABMR. Eculizumab (900 mg IV) led to complete inhibition of the terminal complement cascade (unremarkable AP50 and CH50 activity) and prompt stoppage of complement-dependent antibody-mediated allograft injury (clearance of intra-graft C4d and C5b-9 deposition). Despite complement inhibition, obinutuzumab (1000 mg IV) determined full and long-lasting peripheral B-cell depletion, with significant reduction in all DSA. Graft function improved, remaining stable up to three years of follow-up. No signs of active ABMR and rebound DSA were detected. Obinutuzumab B-cell depletion and inhibition of DSA production were not affected by complement blockage. Further studies are needed to confirm the potential benefit of obinutuzumab in association with complement inhibitors.

Corrigendum: Impact of hyperparathyroidism and its different subtypes on long term graft outcome: a single Transplant Center cohort study

[This corrects the article DOI: 10.3389/fmed.2023.1221086.].

Outcome of atypical hemolytic uremic syndrome: role of triggers and complement abnormalities in the response to C5 inhibition

BACKGROUND

Atypical-hemolytic uremic syndrome (aHUS) is a rare thrombotic microangiopathy often due to uncontrolled complement activation, characterized by high risk of end-stage kidney disease (ESKD). Eculizumab has improved the outcome, however, its efficacy varies among patients and its discontinuation is debated.

METHODS

To identify characteristics associated with treatment response, we analyzed 244 aHUS patients referred to our center. Patients were classified according to the presence/absence of complement abnormalities and/or triggers at onset in 4 categories: (1) primary (complement abnormality without trigger), (2) secondary (trigger without complement abnormality), (3) combined (trigger and complement abnormality), (4) idiopathic (no trigger, no complement abnormality). Response to treatment was evaluated by comparing the response to eculizumab with that of conventional therapy. Short- and long-term outcomes were evaluated with the relapse rate after discontinuation of C5-inhibition.

RESULTS

Patients had a better outcome with eculizumab compared to conventional treatment, with a response rate of 81.9% vs 56.9%, p < 0.001 and a long-term cumulative incidence of ESKD of 5.8% vs 22.5% (hazard ratio 0.25, 95% confidence interval: 0.10-0.80). The excellent global response was driven by the primary and combined groups (89.8% vs 54.0% and 89.3% vs 54.2%, respectively). The relapse rate following discontinuation of the C5-inhibitor was as high as 66.7% in the primary group, 18.7% in the combined, and 0% in the secondary and idiopathic groups.

CONCLUSIONS

Our data show a better outcome in aHUS patients treated with C5-inhibition, particularly in the primary and combined forms, which have a high risk of relapse after discontinuation that is not observed in the secondary and idiopathic forms.

Impact of hyperparathyroidism and its different subtypes on long term graft outcome: a single Transplant Center cohort study

Purpose

We studied the association between parathormone (PTH) levels and long-term graft loss in RTx patients (RTx-p).

Methods

We retrospectively evaluated 871 RTx-p, transplanted in our unit from Jan-2004 to Dec-2020 assessing renal function and mineral metabolism parameters at 1, 6, and 12 months after RTx. Graft loss and death with functioning graft during follow-up (FU, 8.3[5.4-11.4] years) were checked.

Results

At month-1, 79% had HPT, of which 63% with secondary HPT (SHPT) and 16% tertiary HPT (THPT); at month-6, HPT prevalence was 80% of which SHPT 64% and THPT 16%; at month-12 HPT prevalence was 77% of which SHPT 62% and THPT 15%. A strong significant correlation was found between HPT type, PTH levels and graft loss at every time point. Mean PTH exposure remained strongly and independently associated to long term graft loss (OR 3.1 [1.4-7.1], p = 0.008). THPT was independently associated with graft loss at month-1 when compared to HPT absence and at every time point when compared to SHPT. No correlation was found with RTx-p death. Discriminatory analyses identified the best mean PTH cut-off to predict long-term graft loss to be between 88.6 and 89.9 pg/mL (AUC = 0.658). Cox regression analyses highlighted that THPT was strongly associated with shorter long-term graft survival at every time-point considered.

Conclusion

High PTH levels during 1st year of RTx seem to be associated with long term graft loss.

Case report: Eculizumab plus obinutuzumab induction in a deceased donor kidney transplant recipient with DEAP-HUS

The wide-spread use of the anti-complement component 5 monoclonal antibody (moAb) eculizumab has greatly reduced the incidence of relapsing atypical hemolytic uremic syndrome (aHUS) after kidney transplantation (KT). However, the optimal management of aHUS transplant candidates with anti-Complement Factor H (CFH) antibodies remains debated. In these patients, the benefits of chronic eculizumab administration should be weighed against the risk of fatal infections, repeated hospital admissions, and excessive costs. We report the case of a 45-year-old female patient with CFHR1/CFHR3 homozygous deletion-associated aHUS who underwent deceased-donor KT despite persistently elevated anti-CFH antibody titers. As induction and aHUS prophylaxis, she received a combination of eculizumab and obinutuzumab, a humanized type 2 anti-CD20 moAb. The post-operative course was uneventful. After 1-year of follow-up, she is doing well with excellent allograft function, undetectable anti-CFH antibodies, sustained B-cell depletion, and no signs of aHUS activity. A brief review summarizing current literature on the topic is also included. Although anecdotal, our experience suggests that peri-operative obinutuzumab administration can block anti-CFH antibodies production safely and effectively, thus ensuring long-lasting protection from post-transplant aHUS relapse, at a reasonable cost. For the first time, we have demonstrated in vivo that obinutuzumab B-cell depleting properties are not significantly affected by eculizumab-induced complement inhibition.

MO959: Covid-19 Vaccine in Kidney Transplanted Patients. is There A Clinical Relevance? An Italian Single Center Experience

BACKGROUND AND AIMS

COVID-19 is a life-threatening infection among elderly, comorbid patients or transplanted patients. In our recently published paper (Campise, M.; Alfieri, C.M.; et al. Pathogens 2021, 10, 964), we described our single Centre experience with 82 adult kidney-transplant patients (KTxp) with COVID-19 infection during the previous two pandemic outbreaks: 27 KTxp (first outbreak) and 65 (second). We observed a relatively low and possibly underestimated incidence of infection (5.1%) with a incidence of death almost four times higher than in general population (13%). The availability of COVID-19 vaccines has undoubtedly changed the outcome of the infection in both immunocompetent and immunosuppressed patients.

Aim of this second ongoing observational and descriptive study, is to evaluate if the vaccination performed extensively among our KTxp, has modified the incidence and gravity of COVID-19 infection.

METHOD

Data on KTxp with COVID-19 infection (COV+) from the 29 October 2021 to 31 December 2021 were collected. Particularly, we focused our anthropometric, clinical and therapeutic aspects. In the statistical analyses, continuous variables were expressed as median and interquartile range (25%–75%), and nominal variables were reported as percentage of cases.

RESULTS

From the 29 October 2021 to the 31 December 2021, 33 KTxp developed COVID-19 infection, 60% were male. Median age was 50[29–58] years. Transplant vintage was 57[27–163] months. Median serum creatinine was 1.30[1.0–1.9] mg/dL and body mass index was 23[21–28] kg/m². Immunosuppressive schedule included: CNI inhibitors, steroids and mycophenolate (MMF) in 97–90 and 70% of COV + respectively. In 50% of cases native vitamin D supplementation was present, whereas only 30% of cases were treated with renin-angiotensin inhibitors. Only one had insulin dependent diabetes. At the moment of nasopharyngeal swab positivity 64% of COV + had already received three doses of vaccine (Comirnaty (BNT162b2)^®) and 30% 2 doses. Only 3% of pts had received a single dose. One patient had refused vaccination for personal reasons.

Antigenic nasopharyngeal swab was performed in 70% of COV + and molecular swab in 60%. Thirty-five % of COV + were tested with both methods.

