Complement Activation Is Associated With Disease Severity in Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Histopathologic studies have identified immunoglobulin (Ig) deposition and complement activation as contributors of CNS tissue damage in multiple sclerosis (MS). Intrathecal IgM synthesis is associated with higher MS disease activity and severity, and IgM is the strongest complement-activating immunoglobulin. In this study, we investigated whether complement components (CCs) and complement activation products (CAPs) are increased in persons with MS, especially in those with an intrathecal IgM synthesis, and whether they are associated with disease severity and progression.

METHODS

CC and CAP levels were quantified in plasma and CSF of 112 patients with clinically isolated syndrome (CIS), 127 patients with MS (90 relapsing-remitting, 14 primary progressive, and 23 secondary progressive), 31 inflammatory neurologic disease, and 44 symptomatic controls from the Basel CSF databank study. Patients with CIS/MS were followed in the Swiss MS cohort study (median 6.3 years). Levels of CC/CAP between diagnosis groups were compared; in CIS/MS, associations of CC/CAP levels with intrathecal Ig synthesis, baseline Expanded Disability Status Scale (EDSS) scores, MS Severity Score (MSSS), and neurofilament light chain (NfL) levels were investigated by linear regression, adjusted for age, sex, and albumin quotient.

RESULTS

CSF (but not plasma) levels of C3a, C4a, Ba, and Bb were increased in patients with CIS/MS, being most pronounced in those with an additional intrathecal IgM production. In CIS, doubling of C3a and C4a in CSF was associated with 0.31 (CI 0.06-0.56; p = 0.016) and 0.32 (0.02-0.62; p = 0.041) increased EDSS scores at lumbar puncture. Similarly, doubling of C3a and Ba in CIS/MS was associated with 0.61 (0.19-1.03; p < 0.01) and 0.74 (0.18-1.31; p = 0.016) increased future MSSS. In CIS/MS, CSF levels of C3a, C4a, Ba, and Bb were associated with increased CSF NfL levels, e.g., doubling of C3a was associated with an increase of 58% (Est. 1.58; CI 1.37-1.81; p < 0.0001).

DISCUSSION

CNS-compartmentalized activation of the classical and alternative pathways of complement is increased in CIS/MS and associated with the presence of an intrathecal IgM production. Increased complement activation within the CSF correlates with EDSS, future MSSS, and NfL levels, supporting the concept that complement activation contributes to MS pathology and disease progression. Complement inhibition should be explored as therapeutic target to attenuate disease severity and progression in MS.

A multicenter randomized-controlled trial of nucleos(t)ide analogue cessation in HBeAg-negative chronic hepatitis B

BACKGROUND & AIMS

Nucleos(t)ide analogues (NUCs) are the standard and mostly lifelong treatment for chronic HBeAg-negative hepatitis B, as functional cure (loss of HBsAg) is rarely achieved. Discontinuation of NUC treatment may lead to functional cure; however, to date, the evidence for this has been based on small or non-randomized clinical trials. The STOP-NUC trial was designed with the aim of increasing the HBsAg loss rate using a NUC treatment interruption approach.

METHODS

In this multicenter, randomized-controlled trial, 166 HBeAg-negative patients with chronic hepatitis B on continuous long-term NUC treatment, with HBV DNA <172 IU/ml (1,000 copies/ml) for ≥4 years, were randomized to either stop (Arm A) or continue NUC treatment (Arm B) for a 96-week observation period. In total, 158 patients were available for final analysis, 79 per arm. The primary endpoint was sustained HBsAg loss up to week 96.

RESULTS

Our study met its primary objective by demonstrating HBsAg loss in eight patients (10.1%, 95% CI 4.8%-19.5%) in Arm A and in no patient in Arm B (p = 0.006). Among patients with baseline HBsAg levels <1,000 IU/ml, seven (28%) achieved HBsAg loss. In Arm A, re-therapy was initiated in 11 (13.9%) patients, whereas 32 (40.5%) patients achieved sustained remission. A decrease of HBsAg >1 log IU/ml was observed in 16 patients (20.3%) in Arm A and in one patient (1.3%) in Arm B. No serious adverse events related to treatment cessation occurred.

CONCLUSIONS

Cessation of NUC treatment was associated with a significantly higher rate of HBsAg loss than continued NUC treatment, which was largely restricted to patients with end of treatment HBsAg levels <1,000 IU/ml.

IMPACT AND IMPLICATIONS

As HBeAg-negative patients with chronic hepatitis B on nucleos(t)ide analogues (NUCs) rarely achieve functional cure, treatment is almost always lifelong. The STOP-NUC trial was conducted to investigate whether discontinuing long-term NUC treatment can increase the cure rate. We found that some patients achieved functional cure after stopping NUCs, which was especially pronounced in patients with HBsAg levels <1,000 at the end of NUC treatment, and that many did not need to resume therapy. The results of the Stop-NUC trial provide evidence for the concept of stopping NUC treatment as a therapeutic option that can induce functional cure.

Clinical characteristics of patients with non-alcoholic fatty liver disease (NAFLD) in Germany - First data from the German NAFLD-Registry

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) affects more than 18 million individuals in Germany. Real-world data help to better characterize the natural history of disease and standard of care.

METHODS

The German NAFLD-Registry is a prospective non-interventional study initiated by the German Liver Foundation and aims to describe clinical characteristics and observe outcomes in patients with NAFLD recruited in secondary and tertiary care.

RESULTS

From this ongoing study, baseline data of the first 501 patients (mean age 54 years, 48% women) were analysed. 13 % of the study population had a high risk for advanced fibrosis (FIB-4 ≥2.67), approximately one-third had a liver stiffness value ≥9.6kPa measured by transient elastography, and the clinical diagnosis of liver cirrhosis was present in 10%. Typical comorbidities were more prevalent in high risk as compared to low risk patients (FIB-4 <1.3) including arterial hypertension (85 vs. 42%), hypercholesterolemia (39 vs. 16%), and type 2 diabetes mellitus (T2DM) (69 vs. 26%). Patients with T2DM (192/501) had a higher NAFLD disease burden as shown by liver stiffness values ≥9.6 kPa (51%) and clinical diagnosis of cirrhosis (20%). Statins were used in 22% of the main population, while in diabetic patients, metformin, GLP-1 agonists, and SGLT2 inhibitors were used in 65, 17, and 17%, respectively. Uptake of life-style interventions such as physical exercise or nutritional counselling was generally low.

