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Haidinger M, Wechsler P, Ravioli S, Exadaktylos A, Lindner G. Gender equality in palliative medicine editorial boards, authorships and national societies. BMJ Support Palliat Care 2024:spcare-2023-004293. [PMID: 38272655 DOI: 10.1136/spcare-2023-004293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Affiliation(s)
- Michael Haidinger
- Department of Internal Medicine, Bülach Hospital, Bülach, Switzerland
| | - Patrick Wechsler
- Department of Internal and Emergency Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Svenja Ravioli
- Department of Emergency Medicine, King's College London, London, UK
| | | | - Gregor Lindner
- Department of Emergency Medicine, Inselspital Universitatsspital Bern, Bern, Switzerland
- Department of Emergency Medicine, Johannes Kepler Universität Linz, Linz, Austria
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Ravioli S, Lafranchi A, Exadaktylos AK, Haidinger M, Lindner G. Characteristics and outcome of severe hypercalcemia on admission to the emergency department: a retrospective cohort study. Swiss Med Wkly 2023; 153:40069. [PMID: 37191138 DOI: 10.57187/smw.2023.40069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
AIMS OF THE STUDY To investigate the prevalence of hypercalcemia (>2.60 mmol/l) and severe hypercalcemia (≥2.80 mmol/l) on admission. Symptoms, causes, course of serum calcium, treatment and outcome of severe hypercalcemia were evaluated and compared to historical data from previous studies. METHODS In this retrospective cohort study, all patients presenting to the interdisciplinary emergency department of the Buergerspital Solothurn between 01 January 2017 and 31 December 2020 with measurements of serum calcium were included. Chart reviews were performed for patients with calcium ≥2.80 mmol/l to assess clinical presentation, course of disease and treatment for severe hypercalcemia. RESULTS Of 31,963 tested patients, 869 patients (2.7%) had hypercalcemia on the admission, of which 161 had severe hypercalcemia. Non-albumin corrected calcium was 3.07 (0.32) while albumin corrected calcium was 3.34 (0.44). Calcium was higher in patients with malignancy-related hypercalcemia (3.18 [0.34] versus 3.00 [0.3], p <0.001). Neuropsychiatric (35%) and gastrointestinal (24%) were the leading symptoms. Malignancy was the most common identifiable cause of hypercalcemia (40%), with lung cancer (20%), multiple myeloma (14%) and renal cell carcinoma (11%) being the main cancer types. 36% of patients with severe hypercalcemia took calcium supplements. Bisphosphonate treatment was an independent predictor of a fall in calcium until day 5 (regression coefficient: -0.404, standard error 0.11, p <0.001). Hypercalcemia was not mentioned in the final discharge report in 38% of cases. CONCLUSION Severe hypercalcemia is common and malignancy-related in almost half of the cases. Neuropsychiatric and gastrointestinal symptoms were most prevalent. Awareness of hypercalcemia, particularly in cancer patients and those with known triggering factors, should be raised in order to identify and treat this harmful disorder early.
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Affiliation(s)
- Svenja Ravioli
- Department of Emergency Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anne Lafranchi
- Department of Nephrology, Bürgerspital Solothurn, Switzerland
| | | | - Michael Haidinger
- Department of Internal and Emergency Medicine, Bürgerspital Solothurn, Switzerland
| | - Gregor Lindner
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland
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Ravioli S, Oberle J, Haidinger M, Lindner G. Gender equality in national cardiology societies: a cross-sectional study. Am J Med 2023; 136:585-591. [PMID: 36906170 DOI: 10.1016/j.amjmed.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND Higher productivity and team stability has been shown for gender diverse teams. However, there is a relevant and well-known gender gap in clinical and academic cardiovascular medicine. So far, no data concerning gender distribution in presidents and executive boards of national cardiology societies exist. METHODS In this cross-sectional analysis, gender equality in presidents and representatives of all national cardiology societies, which are members of or affiliated with the European Society of Cardiology (ESC) in 2022 was analyzed. In addition, representatives of the American Heart Association (AHA) were evaluated. RESULTS A total of 106 national societies were screened of which 104 were included in the final analysis. Overall, in these 104 societies, 90 out of 106 (85%) presidents were men while 14 (13%) were women. In the analysis of board members and executives, a total of 1128 individuals were included. Overall, 809 (72%) board members were men, 258 (23%) women and 61 (5%) of unknown gender. Except for society presidents in Australia, women were relevantly outnumbered by men in all world regions. CONCLUSION Women were globally underrepresented in leading positions of national cardiology societies in all world regions. As national societies are important regional stakeholders, improving gender equality in executive boards might create women role models, help foster careers and narrow the global cardiology gender gap.