The most frequent symptoms were: fever (70%), cough (75%) and headache (40%). In the previous outbreaks dyspnea was present in 33% of cases dropping to 13% in this cohort. Smell and taste alteration were present in 25% and 28% respectively. We did not perform the COVID-19 sequence. But, on the base of the symptoms referred, we are confident that 17 patients had delta variant and remaining had omicron.

The first therapeutic approaches were the increase of the daily steroid dosage up to 25 mg (60% of cases) together with MMF temporarily withdrawing in 70% of cases and halving in 10%. Forty % of pts were also treated with monoclonal antibodies (Ronapreve ^®) upon infectious disease specialist evaluation. During the first two outbreaks, hospitalization was necessary in 45% of cases, and 13% of pts died. In the present cohort only 10% of patients required oxygen support and hospitalization. Nobody died.

CONCLUSION

Although very preliminary, our results indicate that the vaccination campaign has noticeably ameliorated the incidence, the clinical presentation and the outcome of COVID-19 in KTxp. This comforting data should further sensitize the medical community on vaccination counseling in KTxp as soon as possible. Study with higher number of patients are needed to further clarify the individual response on antibody production and sensitivity to this still life-threatening infection.

MO963: Vitamin D Status and Sars-Cov-2 Infection in A Cohort of Renal Transplanted Patients

BACKGROUND AND AIMS

Immunomodulatory and anti-inflammatory properties have been hypothesized for native vitamin D (nVD). Very little is reported about nVD and risk of Sars-CoV-2 infection (COV) in renal transplant (RTx). In a cohort of renal transplanted patients (RTxp) we retrospectively evaluated: (i) nVD status in patients with (COV+) and without (COV-) COV infection; (ii) the impact of nVD status on severity of COV.

METHOD

The study includes 61 COV + in whom nVD status was available in the year before the infection, and 122 COV- matched 1:2 for age (53[45–64]years), gender (M = 60.7%), RTx vintage (7[2–15] years), presence of diabetes (18%), arterial hypertension (85%) and cardiac symptomatic disease (3%). Renal function, 24-h proteinuria and mineral metabolism (MM) parameters were evaluated at 1, 6 and 12 months before COV whereas nVD status was considered as the mean 25-OH-VD levels at the same timepoints. Severity of COV was based on the need for hospitalization (HOSP+: 27/61, 44.3%) and death (D+: 6/61, 9.8%).

RESULTS

(i) nVD levels were significantly lower in COV + than in COV- (19[12–26] ng/mL and 23[16–30] ng/mL, respectively, P = 0.01). No differences in the other biochemical parameters were found. The COV discriminative power of nVD status was evaluated by ROC curve (AUC 0.61, 95% CI: 0.54–0.68, P = 0.01), with a value of 25-OHVD 23.9 ng/mL showing the best discriminative power (sensibility 72%, specificity 47%). (ii) nVD levels showed a trend towards lower values in HOSP + COV + than HOSP-COV+ (17[8–25] ng/mL versus 20[14–26] ng/mL) and in D + COV + than D-COV+ (13[6–23] ng/mL versus 20[13–26] ng/mL), although these differences did not reach the statistical significance (P = 0.1 and P = 0.2, respectively).

CONCLUSION

With the limitations of the retrospective nature of the study and the small sample size, our data report that:

No association was found between nVD levels in the year preceding the infection and COV severity.

MO961: Mineral Metabolism Parameters and Bone Density During The First Year of Kidney Transplantation

BACKGROUND AND AIMS

We evaluated retrospectively in a cohort of kidney-transplanted patients (KTxp), the variations of mineral metabolism (MM) parameters, femoral and vertebral bone density during the first year of kidney transplantation (KTx).

METHOD

383 KTxp (M = 232), up to the 650 transplanted in our Department (2004–2017) were studied. At 1st(T1) and 12th(T2) mth of KTx biochemical, femoral and vertebral dual-energy X-ray absorption (DEXA) data were recorded. T-score (Ts) -1 &gt;Ts &gt; -2.5 was considered Osteopenia (F-OPN/V-OPN) and Ts &lt; -2.5 osteoporosis (F-OPS/V-OPS).

RESULTS

The KTxp age and dialysis vintage (DV) were 48 ± 12 years and 53 ± 25 months; 67% of KTxp had a history of hemodialysis. In 82.5% of cases, a donor deceased KTx (DD) was performed and in 40% of KTxp had a previous history of steroid therapy. During the first year of KTx 91% and 93% of KTxp received respectively calcineurin inhibitors and mycophenolate, and the steroids cumulative dose (SCD) was 2683 ± 926 mg. At T1, cholecalciferol and calcifediol were supplemented in 5% and 8% of KTxp, and AT T12 in 12% and 15% of KTxp. An increase in BMI (23 ± 3 versus 24 ± 3 kg/m2 P &lt; 0.0001), Ca (9.82 ± 0.83 versus 9.9 ± 0.73 mg/dL, P &lt; 0.0001), P (2.4 ± 0.96 versus 3.1 ± 0.61 mg/dL, P  &lt; 0.0001), 25OH-D (14.4 ± 6.81 versus 18.8 ± 9.7 ng/mL, P  &lt; 0.0001), Hb (11.0 ± 1.4 versus 12.8 ± 1.5 g/dL, P  &lt; 0.0001), albumin (4.2 ± 0.38 versus 4.46 ± 0.35 g/dL, P  &lt; 0.0001) was observed. Serum creatinine (1.41 ± 0.4 versus 1.37 ± 0.3 mg/dL, P = 0.03), PTH (87 ± 73 versus 79 ± 86 pg/mL, P = 0.06 and ALP (107 ± 92 versus 93 ± 58 U/L, P  &lt; 0.0001) had a reduction.

Femoral bone mineral density (F-BMD) at T1 and F-Ts-T1 were 0.749 ± 0.17 g/cm2 and -1.55 ± 1.06. F-OPS-T1 was present in 17.5% and F-OPN-T1 in 53% of KTxp. F-BMD-T1 correlated directly with BMI-T1 (P  &lt; 0.0001) and inversely with 25OH-D-T1 (P  &lt; 0.004). F-Ts-T1 was inversely correlated with DV (P = 0.04), BMI-T1 (P &lt;0.0001) and PTH-T1 (P = 0.02). KTxp with F-OPS-T1 had longer DV and lower BMI (P = 0.02). At T12, F-BMD-T12 and F-Ts-T12 were 0.77 ± 0.67 g/cm2 (P = 0.17 versus F-BMD-T1) and −1.4 ± 0.9 (P = 0.002 versus F-Ts-T1).F-OPS-T12 was present in 13.2% of patients and F-OPN-T1 in 55.2%. F-BMD-T12 correlated directly with BMI-T12 (P  &lt; 0.04). F-Ts-T12 correlated inversely with DV (P = 0.004), Ca at T1 (P = 0.001) and T12 (P = 0.0005) and with [SCD at T12 (P = 0.02)]. Patients with F-OPS-T1 had longer DV (P = 0.004) and higher PTH at T1 and T12 (P = 0.04 and P = 0.08). F-DEXA category worsened in 3.5% of KTxp.

At T1, V-BMD-T1 and V-Ts-T1 were 0.92 ± 0.19 g/cm2 and −1.5 ± 1.58. V-OPS-T1 was present in 30% of KTxp and V-OPN-T1 in 34.5%. V-BMD-T1 correlated directly with BMI-T1 (P  &lt; 0.0001) and Ca-T1 (P = 0.04). V-Ts-T1 was inversely correlated with DV (P = 0.04), PTH-T1 (P = 0.02), Ca-T1 (P = 0.03), ALP-T1 (P = 0.01). A direct correlation between V-Ts-T1 and BMI-T1 (P  &lt; 0.0001) and 25OHD-T1 (P = 0.02) was present. V-OPS-T1 was more prevalent in males (P = 0.01).They had lower BMI (P  &lt; 0.0001), albumin (P = 0.02) and higher Ca-T1 (P = 0.008) and ALP-T1 (P = 0.03). 