CONCLUSION

First data of the German NAFLD registry show that approximately every 10th patient has advanced NAFLD, highlights T2DM patients as a high-risk group and gives insights in the use of comedication and life-style interventions in secondary and tertiary care.

Different perspectives of patients and physicians on LDL-C target achievement in the treatment of hypercholesterolemia: results on secondary prevention from the German PROCYON survey

Background

Lowering low-density lipoprotein cholesterol (LDL-C) in hypercholesterolemia patients at very high cardiovascular (CV) risk is essential in preventing future CV events. However, LDL-C targets often remain unattained.

Purpose

The purpose of the present survey was to identify possible reasons for insufficient LDL-C target achievement despite the availability of efficacious lipid lowering drugs in the clinical setting of hypercholesterolemia management in secondary prevention patients in Germany.

Methods

PROCYON was an online survey with over 5,000 participants on disease perception, awareness, burden, and management of hypercholesterolemia consisting of a patient survey (PROCYON A) and a healthcare practitioner (HCP) survey (PROCYON B). To quantify patient self-activation, the PAM-13 Patient Activation Measure by Insignia Health was incorporated. Results on 1,696 patients in secondary prevention are presented.

Results

Most post-CV event patients do not achieve their LDL-C target. HCPs assume patients' poor adherence to medication and lifestyle adaptions to be the most important reason (Figure 1). However, this contradicts the patients' perception. Accordingly, 87% of the patients are on a lipid lowering therapy and 81% of them have stated to take their medication regularly. They rank their medication for LDL-C reduction as equally important as that for other diseases. In contrast, HCPs think that 46% of their patients do not take hypercholesterolemia seriously. However, HCPs also believe, that LDL target attainment is still “important” or “very important” to 81% of their patients. This is in line with the patients' perception: 84% of the patients consider reaching their target as “important” or “very important”. PAM-13 results underline these results: 60% of the patients are already activated and want to gain control over their disease (PAM-13 level 3 of 4) and 12% reach highest self-activation levels (level 4 of 4). The HCP remains the major source of information for 77% of the patients and only 42% reach out for online resources. The importance of educating patients on adherence is acknowledged by all HCPs. Therefore, 71% express their desire of educational material. With respect to LDL-C levels, 49% of the patients reported no improvement. Of the patients under treatment without LDL-C improvement, only 23% take more than one drug, and 47% reported a change of dose. Furthermore, collaboration between GPs and specialists (cardiologists, diabetologists, lipidologists) was not evident.

Conclusion

Although secondary prevention patients are motivated to pursue their LDL-C targets, HCPs consider patient adherence as major reason for failure. Instead, the survey indicated that therapeutic strategies are not fully exhausted and there is space for treatment improvement either by dose escalation or addition of further lipid lowering drugs. Furthermore, patient education and specialist collaboration could improve patient management.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis Pharma GmbH Figure 1

Differences in hypercholesterolemia patient management in secondary and primary care: lessons learned from the German PROCYON survey

Background

In Germany, cardiovascular (CV) disease was the leading cause of mortality (39% of all deaths), responsible for 340,000 deaths in 2014 (1). Considering its role as a major risk factor for CV disease, awareness for hypercholesterolemia in clinical practice seems insufficient.

Purpose

The purpose of the present survey was to identify patients' journey differences between primary and secondary prevention in patients with hypercholesterolemia.

Methods

PROCYON was a two-part online survey on disease perception, awareness, burden, and management of hypercholesterolemia consisting of a patient survey (PROCYON A) and a healthcare practitioner (HCP) survey (PROCYON B). The survey included over 5,000 patients with and without prior CV events as well as 109 HCPs (general practitioners, internists, cardiologists) involved in primary and secondary prevention.

Results

71% of the HCPs consider low-density lipoprotein cholesterol (LDL-C) as “very important” to assess a patients CV risk and 96% acknowledge a “causal relationship” between CV risk and LDL-C levels. Despite the theoretical awareness of LDL-C as a risk factor, 58% of the secondary prevention patients were initially diagnosed with hypercholesterolemia only while hospitalized due to a CV event, indicating insufficient translation of LDL-C awareness into clinical screening routine.

General practitioners (GP) and internists are the main point of contact for patients with hypercholesterolemia after the diagnosis. In primary and even in secondary prevention, cardiologists play a minor role in hypercholesterolemia patient care (cardiologist vs. GP/internist ratio 1:5), the majority of patients are managed by their general practitioners and internists and (cardiologist vs. GP/internist ratio 2:3) (Table 1). The frequency of LDL-C control assessments is lower in primary prevention patients compared to secondary prevention (Table 2). In primary prevention, only 43% of the patients are on a lipid lowering therapy compared to 87% in secondary prevention. From the point of diagnosis, LDL-C levels improved at least to some extent in only 30% of the primary prevention patients and 51% of the secondary prevention patients. Of the patients without LDL-C improvement who are on drug therapy, 53% (primary prevention) and 39% (the secondary prevention) are still on their initial treatment since diagnosis.

Conclusion(s)

Major differences in relation to assessment intervals, treatment initiation, and specialist care were identified between primary and secondary prevention populations, reflecting a major focus in secondary prevention with respect to primary prevention. The high percentage of patients on secondary prevention diagnosed after the first CV event reflects the need to improve preventive screening. It is essential to identify measures to increase LDL-C risk awareness, improve screening efforts and efficient LDL-C reduction in order to prevent future CV events in both populations.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis Pharma GmbH

Do children with recurrent abdominal pain grow up to become adolescents who control their weight by fasting? Results from a UK population-based cohort

OBJECTIVE

Gastrointestinal (GI) problems are common in eating disorders, but it is unclear whether these problems predate the onset of disordered eating. Recurrent abdominal pain (RAP) is the most prevalent GI problem of childhood, and this study aimed to explore longitudinal associations between persistent RAP (at ages 7 and 9) and fasting for weight control at 16.