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Affiliation(s)
- Svenja Ravioli
- Department of Emergency Medicine, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
| | - Jolanda Oberle
- Department of Internal and Emergency Medicine, Buergerspital Solothurn, Switzerland
| | - Michael Haidinger
- Department of Internal and Emergency Medicine, Buergerspital Solothurn, Switzerland
| | - Gregor Lindner
- Department of Emergency Medicine, Inselspital, University Hospital Bern and University of Bern, Switzerland.
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Haidinger M, Ravioli S, Lindner G. Equality in Recipients of Nephrology Awards from International Societies. Kidney Med 2022; 4:100505. [PMID: 36061367 PMCID: PMC9437596 DOI: 10.1016/j.xkme.2022.100505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ryser B, Rudenko A, Haidinger M, Exadaktylos AK, Ravioli S, Lindner G. Gender distribution in speakers at emergency medicine conferences. Am J Emerg Med 2022; 53:161-162. [DOI: 10.1016/j.ajem.2022.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 11/26/2022] Open
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Ravioli S, Lindner G, Haidinger M. Gender Distribution in Presidents and Board Members of European Nephrology Societies. Clin Kidney J 2021; 15:1017-1018. [PMID: 35498892 PMCID: PMC9050545 DOI: 10.1093/ckj/sfab259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Svenja Ravioli
- Department of Internal and Emergency Medicine, Buergerspital Solothurn, Switzerland
| | - Gregor Lindner
- Department of Internal and Emergency Medicine, Buergerspital Solothurn, Switzerland
| | - Michael Haidinger
- Department of Internal and Emergency Medicine, Buergerspital Solothurn, Switzerland
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Vossen MG, Pferschy S, Milacek C, Haidinger M, Karolyi M, Vass Z, Burgmann H, Maier-Salamon A, Wicha SG, Jäger W, Zeitlinger M, Stimpfl T, Wittek T, Thalhammer F. In vivo / in vitro Correlation of Pharmacokinetics of Gentamicin, Vancomycin, Teicoplanin and Doripenem in a Bovine Blood Hemodialysis Model. Front Pharmacol 2021; 12:702455. [PMID: 34248646 PMCID: PMC8264131 DOI: 10.3389/fphar.2021.702455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 06/03/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Elimination of a drug during renal replacement therapy is not only dependent on flow rates, molecular size and protein binding, but is often influenced by difficult to predict drug membrane interactions. In vitro models allow for extensive profiling of drug clearance using a wide array of hemofilters and flow rates. We present a bovine blood based in vitro pharmacokinetic model for intermittent renal replacement therapy. Methods: Four different drugs were analyzed: gentamicin, doripenem, vancomicin and teicoplanin. The investigated drug was added to a bovine blood reservoir connected to a hemodialysis circuit. In total seven hemofilter models were analyzed using commonly employed flow rates. Pre-filter, post-filter and dialysate samples were drawn, plasmaseparated and analyzed using turbidimetric assays or HPLC. Protein binding of doripenem and vancomycin was measured in bovine plasma and compared to previously published values for human plasma. Results: Clearance values were heavily impacted by choice of membrane material and surface as well as by dialysis parameters such as blood flow rate. Gentamicin clearance ranged from a minimum of 90.12 ml/min in a Baxter CAHP-170 diacetate hemofilter up to a maximum of 187.90 ml/min in a Fresenius medical company Fx80 polysulfone model (blood flow rate 400 ml/min, dialysate flow rate 800 ml/min). Clearance of Gentamicin vs Vancomicin over the F80s hemofilter model using the same flow rates was 137.62 mL vs 103.25 ml/min. Doripenem clearance with the Fx80 was 141.25 ml/min. Conclusion: Clearance values corresponded very well to previously published data from clinical pharmacokinetic trials. In conjunction with in silico pharmacometric models. This model will allow precise dosing recommendations without the need of large scale clinical trials.