At T12, V-BMD-T12 and V-Ts-T12 were 0.90 ± 0.22 g/cm2 and −1.5 ± 1 .33 (both NS versus T1). V-OPS-T12 was present in 27.7% of KTxp and V-OPN-T12 in 37.2%. V-BMD-T12 correlated directly with BMI-T1 and T12 (P  &lt; 0.0001 and P = 0.005) and inversely with Ca-T12 (P = 0.03) and SCD-T12 (P = 0.04). V-Ts-T12 was inversely correlated with DV (P = 0.004), SCD-T12 (P = 0.02) and with Ca at T1 (P = 0.001) and T12 (P = 0.0005). A direct correlation was found with BMI-T1 and T12 (P = 0.0002 and P = 0.001). V-OPS-T12 was more prevalent in DD (P = 0.001). They were older (P = 0.01), had longer DV (P = 0.01). BMI-T1 and T12 were lower in V-OPS-T12 (P = 0.002 and P = 0.03) and Ca-T12 higher (P = 0.01). SCD-T12 was higher in V-OPN-T12 and V-OPS-T12 (P = 0.05). V-DEXA category worsened in 32% of KTxp.

CONCLUSION

In the first year of KTx several modifications of MM are present. Both femoral and vertebral DEXA seem to be strongly related to the pre-KTx status, in particular, nutritional status and dialysis vintage are related to bone status at T1. Strong importance on T12 evaluation is taken by the SCD.

Bloody Diarrhea and Shiga Toxin-Producing Escherichia coli Hemolytic Uremic Syndrome in Children: Data from the ItalKid-HUS Network

OBJECTIVE

To analyze the results of an enhanced laboratory-surveillance protocol for bloody diarrhea aimed at identifying children with Shiga toxin-producing Escherichia coli (STEC) infection early in the course of the disease toward the early identification and management of patients with hemolytic uremic syndrome (HUS).

STUDY DESIGN

The study (2010-2019) involved a referral population of 2.3 million children. Stool samples of patients with bloody diarrhea were screened for Shiga toxin (Stx) genes. Positive patients were rehydrated and monitored for hemoglobinuria until diarrhea resolved or STEC-HUS was diagnosed.

RESULTS

A total of 4767 children were screened; 214 (4.5%) were positive for either Stx1 (29.0%) or Stx2 (45.3%) or both Stx1+2 (25.7%); 34 patients (15.9%) developed STEC-HUS (0.71% of bloody diarrheas). Hemoglobinuria was present in all patients with HUS. Patients with Stx2 alone showed a greater risk of STEC-HUS (23.7% vs 12.7%) and none of the patients with Stx1 alone developed HUS. During the same period of time, 95 other patients were diagnosed STEC-HUS but were not captured by the screening program (26 had nonbloody diarrhea, 11 came from areas not covered by the screening program, and 58 had not been referred to the screening program, although they did meet the inclusion criteria). At HUS presentation, serum creatinine of patients identified by screening was significantly lower compared with that of the remaining patients (median 0.9 vs 1.51 mg/dL).

CONCLUSIONS

Nearly 1% of children with bloody diarrhea developed STEC-HUS, and its diagnosis was anticipated by the screening program for Stx. The screening of bloody diarrhea for Stx is recommended, and monitoring patients carrying Stx2 with urine dipstick for hemoglobinuria is suggested to identify the renal complication as early as possible.

MO922CASUAL FACTORS AND CLINICAL IMPACT OF URINARY TRACT INFECTIONS IN RENAL TRANSPLANTED PATIENTS: AN OBSERVATIONAL RETROSPECTIVE STUDY*

Background and Aims

Urinary tract infections (UTIs) are the most common infectious disease in kidney transplanted patients (KTxps), especially during the first year of kidney transplantation (KTx). This study aims to examine the etiology of UTIs in a large cohort of KTxps, trying to identify their potential predisposing factors both during the first year and in the global follow-up (FU) of KTx. The impact of UTIs on KTx and patient’s survival in the long term will also be analyzed.

Method

In our study 585 KTxps (M 343; median age 49 years), out of the 616 KTxps transplanted in our Department between 2004 and 2016, were studied and followed up for a median time of 8 years. Clinical and biochemical data about the 1st (T1) and the 12th month (T12) of KTx were collected. Parameters related to UTIs, defined by a positive urine culture associated with urinary sediment suggestive of UTI, regardless of clinical symptoms, were considered in the global FU. A number of UTIs ≥3 was considered significant during the 1st year of KTx and in the overall FU. The reduction of the eGFR/year of FU, the loss of graft and the death of KTxps with a functioning graft were evaluated as outcome.

Results

The cohort had a slight prevalence of males (59%) and a median age of 49 years. At the time of KTx, JJ ureteral stent (JJ) was placed in 38% of KTxps, with a median stay time of 47 days. During the FU, 1700 UTIs were found in 458 KTxp, 550 UTIs during the first year of KTx. The pathogens most responsible for UTIs in the global FU were Escherichia coli (61%), Enterococcus (12%) and Klebsiella (8%).

According to the number of UTIs found during the 1st year of KTx, KTxp were categorized in: UTI1≥3 (N=139) and UTI1&lt;3 (N=446). UTI1≥3 were more frequently female and older than UTI1&lt;3, had more prevalence of JJ and ATG induction therapy, and had lower hemoglobin and serum albumin at both T1 and T12. The presence of JJ, belonging to the female gender and induction therapy with ATG were the factors most correlated with IVU1≥3 (OR 1.9, 5.3 and 2.1).

The studied cohort was also categorized according to the number of UTIs during the global FU in UTItot ≥3 (N=168) and UTItot&lt;3 (N=417). UTI tot ≥3 were more frequently females, older, had a longer dialysis vintage and higher prevalence of JJ placement than UTI tot&lt;3. Furthermore, they had significantly lower hemoglobin and serum albumin values, both at T1 and T12. The presence of JJ, the female gender and age at KTx were the factors most related to UTItot ≥3 (OR 1.8, 5.9 and 1.0).

During the FU, the median absolute reduction in eGFR was found to be -0.6[-2.0; +0.9](mL/min)/years. Despite a greater reduction in glomerular filtrate rate in UTI tot≥3 group, the graft loss and the death with functioning graft had no correlation with either UTI1≥3 (7 and 5 patients, respectively) or UTItot≥3 (12 and 8 patients, respectively).

Graft loss was observed in 51 KTxps. The number of infections/follow-up time of these KTxps was comparable to that found in those who had a still functioning transplant at the end of observation, and no statistical differences were found in survival analysis according to IVU tot≥3 category.

During the global FU, 40 KTxp died with functioning graft. Also with regard to this outcome, no significant correlations were observed with the number of UTIs/follow-up time and in the survival analysis.

Conclusion

Our data confirm that UTIs are frequent in KTxps. Some factors, such as induction therapy and JJ use, certainly have a favoring effect in UTIs development. Despite the relation observed between UTIs and eGFR reduction, UTIs had no significant impact on graft loss. Beyond prevention through the improvement of lifestyles and various behavioral aspects, the implementation of personalized immunosuppressive protocols associated with a careful management of JJ are desirable interventions in order to prevent the development of UTIs in KTxps.

Kidney transplant in patients with atypical hemolytic uremic syndrome in the anti-C5 era: single-center experience with tailored Eculizumab

RATIONALE AND OBJECTIVE

Patients with atypical hemolytic uremic syndrome (aHUS) have long been considered ineligible for kidney transplantation (KTx) in several centers due to the high risk of disease recurrence, graft loss and life-threatening complications. The availability of Eculizumab (ECU) has now overcome this problem. However, the best approach towards timing, maintenance schedule, the possibility of discontinuation and patient monitoring has not yet been clearly established.

STUDY DESIGN

This is a single center case series presenting our experience with KTx in aHUS.

SETTING AND PARTICIPANTS

This study included 26 patients (16 females) with a diagnosis of aHUS, who spent a median of 5.5 years on kidney replacement therapy before undergoing KTx. We compared the aHUS relapse rate in three groups of patients who underwent KTx: patients who received no prophylaxis, patients who underwent plasma exchange, those who received Eculizumab prophylaxis. Complement factor H-related disease was by far the most frequent etiology (n = 19 patients).