METHOD

The Avon Longitudinal Study of Parents and Children (ALSPAC) is a UK population cohort of children. Childhood RAP was reported by mothers and defined as RAP 5+ (5 pain episodes in the past year) in our primary analysis, and RAP 3+ (3 pain episodes) in our sensitivity analysis. Fasting for weight control was reported by adolescents at 16. We used logistic regression models to examine associations, with adjustments for potential confounders.

RESULTS

After adjustments, we found no association between childhood RAP 5+ and adolescent fasting for weight control at 16 (OR 1.30 (95% Confidence Intervals [CI] 0.87, 1.94) p = .197). However, we did find an association between RAP 3+ and later fasting, in the fully adjusted model (OR 1.50 [95% CI 1.16, 1.94] p = .002), and after excluding those with pre-existing anxiety (OR 1.52 [95% CI 1.17, 1.97] p = .002).

DISCUSSION

Our findings suggest a possible independent contribution of RAP to later risk of fasting for weight control, and RAP should be enquired about in the assessment of eating disorders. However, frequency of childhood abdominal pain (as captured by ALSPAC) may be less important to long-term outcomes than functional impairment.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

The Fatty Liver Assessment in Germany (FLAG) cohort study identifies large heterogeneity in NAFLD care

Background & Aims

NAFLD is a growing health concern. The aim of the Fatty Liver Assessment in Germany (FLAG) study was to assess disease burden and provide data on the standard of care from secondary care.

Methods

The FLAG study is an observational real-world study in patients with NAFLD enrolled at 13 centres across Germany. Severity of disease was assessed by non-invasive surrogate scores and data recorded at baseline and 12 months.

Results

In this study, 507 patients (mean age 53 years; 47% women) were enrolled. According to fibrosis-4 index, 64%, 26%, and 10% of the patients had no significant fibrosis, indeterminate stage, and advanced fibrosis, respectively. Patients with advanced fibrosis were older, had higher waist circumferences, and higher aspartate aminotransferase and gamma-glutamyltransferase as well as ferritin levels. The prevalence of obesity, arterial hypertension, and type 2 diabetes increased with fibrosis stages. Standard of care included physical exercise >2 times per week in 17% (no significant fibrosis), 19% (indeterminate), and 6% (advanced fibrosis) of patients. Medication with either vitamin E, silymarin, or ursodeoxycholic acid was reported in 5%. Approximately 25% of the patients received nutritional counselling. According to the FibroScan-AST score, 17% of patients presented with progressive non-alcoholic steatohepatitis (n = 107). On follow-up at year 1 (n = 117), weight loss occurred in 47% of patients, of whom 17% lost more than 5% of body weight. In the weight loss group, alanine aminotransferase activities were reduced by 20%.

Conclusions

This is the first report on NAFLD from a secondary-care real-world cohort in Germany. Every 10th patient presented with advanced fibrosis at baseline. Management consisted of best supportive care and lifestyle recommendations. The data highlight the urgent need for systematic health agenda in NAFLD patients.

Lay summary

FLAG is a real-world cohort study that examined the liver disease burden in secondary and tertiary care. Herein, 10% of patients referred to secondary care for NAFLD exhibited advanced liver disease, whilst 64% had no significant liver scarring. These findings underline the urgent need to define patient referral pathways for suspected liver disease.

P2277Utility of cardiovascular implantable electronic device (CIED)-derived patient activity, a novel digital biomarker, to predict inappropriate therapy

Background

The role of cardiovascular implantable electronic device (CIED)-derived activity to predict inappropriate implantable cardioverter-defibrillator (ICD) therapy is not known. The Multicenter Automatic Defibrillator Implantation Trial – Reduce Inappropriate Therapy (MADIT-RIT) enrolled 1500 patients with contemporary indication for an ICD or a CRT-D. We aimed to identify whether activity, as a digital biomarker, predicted inappropriate therapy.

Methods

In 1500 patients enrolled in MADIT-RIT, CIED-derived patient activity was acquired daily. CIED-derived activity was averaged for the first 30 days following randomization and utilized in this study to predict inappropriate therapy post- 30-day. Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression models were used to evaluate first inappropriate therapy by 30-day CIED-derived patient activity quintiles, and by 30-day device derived patient activity as a continuous measurement.

Results

There were a total of 1463 patients with activity data available (90%), 135 patients received at least one inappropriate therapy during the post-30 day follow-up period. Patients in the highest quintile (Q5) of CIED-derived activity (more active) were younger, more often males and more likely to have had a prior ablation of an atrial arrhythmia. Patients in the highest quintile of 30-day CIED-derived median activity had the highest risk of receiving inappropriate therapy, 21% at 2 years as compared 7–11% in the other four quintiles (Figure, p<0.001 for the overall duration). Patients with the highest level of 30-day median patient activity (Q5) had 1.75 times higher risk of any inappropriate therapy as compared with lower levels of activity, Q1-Q4 (HR=1.75, 95% CI: 1.23–2.50, p<0.002). Each 10% increase in CIED-derived 30-day median patient activity was associated with a significant, 73% increase in risk of receiving inappropriate therapy (HR=1.73, 95% CI: 1.17–2.54, p=0.005). Patients in the highest quintile for activity had a 68% increase in the risk of SVT excluding atrial fibrillation, atrial flutter or atrial tachycardia (HR=1.69, 95% CI: 1.26–2.25, p=0.004), despite 96% receiving beta-blocker medications.

Inappropriate ICD Therapies by Activity

Conclusions

CIED-derived 30-day median patient activity predicted subsequent inappropriate therapy in ICD and CRT-D patients enrolled in MADIT-RIT. Patients with high levels of 30-day CIED-derived median patient activity were at a significantly higher risk of receiving inappropriate therapy. Activity, as a digital biomarker, may have utility in predicting and managing the risk of inappropriate therapy in this population.

Acknowledgement/Funding

Boston Scientific

2179Clinical significance of device-derived activity in ICD and CRT-D patients - Data from MADIT-RIT

Background

The Multicenter Automatic Defibrillator Implantation Trial – Reduce Inappropriate Therapy (MADIT-RIT) enrolled 1500 patients and showed that novel ICD programming reduced inappropriate therapy and improved survival. However, the role of device-derived patient activity to predict mortality is not known.

Methods

In 1500 patients enrolled in MADIT-RIT, device-derived patient activity was captured daily. Device-derived activity was averaged for the first 30 days following randomization, and utilized in this study to predict mortality post-30 days. Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression models were used to evaluate all-cause mortality by 30-day device derived patient activity quintiles, and as a 3-level function of 30-day device derived patient activity (Q1, Q2–3, Q4–5).