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Affiliation(s)
- M G Vossen
- Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - S Pferschy
- Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - C Milacek
- Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - M Haidinger
- Department of Internal and Emergency Medicine, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Mario Karolyi
- Department for Infectious Diseases, Sozialmedizinisches Zentrum Sued Kaiser-Franz-Josef-Spital, Wien, Austria
| | - Zoltan Vass
- Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Heinz Burgmann
- Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Alexandra Maier-Salamon
- Department of Pharmaceutical Chemistry, Division of Clinical Pharmacy and Diagnostics, University of Vienna, Vienna, Austria
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - W Jäger
- Department of Pharmaceutical Chemistry, Division of Clinical Pharmacy and Diagnostics, University of Vienna, Vienna, Austria
| | - M Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - T Stimpfl
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - T Wittek
- University Clinic for Ruminants, University of Veterinary Medicine Vienna, Vienna, Austria
| | - F Thalhammer
- Clinical Division of Infectious Diseases and Tropical Medicine, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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Müller MM, Schwaiger E, Kurnikowski A, Haidinger M, Ristl R, Tura A, Pacini G, Werzowa J, Hecking M. Glucose Metabolism After Kidney Transplantation: Insulin Release and Sensitivity With Tacrolimus- Versus Belatacept-Based Immunosuppression. Am J Kidney Dis 2020; 77:462-464. [PMID: 32905816 DOI: 10.1053/j.ajkd.2020.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 07/02/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Martin M Müller
- Department of Internal Medicine III, Nephrology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Schwaiger
- Department of Internal Medicine III, Nephrology, Medical University of Vienna, Vienna, Austria
| | - Amelie Kurnikowski
- Department of Internal Medicine III, Nephrology, Medical University of Vienna, Vienna, Austria
| | - Michael Haidinger
- Department of Internal Medicine III, Nephrology, Medical University of Vienna, Vienna, Austria
| | - Robin Ristl
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- Metabolic Unit, CNR Institute of Neurosciences, Padova, Italy
| | - Giovanni Pacini
- Metabolic Unit, CNR Institute of Neurosciences, Padova, Italy
| | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1st Medical Department, Hanusch Hospital, Vienna, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Nephrology, Medical University of Vienna, Vienna, Austria.
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Haninger-Vacariu N, Vacariu A, Böhm M, Haidinger M, Sunder-Plassmann G, Schmidt A. FP714LONG-TERM NEURODEVELOPMENTAL AND ANTHROPOMETRICAL OUTCOME OF CHILDREN BORN TO FEMALE KIDNEY TRANSPLANT RECIPIENTS. Nephrol Dial Transplant 2018. [DOI: 10.1093/ndt/gfy104.fp714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Natalja Haninger-Vacariu
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria, Vienna, Austria
| | - Apostolos Vacariu
- Department of Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria, Vienna, Austria
| | - Michael Böhm
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria, Vienna, Austria
| | - Michael Haidinger
- Medical University of Vienna, Medical University of Vienna, Vienna, Austria, Vienna, Austria
| | - Gere Sunder-Plassmann
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria, Vienna, Austria
| | - Alice Schmidt
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria, Vienna, Austria
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Werzowa JM, Säemann MD, Mohl A, Bergmann M, Kaltenecker CC, Brozek W, Thomas A, Haidinger M, Antlanger M, Kovarik JJ, Kopecky C, Song PXK, Budde K, Pascual J, Hecking M. A randomized controlled trial-based algorithm for insulin-pump therapy in hyperglycemic patients early after kidney transplantation. PLoS One 2018. [PMID: 29518094 PMCID: PMC5843249 DOI: 10.1371/journal.pone.0193569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Treating hyperglycemia in previously non-diabetic individuals with exogenous insulin immediately after kidney transplantation reduced the odds of developing Posttransplantation Diabetes Mellitus (PTDM) in our previous proof-of-concept clinical trial. We hypothesized that insulin-pump therapy with maximal insulin dosage during the afternoon would improve glycemic control compared to basal insulin and standard-of-care. In a multi-center, randomized, controlled trial testing insulin isophane for PTDM prevention, we added a third study arm applying continuous subcutaneous insulin lispro infusion (CSII) treatment. CSII was initiated in 24 patients aged 55±12 years, without diabetes history, receiving tacrolimus. The mean daily insulin lispro dose was 9.2±5.2 IU. 2.3±1.1% of the total insulin dose were administered between 00:00 and 6:00, 19.5±11.6% between 6:00 and 12:00, 62.3±15.6% between 12:00 and 18:00 and 15.9±9.1% between 18:00 and 24:00. Additional bolus injections were necessary in five patients. Mild hypoglycemia (52–60 mg/dL) occurred in two patients. During the first post-operative week glucose control in CSII patients was overall superior compared to standard-of-care as well as once-daily insulin isophane for fasting and post-supper glucose. We present an algorithm for CSII treatment in kidney transplant recipients, demonstrating similar safety and superior short-term efficacy compared to standard-of-care and once-daily insulin isophane.