RESULTS

Untreated patients and patients undergoing pre-KTx plasma exchange prophylaxis had a relapse rate of 0.81 (CI 0.30-1.76) and 3.1 (CI 0.64-9.16) events per 10 years cumulative observation, respectively, as opposed to 0 events among patients receiving Eculizumab prophylaxis. The time between Eculizumab doses was tailored based on classic complement pathway activity (target to < 30%). Using this strategy, 12 patients are currently receiving  Eculizumab every 28 days, 5 every 24-25 days, and 3 every 21 days.

CONCLUSION

Our experience supports the prophylactic use of Eculizumab in patients with a previous history of aHUS undergoing KTx, especially when complement dysregulation is well documented by molecular biology.

Bone Effect and Safety of One-Year Denosumab Therapy in a Cohort of Renal Transplanted Patients: An Observational Monocentric Study

In 32-kidney transplanted patients (KTxps), the safety and the effects on BMD and mineral metabolism (MM) of one-year treatment with denosumab (DB) were studied. Femoral and vertebral BMD and T-score, FRAX score and vertebral fractures (sVF) before (T0) and after 12 months (T12) of treatment were measured. MM, renal parameters, hypocalcemic episodes (HpCa), urinary tract infections (UTI), major graft and KTxps outcomes were monitored. The cohort was composed mainly of females, n = 21. We had 29 KTxps on steroid therapy and 22 KTxps on vitamin D supplementation. At T0, 25 and 7 KTxps had femoral osteoporosis (F-OPS) and osteopenia (F-OPS), respectively. Twenty-three and six KTxps had vertebral osteoporosis (V-OPS) and osteopenia (V-OPS), respectively. Seventeen KTxps had sVF. At T12, T-score increased at femoral and vertebral sites (p = 0.05, p = 0.008). The prevalence of F-OPS and V-OPS reduced from 78% to 69% and from 72% to 50%, respectively. Twenty-five KTxps ameliorated FRAX score and two KTxps had novel sVF. At T12, a slight reduction of Ca was present, without HpCa. Four KTxps had UTI. No graft rejections, loss of graft or deaths were reported. Our preliminary results show a good efficacy and safety of DB in KTxps. Longer and randomized studies involving more KTxps might elucidate the possible primary role of DB in the treatment of bone disorders in KTxps.

IgM Autoantibodies to Complement Factor H in Atypical Hemolytic Uremic Syndrome

BACKGROUND

Atypical hemolytic uremic syndrome (aHUS), a severe thrombotic microangiopathy, is often related to complement dysregulation, but the pathomechanisms remain unknown in at least 30% of patients. Researchers have described autoantibodies to complement factor H of the IgG class in 10% of patients with aHUS but have not reported anti-factor H autoantibodies of the IgM class.

METHODS

In 186 patients with thrombotic microangiopathy clinically presented as aHUS, we searched for anti-factor H autoantibodies of the IgM class and those of the IgG and IgA classes. We used immunochromatography to purify anti-factor H IgM autoantibodies and immunoenzymatic methods and a competition assay with mapping mAbs to characterize interaction with the target protein.

RESULTS

We detected anti-factor H autoantibodies of the IgM class in seven of 186 (3.8%) patients with thrombotic microangiopathy presented as aHUS. No association was observed between anti-factor H IgM and homozygous deletions involving CFHR3-CFHR1. A significantly higher proportion of patients with bone marrow transplant-related thrombotic microangiopathy had anti-factor H IgM autoantibodies versus other patients with aHUS: three of 20 (15%) versus four of 166 (2.4%), respectively. The identified IgM autoantibodies recognize the SCR domain 19 of factor H molecule in all patients and interact with the factor H molecule, inhibiting its binding to C3b.

CONCLUSIONS

Detectable autoantibodies to factor H of the IgM class may be present in patients with aHUS, and their frequency is six-fold higher in thrombotic microangiopathy forms associated with bone marrow transplant. The autoantibody interaction with factor H's active site may support an autoimmune mechanism in some cases previously considered to be of unknown origin.

Cytomegalovirus Disease in Renal Transplanted Patients: Prevalence, Determining Factors, and Influence on Graft and Patients Outcomes

The prevalence and the factors related to cytomegalovirus (CMV) disease (CMVd) during the 1st year of renal transplantation (RTx) and the relationship between CMVd and early and long-term graft and RTx-patient (RTx-p) survival were evaluated. In 505 RTx-p, followed up for 8(5-11) years, data were recorded after 1-(T1) and 12-(T12) months of RTx. CMVd was defined either by CMV replication without clinical signs of disease (CMVr, 43%), or CMV replication with signs of disease (CMVs, 57%). During the 1st year of RTx, 45% of RTx-p had CMVd (CMVd+). CMVd+ patients were older than CMVd- patients. Female gender and Donor CMV-IgG+ (CMV IgG-D+)/recipient IgG- (CMV IgG-R-) status were more prevalent in CMVd+. At T1, CMVd+ had lower albumin, haemoglobin, and higher uric-acid and reactive C-protein than CMVd- and, at T1 and T12, received more steroids. Albumin-T1 was the unique factor in determining CMVd+, maintaining its significance also after the inclusion of IgG-D+/IgG-R- status to the model. CMVs had higher prevalence of CMV IgG-D+/IgG-R- than CMVr. CMVd, CMVr, and CMVs had no impact on graft loss (11% of RTx-p) and RTx-p death (8% of RTx-p). CMVd is highly prevalent during the 1st year of RTx. Albumin-T1 influences CMVd insurgence. CMVd did not impact on RTx and RTx-p loss.

Ribavirin as a beneficial treatment option for hepatitis C virusassociated glomerular disease

The management of hepatitis C virus (HCV)-induced glomerular disease remains unsatisfactory despite novel advances in antiviral and immunosuppressive therapy. Recent evidence highlighted the role of ribavirin, a drug provided with immunomodulatory properties, in the treatment of glomerular diseases associated with chronic HCV. We administered low-dose ribavirin (200 mg/day or 200 mg twice a week or 200 mg thrice weekly) in a prospective fashion to a group of patients with HCV-associated glomerular disease (n = 7). Ribavirin monotherapy was given in most (n = 6) patients and was accompanied by erythropoietin therapy in all. The primary endpoint was reduction of 24-h proteinuria after treatment ended; the secondary end-points were decrease in serum creatinine and amelioration of urinary abnormalities. We collected data on on-treatment adverse events (AEs), serious AEs, and laboratory abnormalities. Many patients (n = 6) had inactive HCV infection as they had shown HCV RNA clearance from serum after antiviral therapy with direct-acting antivirals. Some patients (n = 4) had membranoproliferative glomerulo- nephritis, the diagnosis being confirmed by kidney histology in three cases; others (n = 2) received diagnosis of diabetic glomerulosclerosis, confirmed in one by kidney biopsy. We observed consistent reduction of 24-h proteinuria in two individuals after ribavirin therapy; another patient reported disappearance of microscopic hematuria. We found severe AE (hemolytic anemia) in three patients which required discontinuation of ribavirin treatment in two patients, one required hospitalization. Other AEs were cutaneous rash (n = 1), dyspepsia (n = 1), and fatigue (n = 1). Low-dose ribavirin was able to give consistent reduction of 24-h proteinuria in two patients; tolerance to ribavirin was unsatisfactory. We need further studies aimed to expand our knowledge on ribavirin therapy of HCV-associated glomerular disease. The low incidence of the disease hampers the conduction of clinical trials on this aim.