Results

There were a total of 1463 patients with data available (98%), 66 of them died during the follow-up post-30 days. Patients in the lowest quintile (Q1: 4%∼1 hour daily activity) of device-derived activity were older, they were more often female, and they more often had diabetes and NYHA class III HF symptoms. Patients in the lowest quintile of 30-day device derived median activity (1 hour daily activity) had the highest risk of mortality, 15% in 2 years as compared to Q2–3 (1–2 hours daily activity, 8–7% 2-year mortality), and Q4–5 (>2 hours daily activity, 2–3% 2-year mortality) (Figure, p<0.001 for the overall duration). Each quintile decrease in device-derived 30-day median patient activity was associated with a significant, 41% increase in mortality (HR=1.41, 95% CI: 1.15–1.71, p=0.001). Patients with the lowest level of 30-day median patient activity (Q1) had 4.13-times higher risk of mortality as compared to the highest level of activity patients, Q4–5 (HR=4.13, 95% CI: 1.89–9.03, p<0.001). Patients with intermediate levels of activity (Q2–3) still had a 2.8-fold increase in death as compared to the highest activity level cohort of patients (HR=2.79, 95% CI: 1.31–5.91, p=0.008).

Figure 1

Conclusions

Device-derived 30-day median patient activity predicted subsequent all-cause mortality in ICD and CRT-D patients enrolled in MADIT-RIT. Patients with low and moderate levels of 30-day device-derived median patient activity (less than 2 hours daily activity) were at a significantly higher risk of death, and these cohorts warrant further investigation and management to improve outcomes.

Acknowledgement/Funding

MADIT-RIT was funded by an unrestricted research grant from Boston Scientific to the University of Rochester.

Abstract P1-11-09: Sleep disturbance and quality of life among breast cancer survivors

Introduction: Breast cancer survivors are at risk for substantial sleep disturbance, which can negatively affect quality of life. Sleep disturbance can be exacerbated by co-occurring emotional concerns such as depressive symptoms and anxiety. Prior research has largely focused on linkages between sleep disturbance and emotional concerns among individuals with early stage disease. To dive deeper, we examined sleep disturbance and its correlates among breast cancer survivors with and without metastatic disease.

Methods: 631 female breast cancer survivors (168 ever experiencing metastatic disease [MBC]; 463 never metastatic [BC]) enrolled in the Cancer Support Community's online Cancer Experience Registry, provided socio-demographic information, and reported cancer-related distress (CancerSupportSource®, a 25-item measure with depression and anxiety risk screening subscales) and levels of pain interference (PI) and sleep disturbance (PROMIS-29 subscales). We examined associations between risk for depression/anxiety, PI, and worse sleep disturbance with multivariate regression, adjusting for metastatic disease, treatment history, and number of comorbidities.

Results: Participants were 84% non-Hispanic White; mean age=54.8 years, SD=12.2; mean time since diagnosis=4.4 years, SD=5.5. 72% ever received chemotherapy; 60% radiation therapy; 56% hormone therapy; 91% had surgery for their cancer. 47% reported moderate to very serious concern about sleep problems; concern about sleep did not differ by metastatic history. 20% of participants reported a level of sleep disturbance that was significantly worse (&gt;1SD) than the U.S. population average and 18% reported PI that was significantly worse (&gt;1SD) than the U.S. population average; these did not differ by metastatic history. Using CancerSupportSource anxiety and depression risk screening subscales, 47% of participants were identified as at risk for clinically significant levels of anxiety, and 35% at risk for clinically significant levels of depression. Participants with MBC were more likely to be at risk for clinically significant levels of anxiety (χ2=.7.98, p&lt;.01). Depression risk did not differ between MBC and BC survivors. Greater sleep disturbance was associated with having ever received radiation therapy (r=.11, p&lt;.01), number of reported comorbidities (r=.37, p&lt;.001), greater PI (r=.46, p&lt;.001), and greater risk for clinically significant depression (r=.38, p&lt;.001) and anxiety (r=.35, p&lt;.001). In multivariate analysis, risk for clinically significant levels of depression (semipartial r=.12, p&lt; .005), anxiety (semipartial r=.05, p&lt; .05), and greater PI (semipartial r=.24, p&lt; .001) remained associated with greater sleep disturbance after controlling for treatment history, metastatic status, and number of comorbidities, (R2=.28, F(4,588)=56.26, p&lt;.001).

Conclusion: Being at risk for clinically significant levels of depression and anxiety and experiencing greater pain interference are associated with worse sleep disturbance among breast cancer survivors across the illness trajectory. Health care providers are encouraged to discuss with patients how they can address sleep disturbance concerns, including referrals to integrative therapies that address the constellation of affective, pain, and sleep symptoms.

Citation Format: McManus S, Zaleta AK, Miller MF, Olson J, Saxton MC, Stein K. Sleep disturbance and quality of life among breast cancer survivors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-09.

Peer support for physical activity adoption among breast cancer survivors: Do the helped resemble the helpers?

Interventions offering peer mentoring programmes promoting moderate-to-vigorous physical activity (MVPA) have shown improvements in MVPA and well-being from baseline; however, research is limited. The purpose of this study was to compare the physical activity (PA) levels and psychosocial well-being of coaches and participants at baseline and following a 12-week intervention. Breast cancer survivors (<5 years) were recruited and randomised into either exercise (Reach-to-Recovery (RTR) + PA) or control (RTR Control). Participants in both groups were individually assigned one of the 18 available coaches who delivered either the MVPA intervention or the control condition via telephone. PA (7-Day PA Recall), psychosocial well-being, fatigue and mood were assessed at baseline and intervention completion. Seventy-six breast cancer survivors (average age = 55.62 (±9.55)) were randomised. At baseline, all participants showed significantly lower MVPA (p = .001) and well-being (p < .05) as compared to coaches. However, post-intervention showed significant improvement in PA and well-being in RTR + PA, so that they were no longer significantly different from the coaches. Post-intervention, MVPA (p < .01), quality of life (p < .05) and fatigue (p < .05) remained significantly lower in RTR Controls compared to coaches. Future interventions should consider the behavioural patterns not only of the participants, but also of those who deliver the interventions.