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Affiliation(s)
- Johannes M. Werzowa
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1 Medical Department, Hanusch Hospital, Vienna, Austria
- * E-mail:
| | - Marcus D. Säemann
- 6 Medical Department, Wilhelminenspital, Vienna, Austria
- Faculty of Medicine, Sigmund Freud University, Vienna, Austria
| | - Alexander Mohl
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Michael Bergmann
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Christopher C. Kaltenecker
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Brozek
- Ludwig Boltzmann Institute of Osteology at the Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, 1 Medical Department, Hanusch Hospital, Vienna, Austria
| | | | - Michael Haidinger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Marlies Antlanger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Johannes J. Kovarik
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Chantal Kopecky
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Peter X. K. Song
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Klemens Budde
- Charité Campus Mitte, Department of Internal Medicine, Division of Nephrology, Berlin, Germany
| | - Julio Pascual
- Servicio de Nefrología, Hospital del Mar-IMIM, Barcelona, Spain
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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Antlanger M, Kammerlander AA, Ullrich R, Haidinger M, Bonderman D, Mascherbauer J, Säemann MD. When it rains, it pours: Peripartum cardiomyopathy with features of left-ventricular noncompaction in a hemodialysis patient. Hemodial Int 2016; 20:E14-E17. [PMID: 27147549 DOI: 10.1111/hdi.12427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pregnancy and associated pre-eclampsia carry a high maternal risk in hemodialysis patients, yet no guidelines on how to monitor these patients' cardiovascular function exist. A 34-year-old hemodialysis patient presented with peripartum cardiomyopathy after a late second trimester miscarriage. On cardiac magnetic resonance imaging, diagnostic features of left ventricular noncompaction were apparent. Yet, histological and gene panel analyses remained negative. Upon stringent dry weight control and pharmacological heart failure therapy, the pathological changes showed complete regression. As pregnant hemodialysis patients have an excessively increased risk for pre-eclampsia-related cardiac disease, thorough screening appears valuable in these patients.
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Affiliation(s)
- Marlies Antlanger
- Department of Internal Medicine III, Division of Nephrology and Dialysis.
| | | | - Robert Ullrich
- Department of Pathology, Medical University of Vienna, Austria
| | - Michael Haidinger
- Department of Internal Medicine III, Division of Nephrology and Dialysis
| | | | | | - Marcus D Säemann
- Department of Internal Medicine III, Division of Nephrology and Dialysis
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Haidinger M, Antlanger M, Kopecky C, Kovarik JJ, Säemann MD, Werzowa J. Post-transplantation diabetes mellitus: evaluation of treatment strategies. Clin Transplant 2016; 29:415-24. [PMID: 25777150 DOI: 10.1111/ctr.12541] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Post-transplantation diabetes mellitus (PTDM) is a serious complication after kidney transplantation, but evidence regarding long-term outcomes of treatment regimens remains scarce. AIM AND METHODS The aim of this retrospective cohort analysis was to assess the long-term efficiency and safety of antidiabetic treatments in kidney transplant recipients (KTRs), who were diagnosed with PTDM by an oral glucose tolerance test (OGTT). RESULTS Of 561 KTRs that were screened for PTDM at our outpatient clinic, 71 (13%) had a diabetic OGTT and were included in this study. Mean follow-up was 34.2 ± 16.1 months. Thirty-six PTDM patients (51%) received antidiabetic treatment after diagnosis with either a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sulfonylurea, pioglitazone, or insulin. These patients had significantly higher fasting glucose and two-h plasma glucose (2HPG) values at baseline than those who remained without therapy. In contrast to lifestyle modification alone or sulfonylureas, DPP-4 inhibitors improved glycemic control significantly. Adverse events were generally mild and occurred at similar rates in all groups. CONCLUSION While sulfonylureas failed to improve glycemic control, DPP-4 inhibitors appeared effective and safe for the therapy of PTDM after kidney transplantation.