Laser capture microdissection on formalin-fixed and paraffin-embedded renal transplanted biopsies: Technical perspectives for clinical practice application

Renal biopsy (RBx) is an essential tool in the diagnostic and therapeutic process of most native kidney diseases and in the renal transplanted graft. Laser capture microdissection (LCM), combined with molecular biology, might improve the diagnostic power of RBx. However, the limited amount of available renal tissue is often an obstacle for achieving a satisfactory qualitative and quantitative analysis. In our work we present a method which allows us to obtain good quality and quantity of RNA from formalin-fixed and paraffin-embedded (FFPE) renal tissue derived from RBx performed in transplanted patients. Histology, immunohistochemistry, LCM, pre-amplify system and qRT-PCR of biomarkers related to tubular damage, inflammation and fibrosis on FFPE RBx were performed. Glomeruli, tubules and interstitium of three RBx (RB-A: no alteration; RB-B and -C: the progressive rise of creatinine) were compared. The method proposed, could well be useful in future clinical practice. It is quick, easy to perform and allows the analyses of many biomarkers. In addition, it could be extended to all types of RBx without any limitation on the sample amount. Nevertheless, the need for a higher number of well-trained technicians might represent some limitation, counterbalanced by the opportunity to elaborate more accurate diagnosis and, consequently, more targeted therapies.

P1700CYTOMEGALOVIRUS DISEASE IN RENAL TRANSPLANTED PATIENTS: DETERMINING FACTORS AND ITS RELATION WITH GRAFT OUTCOME AND PATIENTS SURVIVAL

Background

CMV disease (CMVd) is a frequent complication in renal transplanted patients (RTxp), especially during the first year of transplantation (RTx). CMVd impacts on long term graft and patients outcomes is still debated. Our observational retrospective study aims to evaluate: 1) the prevalence of CMVd during the first year of RTx; 2) the factors related to CMVd; 3) the relationship between CMVd and early and long term graft and patients survival.

Method In 505 RTxp (age: 50[41;58]yrs – 292 males), up to the 616 transplanted in our unit between 2004 and 2016, clinical, blood and urinary parameters were recorded after 1 (T1) and 12 (T12) months of RTx. eGFR was estimated by MDRD formula. Donor (D) and Recipient (R) CMV serology was tested at the moment of RTx. CMV IgG-D+/IgG-R- RTxp (12%) and high risk patients (second or more RTx, ATG induction therapy), received prophylaxis therapy until the 3rd month of RTx. CMVd, was defined by the presence either of CMVr (CMV replication without clinical signs of CMV disease) or CMVs (CMV replication with signs of disease and/or need of antiviral therapy/reduction of immunosuppressive therapy). Median follow up (FU) was 8[5-11]yrs. The following outcomes were investigated: 1) graft: reduction of eGFR &gt;20% between T1 and T12; reduction of eGFR &gt;50% between T1 and end of FU (eGFRr&gt;50%); graft loss (GL); eGFRr&gt;50% + GL.; 2) RTxp survival at the end of FU.

Results Ninty percent of RTxp had a kidney from a deceased D; 73% and 21% received haemodialysis (HD+) and peritoneal dialysis before RTx. Dialysis vintage was 50[33-75] months. In 12% of RTxp, induction therapy included ATG. Cumulative steroids dose was 880[840-105]mg and 2272[2598-3223]mg at T1 and T12 respectively. During the first year of RTx, 45% of patients had CMVd (CMVd+). CMVd+ were older than CMV free RTxp (CMVd-). Female gender, HD+ and CMV IgG-D+/IgG-R- were more prevalent in CMVd+. In addition, at T1, CMVd+ had lower albumin, haemoglobin and higher PTH, uric acid and reactive C protein levels than CMVd- and, both at T1 and T12, received higher steroid dose. In multivariate analysis, albumin-T1 was the most significant modifiable factor in determining CMVd+ (p=0.009 OR 0.50 – IC 0.29-0.84). Albumin-T1 maintained its significance also after the addiction of CMV serology IgG-D+/IgG-R- to the model (albumin T1: p=0.008 OR 0.48 – IC 0.29-0.84; CMV serology IgG-D+/IgG-R-: p=0.01 OR 2.16 – IC 1,18 -3,95). Among CMVd, 19% and 25% had respectively CMVr and CMVs. CMVs were characterized by lower dialysis vintage and higher prevalence of CMV IgG-D+/IgG-R- than CMVr. GL and death were observed in 11% and 8% of RTxp respectively. In univariate and survival analyses, CMVd, CMVr and CMVs didn’t show any impact on the graft and patients outcomes examined.

Conclusion Our retrospective study confirms the high prevalence of CMVd during the first year of RTx, and identifies albumin at T1 as the most impacting parameter in influence CMVd insurgence. This might reflect the importance of the pre-RTx status in CMVd development after RTx. Nevertheless, CMVd seems not impact significantly on early and long term outcomes, experienced however in a small part of the cohort studied. Future studies, possibly prospective and including higher number of patients might better elucidate this issue.

P0893BONE EFFECTS AND SAFETY OF ONE YEAR DENOSUMAB THERAPY IN A COHORT OF RENAL TRANSPLANTED PATIENTS: AN OBSERVATIONAL MONOCENTRIC STUDY

Background and aims

Bone and mineral metabolism (MM) disorders are relevant problems in renal transplanted patients (RTxp). In our observational monocentric study, we evaluated the effects on femoral and lumbar bone mineral density (BMD) and on MM parameters, and the safety of one year-treatment with Denosumab (DB) in a cohort of RTxp.

Method

We recorded data about 32 RTxp treated with DB in our Center in the last year. RTxp were evaluated for BMD and T-score (Ts) before the start (T0) and after 12 months (T12) of treatment. Osteopenia was defined, at femoral (F-OPN) and lumbar (L-OPN) sites as Ts:-1&gt;Ts&gt;-2.5 whereas osteoporosis, in the same sites (F-OPS and L-OPS) as Ts&lt;-2.5. X ray evaluation for spontaneous vertebral fractures (sVF) was made at T0 and, in 25 RTxp repeated at T12. MM and renal function parameters (serum creatinine, sCr and daily urinary protein excretion, ProtU) were recorded at T0 and after 1,3,6, and 12 months of therapy. The clinical indications for DB therapy, in the presence of Ca&gt;9.0 mg/dL were the finding at T0 of: 1) F-OPS and/or V-OPS; 2) sVF. During the year of treatment, hypocalcemic (HpCa=Ca&lt;8.0 mg/dL) episodes, infections, graft rejections and loss and RTxp survival were monitored.

Results

The cohort was composed mainly by females (n=21). The time of RTx was 144[59-232]mths. Steroid therapy was prescribed in 30 RTxp (93%), 22(68%) and in 2 (6%) RTxp were taking 25OHD and 1-25OH. Three RTxp (9%) were receiving Ca supplements. Bisphosphonate therapy was reported in 15 RTxp (46%) in the year before DB start. At T0, 25(78%) and 7 (22%) RTxp had F-OPS and F-OPN. Twenty-three (71%) and 6 (20%) RTxp had L-OPS and L-OPN. In 3 RTxp normal lumbar T-score was found. sVF were present in 17 RTxp (53%). Ca and P were 9.6±0.6 mg/dL and 3.1±0.6 mg/dL whereas PTH, ALP and 25OHD were 64±32 pg/mL, 80±37 U/L and 28±16 mg/dL. SCr and Prot-U were 1,32±0,4 mg/dL and 0,23±0,16 g/24h. At T12, F-Ts increased significantly (T0: -3.0[-3.5/-2.5] vs T12:-2.8[-3.5/-2.4) as like as V-Ts (T0: -3.0[-3.7/-1.9] vs T12:-2.8[-3.0/-1.6) both p&lt;0.0001. A significant increase was found also in BMD: F-BMD +2.4%[-1.1%/+13%] (p&lt;0.0001), V-BMD +2.6%[-3.4%/+12%] (p=0.009). The prevalence of F-OPS reduced from 78% to 73% (p&lt;0.0001) and 4 RTxp ameliorated their Ts category. Prevalence of V-OPS reduced to 53% at T12 from 71% (p&lt;0.001), and 4 RTxp ameliorated their Ts category. In 2 RTxp were found novel sVF. During the treatment no significant modifications of Ca were found, with only a slight but significant difference between T0 and T12 (T12 Ca: 9.22±1.17, p=0.01). PTH and ALP were significantly higher at T3, T6 and T12 respect T0. No differences in 25OH, sCr and ProtU were found. During the year of treatment, in 3 RTxp 25OHD supplementation was started. No one required novel Ca supplementation. DB therapy wasn’t associated to HpCa episodes. Four RTxp had infections during the time of treatment (mean time of DB treatment:114 days). They had positive pathologic anamnesis for urinary tract infections (UTI). Two of them had symptomatic UTI and 2 required hospitalization for sepsis. No biopsy proven graft rejections were observed during the time of treatment and no graft loss or RTxp death were reported.