Helicobacter Pylori Serology in Relation to Hepatitis C Virus Infection and IL28B Single Nucleotide Polymorphism

The aim of the study was to evaluate the serological rate of Helicobacter pylori (H. pylori) infection in patients with chronic hepatitis C virus (HCV) infection and determine any correlations with liver damage and IL28B single-nucleotide polymorphism (SNP). One hundred eighty-nine patients with chronic HCV infection were included in the study, and H. pylori status was defined based on anti-H. pylori-IgG or anti-CagA-IgG antibodies using enzyme-linked immunosorbent assay (ELISA). Liver damage was assessed using histology or transient elastography. IL28B C/T polymorphism (rs12979860) was evaluated in circulating blood cells using a PCR-based restriction fragment length polymorphism assay. Overall H. pylori serology was positive in 38.1% of our HCV-infected subjects. Among those, the anti-CagA-IgG positivity rate was 43.1% and was within the range of previously described populations of the same region. Highest prevalence of H. pylori was found in patients between 31 and 40 years compared to other age subgroups. The seropositivity rate was higher in the non-cirrhotic group than the cirrhotic one (45.4% vs. 20.0%, p < 0.05). No difference was found in IL28B genotype between H. pylori-positive and -negative cohorts. However, we observed a trend for the lower anti-CagA-IgG expression level in relation to the IL28B T-allele. Our results do not support an association between HCV and H. pylori infection. Whether IL28B SNP has a functional role in modulation of serological response to H. pylori CagA needs further investigation.

Predictors of functional benefit of hepatitis C therapy in a ‘real-life’ cohort

AIM

To define predictors of functional benefit of direct-acting antivirals (DAAs) in patients with chronic hepatitis C virus (HCV) infection and liver cirrhosis.

METHODS

We analysed a cohort of 199 patients with chronic HCV genotype 1, 2, 3 and 4 infection involving previously treated and untreated patients with compensated (76%) and decompensated (24%) liver cirrhosis at two tertiary centres in Germany. Patients were included with treatment initiation between February 2014 and August 2016. All patients received a combination regimen of one or more DAAs for either 12 or 24 wk. Predictors of functional benefit were assessed in a univariable as well as multivariable model by binary logistic regression analysis.

RESULTS

Viral clearance was achieved in 88% (175/199) of patients. Sustained virological response (SVR) 12 rates were as follows: among 156 patients with genotype 1 infection the SVR 12 rate was 90% (n = 141); among 7 patients with genotype 2 infection the SVR 12 rate was 57% (n = 4); among 30 patients with genotype 3 infection the SVR 12 rate was 87% (n = 26); and among 6 patients with genotype 4 infection the SVR 12 rate was 67% (n = 4). Follow-up MELD scores were available for 179 patients. A MELD score improvement was observed in 37% (65/179) of patients, no change of MELD score in 41% (74/179) of patients, and an aggravation was observed in 22% (40/179) of patients. We analysed predictors of functional benefit from antiviral therapy in our patients beyond viral eradication. We identified the Child-Pugh score, the MELD score, the number of platelets and the levels of albumin and bilirubin as significant factors for functional benefit.

CONCLUSION

Our data may contribute to the discussion of potential risks and benefits of antiviral therapy with individual patients infected with HCV and with advanced liver disease.

Real-world experience with the all-oral, interferon-free regimen of ombitasvir/paritaprevir/ritonavir and dasabuvir for the treatment of chronic hepatitis C virus infection in the German Hepatitis C Registry

Real-world studies are relevant to complement clinical trials on novel antiviral therapies against chronic hepatitis C; however, clinical practice data are currently limited. This study investigated effectiveness and safety of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r)±dasabuvir (DSV)±ribavirin (RBV) for treatment of HCV genotype (GT) 1 and GT4 infection in a large real-world cohort. The German Hepatitis C Registry is an observational cohort study prospectively collecting clinical practice data on direct-acting antiviral therapies. Patients with GT1/4 infection treated with OBV/PTV/r±DSV±RBV were analysed. Effectiveness was assessed by sustained virologic response in 558 patients who reached post-treatment week 12 (SVR12). Safety is reported in 1017 patients who initiated treatment. Of the patients, 892 (88%) had GT1 and 125 (12%) had GT4 infection. Prior treatment experience and cirrhosis were reported in 598 (59%) and 228 (22%) patients, respectively. Overall, SVR12 (mITT) was 96% (486/505) in GT1- and 100% (53/53) in GT4 patients. SVR12 rates were high across subgroups including patients with cirrhosis (95%, 123/129), patients with moderate to severe renal impairment (100%, 34/34), and subgroups excluded from registrational trials like patients ≥70 years (96%, 64/67) and failures to prior protease inhibitor treatment (96%, 46/48). Adverse events (AEs) and serious AEs were reported in 52% (525/1017) and 2% (21/1017) of patients, respectively, and led to treatment discontinuation in 1.5% (15/1017) of patients. OBV/PTV/r±DSV±RBV was effective and generally well tolerated for treatment of HCV infection in clinical practice.

Interferon-free treatment of chronic hepatitis C virus infection in patients with inherited bleeding disorders

Chronic hepatitis C virus (HCV) infection causes significant mortality in patients with inherited bleeding disorders, however, data of interferon-free antiviral regimes are scarce in this population.

PATIENTS, METHODS

Real-life data of interferon-free therapies of 18 patients with inherited bleeding disorders and chronic HCV genotype 1 infection (94% male, liver cirrhosis Child A/B n = 4/1).

RESULTS

Treatment naïve patients were treated for eight weeks with sofosbuvir (SOF)/ledipasvir (n = 3) or for 12 weeks with SOF/ledipasvir (n = 4), SOF/ledipasvir/ribavirin (n = 1), or paritaprevir/r, ombitasvir, dasabuvir (n = 1). Treatment experienced patients without cirrhosis received SOF/ledipasvir (n = 3) or paritaprevir/r, ombitasvir, dasabuvir ± ribavirin (n = 2) for 12 weeks. Re-treated cirrhotic individuals were treated for 24 weeks with SOF/ledipasvir (n = 2) and SOF/daclatasvir (n = 1), or for 12 weeks SOF/simeprevir/1200 mg/d ribavirin (n = 1). Sustained virologic response (SVR-12) was achieved by 17/18 individuals without severe on-treatment side effects.