Conclusions

The preliminary results presented in our study, limited by the monocentric, not randomized design and by the smallness of the cohort, reported a good bone efficacy of DB in RTxp, especially at lumbar level. The therapy was characterized by a good general safety. Future longer and randomized studies, involving more RTxp might elucidate the possible primary role of DB in the treatment of bone disorders in RTxp.

Surgical Complications during Continuous Ambulatory Peritoneal Dialysis

In 30 patients (20 males and 10 females) undergoing CAPD, we observed 15 catheter-related complications -group A: leakage, dislodgement, slipping-out, protrusion of the external cuff, hemoperitonitis, and eight abdominal-cavity complications -group B: umbilical, inguinal, incisional and diaphragmatic hernias. Group A complications which occurred in 30% of the men and 80% of the women (mean age 47.2 ± 9) were easy to manage; group B complications developed mainly in elderly males (seven men and one woman, mean age 61.4 ± 5); these required temporary change of mode of dialysis in three, and permanent transfer from CAPD in two.

From this review we have concluded that loss of anatomical integrity of the abdominal cavity is one of the main factors which prevents the continuation of CAPD.

Kinetics of Anti-Xa Activity during Combined Defibrotide - Heparin Administration in Hemodialysis

Defibrotide, a polydesoxyribonucleotide derivative with antithrombotic and fibrinolytic activity, capable of inducing the release of PGI2 from vascular endothelia, was proposed as an alternative to standard heparin coverage during blood dialysis for patients at risk of bleeding. The original procedure featured the preliminary washing of the dialysis circuit with heparin, which was then recirculated and eliminated, and the two drugs, heparin and defibrotide, are known to interact with each other. The purpose of this present study was to explore the ex-vivo heparin activity (assessed as anti-Xa activity) in diverse hemodialysis models using defibrotide (800 mg intravenous, in 4 bolus injections) and various dosages of heparin. Anti-Xa activity is negligible in dialysis conducted with defibrotide alone. When the circuit was prewashed with heparin (5000 and 2500 IU), there was evident anti-Xa activity (0.3-0.5 U/ml) in the first 30-60 minutes of dialysis; continuous heparin infusion (500 U/hour) resulted in high anti-Xa activity levels at the end of dialysis. Thus the best hemodialysis procedure for patients at high risk of bleeding should be one utilizing only defibrotide, or defibrotide plus small amounts of calcium heparin infused at the rate of 500 U/hour for not more than two hours.

Immunosuppressive and antiviral treatment of hepatitis C virus-associated glomerular disease: A long-term follow-up

BACKGROUND

The evidence in the medical literature on the treatment of hepatitis C virus-associated glomerular disease is extremely limited. The advent of nonconventional immunosuppressive agents and direct-acting antivirals promises high efficacy and safety.

AIMS

We conducted an open-label, single-arm clinical study to examine the efficacy and safety of a combined approach for hepatitis C virus-associated glomerular disease.

METHODS

In the first phase of the study, patients with hepatitis C virus-associated glomerular disease received interferon-based antiviral therapy and immunosuppressive agents; since 2013, interferon-free antiviral therapy was adopted and novel immunosuppressants (including B-cell depleting agents and mycophenolate mofetil) or immunomodulators (ribavirin) were choiced. Virological and clinical responses were evaluated over a long observation period (median follow-up of 60 weeks and 46.5 months after the end of treatment with interferon and direct-acting antiviral agents, respectively).

RESULTS

We enrolled 25 consecutive patients with hepatitis C virus-associated glomerular disease, 8 being liver transplant recipients for hepatitis C. A total of 13 patients received therapy with direct-acting antivirals and experienced sustained viral response (serum hepatitis C virus RNA <12 IU/mL, 12 weeks after treatment ended, sustained viral response12). The mean (±standard deviation) proteinuria decreased from 2.61 ± 1.01 at baseline to 1.71 ± 1.43 (g/day) at sustained viral response 48, p = 0.031; microscopic hematuria and serum cryoglobulins disappeared in six (50%) and seven (64%) patients, respectively, after sustained viral response by direct-acting antivirals. Adverse events occurred in 69% (9/13) of patients and were mild, with four cases of ribavirin-related anemia requiring blood transfusions (no drop-outs). After sustained viral response by direct-acting antivirals, immunosuppressive and immunomodulatory agents were initiated in clinical relapsers ( n = 2) and nonresponders ( n = 3) with some benefit. Among patients on interferon-based regimens ( n = 12), viral response (sustained viral response 24) and dropout rates were 58% (7/12) and 33% (4/12), respectively. After sustained viral response by interferon-based therapy, clinical relapsers ( n = 3) were successfully managed with immunosuppressive agents in two patients.

CONCLUSION

Treatment with direct-acting antivirals provides excellent rates of viral response and safety in patients with hepatitis C virus-related glomerular disease; viral response was frequently accompanied by clinical improvement. The absence of hepatitis C virus RNA from serum allowed immunosuppressive and immunomodulatory therapies with benefits for glomerular abnormalities and no concern on hepatitis C virus replication.

Complement functional tests for monitoring eculizumab treatment in patients with atypical hemolytic uremic syndrome: an update

BACKGROUND

Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA) characterized by platelet consumption, hemolysis, and organ damage. Eculizumab (ECU), a humanized antibody that blocks complement activity, has been successfully used in aHUS, but the best treatment schedule is not yet clear.

METHODS

Here, we report our experience with ECU maintenance treatment and the interval between subsequent doses being extended based on global classical complement pathway (CCP) activity aimed at <30% for maintaining aHUS into remission.

RESULTS

We report on 38 patients with aHUS, 13 children, 21 female, with a median age of 25.0 years (range 0.5-60) at disease onset treated with ECU standard schedule for a median of 2.6 months (range 0.4-24.6). Once stable TMA remission was obtained, the interval between ECU doses was extended based on complement function, with a target CCP activity of <30%. With this approach, 22 patients regularly receive ECU infusion every 28 days and 16 every 21. During a median observation period on ECU, an extended interval of 26.9 months (range 0.8-80.9), with a cumulative observation period of 1,208 months, none of the patients relapsed.

CONCLUSION

Monitoring complement activity allows a safe reduction in the frequency of ECU administration in aHUS while keeping the disease in remission.

Rituximab therapy for primary glomerulonephritis: Report on two cases

The evidence in the medical literature on the efficacy and safety of rituximab therapy for primary glomerulonephritis is limited and controversial. We describe two male Caucasian patients with rapidly progressive kidney failure due to primary proliferative glomerulonephritis. Both of them received high-dose intravenous corticosteroids and oral cyclophosphamide with limited benefit. The first patient (hepatitis C virus-negative mixed cryoglobulinemia) underwent plasma-exchange with intravenous immunoglobulins; he showed significant benefit on kidney function (he became dialysis independent with serum creatinine going back to 1.6 mg/dL) after one rituximab pulse even if urinary abnormalities were still present. No improvement in renal function or urinary changes occurred in the second patient. Both these individuals developed sepsis over the follow-up, the first patient died two months after rituximab therapy. This report is in keeping with the occurrence of severe infections after rituximab therapy in patients with renal impairment at baseline and concomitant high-dose steroids.

Complement functional tests for monitoring eculizumab treatment in patients with atypical hemolytic uremic syndrome

BACKGROUND

Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy characterized by hemolysis, platelet consumption, and renal injury. Eculizumab, a mAb that blocks complement activity, has been successfully used in aHUS.

OBJECTIVES

To optimize eculizumab therapy in aHUS patients by monitoring complement functional tests and markers of disease activity.

PATIENTS/METHODS

We studied 18 patients with aHUS (10 males; eight females; age range, 2-40 years) treated with eculizumab to induce and/or maintain disease remission. Patients were followed up for a cumulative observation period of 160 months, during which blood samples were obtained at various time intervals to measure complement activity (Wieslab for the classical, alternative and mannose-binding lectin complement pathways) and the parameters of disease activity (haptoglobin and lactate dehydrogenase serum levels, and platelet count). The intravenous eculizumab doses of 12-33 mg kg(-1) were initially administered every week, with the interval between doses being gradually extended to 2 weeks, 3 weeks and 4 weeks on the basis of strict laboratory and clinical control.

RESULTS

Complement activity was normal before eculizumab treatment, regardless of the state of the disease (activity or remission). It was completely suppressed 1 week, 2 weeks and 3 weeks after the last eculizumab infusion (mean values ± standard deviation: 1% ± 1% to 3% ± 5% for both the classical and alternative pathways; P = 0.0001 vs. baseline), and partially suppressed after 4 weeks (22% ± 26% and 16% ± 27%; P = 0.0001 vs. baseline). The increase in the time interval between eculizumab infusions did not change disease activity markers.

CONCLUSIONS

Monitoring complement tests can allow a safe reduction in the frequency of eculizumab administration in aHUS while keeping the disease in remission.

Antiviral therapy for HCV-associated cryoglobulinemic glomerulonephritis: case report and review of the literature

We describe the case of a 51-year-old woman with HCV-associated cryoglobulinemic glomerulonephritis (GN). She presented mild deterioration of kidney function, non-nephrotic proteinuria, and active urinary sediment. Kidney biopsy showed features of membranoproliferative changes with some sclerosis. Sustained viral response (SVR) was obtained by 6 months of antiviral therapy (peg-IFN-α2a plus ribavirin). SVR was linked with improvement of kidney function and remission of proteinuria. Clinical and virological remission persists over a 25-month follow-up. This case report emphasizes efficacy and safety of antiviral treatment of HCV-associated glomerulonephritis--preliminary but encouraging results exist. We identified by systematic review of the literature 9 studies (156 unique patients); the pooled estimate of frequency of sustained virological response after IFN-based therapy was 0.49 (95% confidence interval, CI: 0.21, 0.77; p < 0.0005; random effects model). Heterogeneity was found (I(2) = 98.9%, p < 0.0001). Two possible regimens should be considered for the treatment of HCV-associated cryoglobulinemic GN according to the clinical presentation. Immunosuppressive therapy is recommended for HCV-related kidney disease having aggressive course, and recent evidence supports rituximab (RTX) use with a reduced exposure to corticosteroids. We identified six studies (66 unique patients) on RTX therapy for HCV-associated kidney disease; at the end of RTX therapy, the pooled estimate of the mean decrease in proteinuria was 1.4 g/24 h (95% CI: 0.75, 2.05, p < 0.001); The p test for heterogeneity gave a value of 0.94 (I(2) = 0). Several questions related to RTX use remain. HCV-induced GN is uncommon among CKD patients of developed countries, and this clearly hampers prospective controlled clinical trials aimed to evaluate efficacy and safety of antiviral or immunosuppressive therapy in this population.

Immediate graft function positively affects long-term outcome of renal allografts from older but not from younger donors

There is disagreement about the impact of delayed graft function (DGF) on renal allograft outcome. This may depend on several variables including the age of the donor. We evaluated whether DGF could have different effects in recipients of kidneys from donors aged more than 60 years versus well-matched recipients of younger kidney donors. Patients were retrospectively subdivided into 3 groups. Immediate graft function (IGF), DGF without dialysis (DGF-ND), DGF requiring dialysis (DGF-D). DGF-ND and DGF-D occurred more frequently among 198 older than 198 younger donors (P = .016 and P = .044, respectively). The 5-year patient (96% vs 93%) and pure graft (96% vs 89%) survivals were significantly better in younger recipients, while the incidence of acute rejection was similar. After a mean follow-up of 66 +/- 44 months in older donor recipients, the graft survival was significantly better among IGF than patients in the DGF-ND (P = .046) or DGF-D (P = .003) groups. Instead, in younger recipients there was no difference in graft survival between IGD and DGF-ND. Only patients with DGF-D showed a significantly worse outcome. Upon multivariate analysis of older donors, their recipients, showed the pattern of graft function recovery to be the only variable associated with allograft outcome. Instead in younger donor recipients, acute rejection and time on dialysis were the main variables associated with a poor outcome. In older donor recipients, DGF was an independent variable associated with a poor graft outcome. In younger donor recipients, duration of dialysis and rejection were the most important predictors of poor graft outcomes.

The clinical impact of chronic transplant glomerulopathy in cyclosporine era

BACKGROUND

The clinical impact of chronic transplant glomerulopathy (CTG) on the outcome of kidney allograft receiving calcineurin inhibitors (CNIs) remains uncertain. A retrospective study of renal transplant recipients at Ospedale Maggiore of Milan was undertaken to evaluate the clinical outcome of patients with CTG.

METHODS

Among 666 biopsies taken at least 6 months after transplantation (Tx) in 498 transplant patients treated with CNIs, 28 cases (5.6%) of chronic transplant glomerulopathy (CTG) were identified and their clinical features at Tx, at follow-up and graft survival were compared with those of 56 controls transplanted in the same period and with kidney functioning 12 months after Tx. Clinical characteristics at biopsy and at 1 year after Tx were similar in the two groups.

RESULTS

After diagnosis graft function deteriorated in 22 patients (78.5%), while it remained stable in 6. Graft loss developed in 92 % of patients with proteinuria >2.5 g/day and in 33 % of those with lower proteinuria (P<0.005). In cases with more severe CTG the rate of graft loss was higher, though not significantly. Graft survival at 10 years was 48% in patients with CTG and 88% in controls (P<0.0001).

CONCLUSIONS

The incidence and clinical course of CTG do not seem to be modified by CNI-based immunosuppression. The evolution is unpredictable but the severity of glomerulopathy and proteinuria at follow-up are associated with progression to graft failure. Patients with CTG have a graft survival significantly worse than that of the general population of transplanted patients.

Effect of Incremental Doses of Folate on Homocysteine and Metabolically Related Vitamin Concentrations in Nondiabetic Patients on Peritoneal Dialysis

The role of folate supplementation in reducing hyperhomocystinemia in patients on dialysis has been reported, but the optimal dose of folate is still unknown. The aim of the present study was to investigate whether greater than 5 mg/day folate supplementation provides any additional effect on plasma homocysteine (HCY) levels. The study was prospective, open, and had no control group. Of the 64 eligible nondiabetic patients on peritoneal dialysis with hyperhomocystinemia (>20 micromol/L), 56 were given oral folate (5 mg/day) for 3 months. When Hcy did not fall below 20 micromol/L, folate doses were increased by 5 mg every 3 months to up to 15 mg/day. With 5 mg/day supplementation, serum folate concentrations increased above the upper confidence limit in 23 patients and erythrocyte folate concentrations in 27 patients. Hcy levels decreased to less than 15 micromol/L in 6 cases and by more than 50% in 12 cases. Nineteen of the remaining patients were given 10 mg/day folate. After increasing the dose, serum and erythrocyte folate levels rose above the upper detection limit. In one patient, plasma Hcy concentrations decreased to less than 15 micromol/L. Ten patients were given 15 mg/day oral folate for an additional 3 months with no effect on homocystinemia. This study confirms that oral folate supplementation may improve hyperhomocystinemia even in patients on dialysis with normal serum or erythrocyte folate concentrations. In fact, serum and erythrocyte levels cannot predict the effect of supplementation on plasma Hcy levels. However, 5 mg/day folate supplementation normalized Hcy in 10% of cases and reduced Hcy levels in another 21%. Increasing the folate dose to greater than 5 mg/day had a minimal (10 mg/day) or no (15 mg/day) additional effect on Hcy concentrations. Despite the minimal effect of increasing folate doses, given the low cost, the absence of side effects, and the high cardiovascular risk for patients on peritoneal dialysis, a careful attempt to increase the dose of oral folate up to 10 mg/day might be suggested.