CONCLUSIONS

In real-life, HCV-infected patients with inherited bleeding disorders can be effectively and safely treated with interferon-free therapies.

Prevalence and predictors of complications following facial reconstruction procedures

Facial reconstruction procedures are immensely challenging and are done for a multitude of reasons. The purpose of this report is to provide nationally representative estimates of different types of facial reconstructive procedures and to examine prevalence and predictors of a wide range of complications associated with these procedures in the USA. The Nationwide Inpatient Sample, the largest inpatient dataset for the USA, was used. Data for the years 2004-2010 related to facial reconstruction procedures were identified through ICD-9-CM procedure codes. Associated complications were identified using secondary diagnosis field codes. Multivariable logistic regression models were used to examine the association between patient/hospital-level factors and the occurrence of complications. A total 26,374 facial reconstruction procedures were performed. About 20% of all patients who had facial reconstruction procedures developed a complication. Frequently occurring complications included postoperative pneumonia (4.9% of hospitalizations), hemorrhage (3.9%), other infections (3.6%), non-healing wounds (3.5%), and iatrogenically induced complications (3.2%). Significant factors found to be consistently associated with different types of complications included age, co-morbid burden, sex, and type of admission. The reported results are generalizable within limitations and can be used by health care providers to tailor quality improvement initiatives to minimize or better treat complications in the high-risk cohorts.

9 ENDOSCOPY-MEDIATED INTRATUBAL INSEMINATION IN THE COW – A PRELIMINARY REPORT ABOUT THE APPLICATION OF A NOVEL MINIMALLY INVASIVE INSEMINATION TECHNIQUE

On their long path through the female reproductive tract to the fertilization site, spermatozoa are exposed to diverse influences and hazards of the cervical, uterine, and oviducal environment that naturally select viable sperms for the following fertilization. Consequently, this results in a reduction from several billions of sperms in the ejaculate to a functional sperm reservoir within the range of 102 in the isthmus of the Fallopian tube. A technique to deposit spermatozoa directly into the ampulla, thus bypassing most of the reproductive tract, enables a rigorous reduction in number of sperms deposited. Furthermore, it provides a direct assessment of sperm fertility. The aim of our study was to establish an endoscopy-assisted intratubal insemination technique using different sperm dosages, fresh or cryopreserved, to determine adequate conditions for optimal fertilization. Eighteen Simmental heifers were inseminated with fresh semen, and 9 heifers were inseminated with frozen semen using this novel technique. The heifers were synchronized using a modified Ovsynch protocol, and insemination was conducted 18 to 20 h after the second gonadotropin-releasing hormone application. Insemination of heifers was performed under epidural anaesthesia. A tubing system bearing the endoscope and an insemination device was introduced through the vaginal wall into the peritoneal cavity. The insemination device consisted of a tube connected to a curved glass capillary tube loaded with semen. After a visual examination of the ovaries for the presence of an ovulatory Graafian follicle, the capillary tube was inserted directly via the infundibulum into the ipsilateral ampulla and the semen dose was deposited. The entire procedure took ~10 min. Two days later the oviduct was flushed by the same technique. A tubing system connected to a metal catheter served for flushing the embryos and unfertilized oocytes from the oviduct into the uterine horn. Afterward, embryos and oocytes were collected by flushing the uterine horn using an embryo flushing catheter and an embryo filter (EmCon). Embryos were stained using a Hoechst dye to visualise the numbers of attached spermatozoa to the zonae pellucidae. From 18 inseminations with fresh semen doses of 7 to 28 million sperms, 7 embryos at the 2- to 8-cell stage were found. Two of these embryos had more than 10 accessory sperms (AS), 3 had 3 to 6 AS, and 2 were without AS. From 9 inseminations with frozen semen doses containing 1.5 million sperms, we obtained 2 embryos, one at the 4-cell stage without AS and one at the 8-cell stage with 5 AS. Additionally, 3 unfertilized oocytes were collected. In conclusion, these preliminary results demonstrate a promising technique for intratubal AI, which has to be further optimized by studying numbers and treatment of spermatozoa and time of insemination.

232 EFFECT OF SUPEROVULATION PRETREATMENT ON DEVELOPMENTAL CHARACTERISTICS OF IN VITRO-FERTILIZED BOVINE EMBRYOS TRANSFERRED TO THE OVIDUCT-UTERUS ENVIRONMENT

Superovulation is a routine procedure to stimulate growth and ovulation of multiple follicles. However, the hormonal changes in the reproductive tract after superovulation treatment affect the environment and subsequently the early embryo development. The aim of the study was to examine the effect of superovulation pretreatment on embryo development and gene expression of IVM/IVF derived embryos subsequently cultured in vivo. The cumulus‐oocyte complexes derived from slaughterhouse ovaries were in vitro matured and fertilized. The denuded presumptive zygotes were cultured in CR1 medium with 5% oestrous cow serum. A total of 788 cleaved embryos at Day 2 were transferred by transvaginal endoscopy into the oviduct of synchronized and superovulated heifers (superstimulated group, SS) and 784 cleaved embryos were transferred into the ipsilateral oviduct of single ovulated synchronized heifers (single ovulation group, SO). In total, 10 Simmental heifers were used for in vivo culture in a crossover design. The in vivo culture was repeated once at an interval of at least 6 weeks in the same animal. At Day 7, embryos were recovered by combined flushing of the oviducts by endoscopy and the adjacent part of the uterine horns by conventional procedure. The numbers of recovered blastocysts were recorded and the embryos were cultured for the following 48 h to determine the blastocyst rate at Days 8 and 9. Simultaneously, 410 cleaved embryos were cultured in vitro for 9 days (control group, C). Triplicate pools of 10 blastocysts recovered at Day 7 from each treatment group were used for RNA isolation. Real-time PCR using sequence specific primers was performed in StepOnePlus™ real time PCR system (Applied Biosystem, Foster City, CA, USA). A comparative threshold cycle method was used to quantify expression levels of the candidate genes compared to the internal control GAPDH gene. The number of recovered embryos after in vivo culture was significantly lower in the SS group compared with the SO group (66.9 v. 79.5%, respectively; P < 0.05). The blastocyst rates at Days 7, 8, and 9 in the SS, SO, and C groups were not significantly different (31.9, 43.3, and 47.1% v. 35.2, 48.5, and 53.5% v. 37.8, 50, and 56.1%, respectively). Molecular analysis of selected genes playing important roles during pre-implantation development revealed significantly lower expression levels of IL6, IL18, and ABCC2 between both experimental in vivo culture groups and the C-group. The IL18 was also significantly down-regulated in the SS-group compared to the SO-group. The transcription factor NFκB was found to be down-regulated in the SS-group compared to the SO and C groups (P < 0.05). In conclusion, we showed that the superovulation pretreatment did not affect blastocyst yield during the culture period but seemed to influence the expression of developmentally important genes in the resulting embryos.

Cost effectiveness of collagen crosslinking for progressive keratoconus in the UK NHS

BACKGROUND

Keratoconus is a progressive degenerative corneal disorder of children and young adults that is traditionally managed by refractive error correction, with corneal transplantation reserved for the most severe cases. UVA collagen crosslinking is a novel procedure that aims to prevent disease progression, currently being considered for use in the UK NHS. We assess whether it might be a cost-effective alternative to standard management for patients with progressive keratoconus.

METHODS

We constructed a Markov model in which we estimated disease progression from prospective follow-up studies, derived costs derived from the NHS National Tariff, and calculated utilities from linear regression models of visual acuity in the better-seeing eye. We performed deterministic and probabilistic sensitivity analyses to assess the impact of possible variations in the model parameters.

RESULTS

Collagen crosslinking is cost effective compared with standard management at an incremental cost of £ 3174 per QALY in the base case. Deterministic sensitivity analysis shows that this could rise above £ 33,263 per QALY if the duration of treatment efficacy is limited to 5 years. Other model parameters are not decision significant. Collagen crosslinking is cost effective in 85% of simulations at a willingness-to-pay threshold of £ 30,000 per QALY.

CONCLUSION

UVA collagen crosslinking is very likely to be cost effective, compared with standard management, for the treatment of progressive keratoconus. However, further research to explore its efficacy beyond 5 years is desirable.

Effects of macrophage-dependent peroxisome proliferator-activated receptor γ signalling on adhesion formation after abdominal surgery in an experimental model

BACKGROUND

The pathophysiology of adhesion formation after abdominal and pelvic surgery is still largely unknown. The aim of the study was to investigate the role of macrophage polarization and the effect of peroxisome proliferator-activated receptor (PPAR) γ stimulation on adhesion formation in an animal model.

METHODS

Peritoneal adhesion formation was induced by the creation of ischaemic buttons within the peritoneal wall and the formation of a colonic anastomosis in wild-type, interleukin (IL) 10-deficient (IL-10(-/-) ), IL-4-deficient (IL-4(-/-) ) and CD11b-Cre/PPARγ(fl) (/fl) mice. Adhesions were assessed at regular intervals, and cell preparations were isolated from ischaemic buttons and normal peritoneum. These samples were analysed for macrophage differentiation and its markers, and expression of cytokines by quantitative PCR, fluorescence microscopy, arginase activity and pathological examination. Some animals underwent pioglitazone (PPAR-γ agonist) or vehicle treatment to inhibit adhesion formation. Anastomotic healing was evaluated by bursting pressure measurement and collagen gene expression.

RESULTS

Macrophage M2 marker expression and arginase activity were raised in buttons without adhesions compared with buttons with adhesions. IL-4(-/-) and IL-10(-/-) mice were not affected, whereas CD11b-Cre/PPARγ(fl) (/fl) mice showed decreased arginase activity and increased adhesion formation. Perioperative pioglitazone treatment increased arginase activity and decreased adhesion formation in wild-type but not CD11b-Cre/PPARγ(fl) (/fl) mice. Pioglitazone had no effect on anastomotic healing.

CONCLUSION

Endogenous macrophage-specific PPAR-γ signalling affected arginase activity and macrophage polarization, and counter-regulated peritoneal adhesion manifestation. Pharmacological PPAR-γ agonism induced a shift towards macrophage M2 polarization and ameliorated adhesion formation in a macrophage-dependent manner. Surgical relevance Postoperative adhesion formation is frequently seen after abdominal surgery and occurs in response to peritoneal trauma. The pathogenesis is still unknown but includes an imbalance in fibrinolysis, collagen production and inflammatory mechanisms. Little is known about the role of macrophages during adhesion formation. In an experimental model, macrophage M2 marker expression was associated with reduced peritoneal adhesion formation and involved PPAR-γ-mediated arginase activity. Macrophage-specific PPAR-γ deficiency resulted in reduced arginase activity and aggravated adhesion formation. Pioglitazone, a PPAR-γ agonist, induced M2 polarization and reduced postoperative adhesion formation without compromising anastomotic healing in mice. Pioglitazone ameliorated postoperative adhesion formation without compromising intestinal wound healing. Therefore, perioperative PPAR-γ agonism might be a promising strategy for prevention of adhesion formation after abdominal surgery.

Early virological response may predict treatment response in sofosbuvir-based combination therapy of chronic hepatitis c in a multi-center "real-life" cohort

Background

The combination of sofosbuvir (SOF), ribavirin (RBV) and peg-interferon-alfa-2a (peg-IFN-alfa-2a) as well as the combination of SOF and RBV for the treatment of patients infected with hepatitis c virus (HCV) has improved rates of sustained virological response (SVR) considerably in recent trials. However, there is only limited data concerning the efficacy and safety in a “real-life” cohort.

Methods

We analyzed a cohort of 119 patients with chronic HCV infection treated at four investigational sites in Germany. All patients received either a combination treatment of SOF, RBV and peg-IFN-alfa-2a or SOF and RBV.