Cancer among patients on renal replacement therapy: a population-based survey in Lombardy, Italy

Longer and better survival of End-Stage Renal Disease (ESRD) patients undergoing renal replacement therapy (RRT) is now associated with a higher prevalence of new elderly patients receiving renal replacement therapy (dialysis). In order to help clarify the association of cancer risk with RRT, the incidence of cancer in a population-based cohort of uraemic patients in the Region of Lombardy, northern Italy, was undertaken using data from the Lombardy Regional Dialysis and Renal Transplant Registry. A total of 479 cases of cancer of all sites was recorded in this population. There were statistically significantly elevated risks of primary liver cancer, kidney cancer, thyroid cancer, lymphoma and multiple myeloma. When the data were examined according to primary renal diseases, there did not appear to be any particular association between excess cancer risk and the underlying pathology. While some caution must be expressed in interpreting these data, due to the relatively small numbers of cases expected in many of the disease entities, the results indicate an excess of renal-cell and liver carcinomas and lymphomas in patients receiving RRT and highlight the necessity of careful follow-up and awareness of these associations, together with the need for early detection of such tumours.

The impact of long-term hemodialysis on pituitary-adrenocortical function

The activity of the hypothalamic-pituitary-adrenal axis in hemodialyzed (HD) patients has been investigated, with conflicting results. Different results are reported concerning both basal ACTH and cortisol concentration and the responses to different stimulating agents, in chronic hemodialyzed patients. The present study was performed in order to asses whether the length of the hemodialytic treatment may affect the pituitary and adrenocortical response to stimulation with ovine CRH (oCRH) and with exogenous ACTH in a group of patients on chronic HD for more than 10 years. Ten uremic patients (aged 38-71, 6 males and 4 females) on chronic hemodialysis for at least 10 years and 7 healthy subjects matched for age and sex were studied. The patients were tested on the day preceding dialysis session. Each subject received on different non-consecutive days oCRH (100 micrograms i.v. in bolus) and ACTH (Synacthen 0.25 mg i.v. in bolus), and blood samples were obtained at appropriate intervals. Basal ACTH and cortisol levels of HD patients were in the upper limit of normal range (ACTH 39.21 +/- 11.11 pg/mL in HD patients vs. 26.88 +/- 14.12 pg/mL in controls; cortisol 19.96 +/- 5.07 in HD patients vs. 12.66 +/- 4.44 in controls); however, the means were not significantly different compared with controls. Following oCRH administration a net increase of ACTH and cortisol was observed in every patient tested (ACTH peak 83.81 +/- 28.49 in HD vs. 78.73 +/- 22.87 pg/mL in controls; cortisol peak 30.73 +/- 19.31 in HD vs. 20.05 +/- 3.19 micrograms/dL in controls).(ABSTRACT TRUNCATED AT 250 WORDS)

Unilateral nephrectomy and progression of renal failure

Extensive ablation of renal mass in experimental animals leads to progressive glomerulosclerosis and chronic renal failure (CRF). Clinical studies are far from answering the question whether patients with reduced renal mass are at risk of developing progressive CRF. The aim of our study was to examine the morphological and functional aspects of the remnant kidney in a group of patients who underwent unilateral nephrectomy for renal tuberculosis: 313 patients (161 M, 152 F) mean age 57.2 +/- 10.7, were examined after a period ranging from 13.56 to 591.2 months. All patients were on ad libitum diet. Hypertension was found in 34.19% of the patients; SBP was 155.29 +/- 19.9 mmHg and DBP was 92.74 +/- 13.07 mmHg. Estimation of renal size performed by ultrasound scanner gave the following results: length 116.78 +/- 8.99 mm; width 58.24 +/- 7.21 mm; thickness 17.88 +/- 1.96 mm. Kidney function assessed by serum creatinine levels showed a mean level of 1.28 +/- 0.53 mg%. Forty-two patients (13.41%) had serum levels > 1.5 mg% but 18 of them had nonconcomitant systemic or renal involvement. Microalbuminuria determined by RIA assay was found in 50.5% of the patients. In our group of patients renal functional impairment was low and hyperfiltration expressed as microalbuminuria does not appear to be a primary factor in the progression of renal failure.

Kinetics of anti-Xa activity during combined defibrotide-heparin administration in hemodialysis

Defibrotide, a polydesoxyribonucleotide derivative with antithrombotic and fibrinolytic activity, capable of inducing the release of PGI2 from vascular endothelia, was proposed as an alternative to standard heparin coverage during blood dialysis for patients at risk of bleeding. The original procedure featured the preliminary washing of the dialysis circuit with heparin, which was then recirculated and eliminated, and the two drugs, heparin and defibrotide, are known to interact with each other. The purpose of this present study was to explore the ex-vivo heparin activity (assessed as anti-Xa activity) in diverse hemodialysis models using defibrotide (800 mg intravenous, in 4 bolus injections) and various dosages of heparin. Anti-Xa activity is negligible in dialysis conducted with defibrotide alone. When the circuit was prewashed with heparin (5000 and 2500 IU), there was evident anti-Xa activity (0.3-0.5 U/ml) in the first 30-60 minutes of dialysis; continuous heparin infusion (500 U/hour) resulted in high anti-Xa activity levels at the end of dialysis. Thus the best hemodialysis procedure for patients at high risk of bleeding should be one utilizing only defibrotide, or defibrotide plus small amounts of calcium heparin infused at the rate of 500 U/hour for not more than two hours.

Effects of calcifediol treatment on the progression of renal osteodystrophy during continuous ambulatory peritoneal dialysis

Mineral metabolism was studied in 31 patients with chronic renal failure on continuous ambulatory peritoneal dialysis (CAPD) for a year. After baseline observations, 1-year calcifediol treatment was started in all the patients (100 micrograms/day). After therapy, progressive normalization of calcium levels was found in all the patients, while plasma phosphate did not change. After therapy, plasma alkaline phosphatase and parathyroid hormone decreased significantly. 1,25-Dihydroxyvitamin D showed a slight increase, and 25-hydroxyvitamin D (extremely low at the start of the study) rose, reaching normal levels, after 1 year of treatment. Bone mineral density and bone biopsy indexes showed general improvement after calcifediol. In conclusion, calcifediol seems to act positively on the disorders of mineral metabolism in CAPD.

Failure of platelet markers to evaluate membrane biocompatibility during a combined hemodialysis-hemoperfusion treatment

Plasma levels of the platelet markers beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4) are among the most sophisticated indexes of biocompatibility available to evaluate new members for hemodialysis. This investigation was designed to determine the extent of platelet activation by measuring the alpha-granule release products, beta-TG and PF4; anticoagulation and thrombogenesis by monitoring plasma heparin; and fibrinopeptide A (FPA) and thromboxane B2 (TX B2) levels during treatment with a combined hemodialysis-hemoperfusion system. Both in vivo and in vitro results showed that the platelet markers had a pattern different from that generally observed during treatment with hemodialysis alone. This is due to the avidity of charcoal for the markers studied, which therefore cannot be used to evaluate the biocompatibility of the system.

Biofiltration and calcium-phosphate metabolism

We evaluated the effect of one session of biofiltration on calcium-phosphate metabolism in four uremic patients and compared the results with those of a previous traditional hemodialysis (Cuprophane membrane) session, on the same subjects. The most noteworthy results were: both total and ionized plasma calcium rose less in biofiltration; phosphate clearance and parathyroid hormone clearance were higher in biofiltration; plasma 25-OH D did not change in either dialysis technique.