Results

The rates of SVR at 12 weeks after end of treatment (SVR 12) were as follows: Among 76 patients with genotype 1 infection the SVR 12 rate was 74 % (n = 56), among 14 patients with genotype 2 infection the SVR 12 rate was 79 % (n = 11), among 24 patients with genotype 3 infection the SVR 12 rate was 92 % (n = 22) and among 5 patients with genotype 4 infection the SVR 12 rate was 80 % (n = 4). Of all 26 patients with a relapse in our cohort, 69 % (n = 18) of these patients presented with liver cirrhosis and 58 % (n = 15) were treatment experienced. Notably, the level of HCV-RNA after 4 weeks of treatment was a significant predictor of treatment response in genotype 1 patients. Patients with HCV-RNA levels ≥ 12 IU ml-1 after 4 weeks of treatment achieved SVR 12 only in 30 % (n = 17/56, p < 0.0001) of cases and treatment response was even lower with SVR 12 of 25 % (n = 5/20, p = 0.0016) in the subgroup of patients with cirrhosis.

Conclusion

We observed a high rate of SVR 12 with SOF-based treatment regimes, however probably due to the high number of patients with liver cirrhosis and prior treatment experience, treatment response rates were lower than in previously published trials. In genotype 1 patients the analysis of early virological response may predict treatment response in SOF-based combination therapies.

The novel CGRP receptor antagonist BIBN4096BS alleviates a postoperative intestinal inflammation and prevents postoperative ileus

BACKGROUND

Abdominal surgery results in neuronal mediator release and subsequent acute intestinal hypomotility. This phase is followed by a longer lasting inflammatory phase resulting in postoperative ileus (POI). Calcitonin gene-related peptide (CGRP) has been shown to induce motility disturbances and in addition may be a candidate mediator to elicit neurogenic inflammation. We hypothesized that CGRP contributes to intestinal inflammation and POI.

METHODS

The effect of CGRP in POI was tested in mice treated with the highly specific CGRP receptor antagonist BIBN4096BS and in CGRP receptor-deficient (RAMP-1(-/-) ) mice. POI severity was analyzed by cytokine expression, muscular inflammation and gastrointestinal (GI) transit. Peritoneal and muscularis macrophages and mast cells were analyzed for CGRP receptor expression and functional response to CGRP stimulation.

KEY RESULTS

Intestinal manipulation (IM) resulted in CGRP release from myenteric nerves, and a concurrent increased interleukin (IL)-6 and IL-1β transcription and leukocyte infiltration in the muscularis externa and increased GI transit time. CGRP potentiates IM-induced cytokine transcription within the muscularis externa and peritoneal macrophages. BIBN4096BS reduced cytokine levels and leukocyte infiltration and normalized GI transit. RAMP1(-/-) mice showed a significantly reduced leukocyte influx. CGRP receptor was expressed in muscularis and peritoneal macrophages but not mast cells. CGRP mediated macrophage activation but failed to induce mast cell degranulation and cytokine expression.

CONCLUSIONS & INFERENCES

CGRP is immediately released during abdominal surgery and induces a neurogenic inflammation via activation of abdominal macrophages. BIBN4096BS prevented IM-induced inflammation and restored GI motility. These findings suggest that CGRP receptor antagonism could be instrumental in the prevention of POI.

High PSA anxiety and low health literacy skills: drivers of early use of salvage ADT among men with biochemically recurrent prostate cancer after radiotherapy?

BACKGROUND

Although commonly used, early initiation of salvage androgen deprivation therapy (ADT) has not been proven to enhance survival. We evaluated whether prostate-specific antigen (PSA) anxiety or health literacy are associated with use of early salvage ADT among men with recurrent prostate cancer after radiotherapy.

PATIENTS AND METHODS

The prospective Comprehensive, Observational, Multicenter, Prostate Adenocarcinoma Registry was used to study 375 men with biochemically recurrent prostate cancer after external beam radiation or brachytherapy. Multivariable logistic regression was used to determine whether PSA anxiety and health literacy are associated with salvage ADT as initial management after biochemical recurrence.

RESULTS

Sixty-eight men (18.1%) received salvage ADT as initial management for PSA recurrence. Men with high PSA anxiety were twice as likely to receive salvage ADT compared with men who did not have high PSA anxiety on both univariable [28.8% versus 13.1%; odds ratio (OR) 2.15; 95% confidence interval (CI) 1.16-4.00; P = 0.015] and multivariable analysis [adjusted OR (AOR) 2.36; 95% CI 1.21-4.62; P = 0.012]. Furthermore, men who had higher levels of health literacy were nearly half as likely to undergo salvage ADT compared with men who had lower levels of health literacy on univariable analysis (15.2% versus 26.3%; OR 0.50; 95% CI 0.29-0.88; P = 0.016), with a trend toward this association on multivariable analysis (AOR 0.58; 95% CI 0.32-1.05; P = 0.07).

CONCLUSIONS

Among men with PSA recurrence after radiotherapy, odds of use of salvage ADT were nearly twice as great among men with high PSA anxiety or low health literacy, suggesting that these men are receiving higher rates of unproven treatment. Given that early salvage ADT is costly, worsens quality of life, and has not been shown to improve survival, quality improvement strategies are needed for these individuals.

[Aex - the area under the expiratory flow-volume loop]

Preschool children often show total expiration times of less than one second in pulmonary function tests. Therefore, FEV1 cannot be used for evaluation of obstructive pulmonary diseases in small children. Aex, the area under the expiratory flow-volume loop, does not depend on the expiration time. The Aex value varies according to the convex or concave shape of the flow volume loop, can be quantified and is a valuable parameter in the diagnosis of obstructive airway diseases.In this study FEV1 und Aex values of 19882 flow-volume loops were measured and compared. The comparison shows a very high correlation coefficient of r = 0.99.The changes of both parameters in an individual after provocation or bronchospasmolysis also demonstrate a strong correlation. A 20 % change of FEV1 equals an Aex change of 36 %.We conclude that measuring Aex is a good alternative to measuring FEV1 especially if the FEV1 cannot be obtained due to short expiration times.

[Allogeneic kidney transplantation. Preoperative, perioperative and postoperative management]

Allogeneic renal transplantation is the best treatment for many patients with chronic renal failure and end-stage kidney disease. Especially the health-related quality of life markedly improves after renal transplantation and the side effects of dialysis treatment as well as the progression of organ and tissue deterioration related to renal failure which are not treated effectively by dialysis are greatly reduced. To achieve good results of renal transplantation, however, the best possible preoperative as well as perioperative and postoperative conditions have to be established and patients on waiting lists need to be well prepared. Interdisciplinary patient care is needed before and after renal transplantation in order to achieve durable and long-term success of renal transplantation.