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Affiliation(s)
- M Haidinger
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Kovarik JJ, Antlanger M, Domenig O, Kaltenecker CC, Hecking M, Haidinger M, Werzowa J, Kopecky C, Säemann MD. Molecular regulation of the renin–angiotensin system in haemodialysis patients. Nephrol Dial Transplant 2016; 31:851. [DOI: 10.1093/ndt/gfw071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Werzowa J, Pacini G, Hecking M, Fidler C, Haidinger M, Brath H, Thomas A, Säemann MD, Tura A. Comparison of glycemic control and variability in patients with type 2 and posttransplantation diabetes mellitus. J Diabetes Complications 2015; 29:1211-6. [PMID: 26264400 DOI: 10.1016/j.jdiacomp.2015.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/09/2015] [Accepted: 07/11/2015] [Indexed: 12/14/2022]
Abstract
AIM Posttransplantation diabetes mellitus (PTDM) is a common complication after renal transplantation leading to increased cardiovascular morbidity and mortality. In subjects with type 2 diabetes (T2DM) increased glycemic variability and poor glycemic control have been associated with cardiovascular complications. We therefore aimed at determining glycemic variability and glycemic control in subjects with PTDM in comparison to T2DM subjects. METHODS In this observational study we analyzed 10 transplanted subjects without diabetes (Control), 10 transplanted subjects with PTDM, and 8 non-transplanted T2DM subjects using Continuous Glucose Monitoring (CGM). Several indices of glycemic control quality and variability were computed. RESULTS Many indices of both glycemic control quality and variability were different between control and PTDM subjects, with worse values in PTDM. The indices of glycemic control, such as glucose mean, GRADE and M-value, were similar in PTDM and T2DM, but some indices of glycemic variability, that is CONGA, lability index and shape index, showed a markedly higher (i.e., worse) value in T2DM than in PTDM (P value range: 0.001-0.035). CONCLUSIONS Although PTDM and T2DM subjects showed similar glycemic control quality, glycemic variability was significantly higher in T2DM. These data underscore potential important pathophysiological differences between T2DM and PTDM indicating that increased glycemic variability may not be a key factor for the excess cardiovascular mortality in patients with PTDM.
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Affiliation(s)
- Johannes Werzowa
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
| | | | - Manfred Hecking
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Catharina Fidler
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Michael Haidinger
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Helmut Brath
- Diabetes Outpatient Clinic, Health Center South, Vienna, Austria
| | | | - Marcus D Säemann
- Clinical Division of Nephrology and Dialysis, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- CNR Institute of Neuroscience, Padova, Italy
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Abstract
Posttransplantation diabetes mellitus (PTDM) is a major complication after renal transplantation due to its negative impact on patient and graft survival, and affects up to 40% of renal transplant recipients. The generation of evidence regarding its optimal treatment is now progressing with some emphasis on early postoperative insulin treatment that targets β-cell failure. This therapy seems to benefit renal transplant patients but contrasts with previous PTDM guidelines that were following treatment of type 2 diabetes mellitus (DM): oral antidiabetics first, insulin last. Similarly, in the current PTDM consensus recommendations, diagnostic procedures are in accordance with the American Diabetes Association (ADA) recommendations for diagnosis of DM. PTDM and type 2 DM, however, are distinct disease entities with different pathophysiological backgrounds. This review will discuss the significance of the standard diagnostic criteria for DM in patients after renal transplantation without prior DM. In particular, the role of glycated hemoglobin (HbA1c) and oral glucose tolerance testing (OGTT) will be reviewed. In addition, the potential role of other glycated proteins and continuous glucose monitoring will be covered, although these parameters are not yet part of the consensus recommendations.
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Affiliation(s)
- J Werzowa
- Department of Internal Medicine III, Section of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria,
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Ederer IA, Lucca I, Hofbauer SL, Haidinger M, Haitel A, Susani M, Shariat SF, Klatte T. Histopathology and prognosis of de novo bladder tumors following solid organ transplantation. World J Urol 2015; 33:2087-93. [DOI: 10.1007/s00345-015-1554-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 04/01/2015] [Indexed: 12/11/2022] Open
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Werzowa J, Säemann M, Haidinger M, Krebs M, Hecking M. Antidiabetic therapy in post kidney transplantation diabetes mellitus. Transplant Rev (Orlando) 2015; 29:145-53. [PMID: 25641399 DOI: 10.1016/j.trre.2015.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/11/2015] [Indexed: 02/08/2023]
Abstract
Post-transplantation diabetes mellitus (PTDM) is a common complication after kidney transplantation that affects up to 40% of kidney transplant recipients. By pathogenesis, PTDM is a diabetes form of its own, and may be characterised by a sudden, drug-induced deficiency in insulin secretion rather than worsening of insulin resistance over time. In the context of deteriorating allograft function leading to a re-occurrence of chronic kidney disease after transplantation, pharmacological interventions in PTDM patients deserve special attention. In the present review, we aim at presenting the current evidence regarding efficacy and safety of the modern antidiabetic armamentarium. Specifically, we focus on incretin-based therapies and insulin treatment, besides metformin and glitazones, and discuss their respective advantages and pitfalls. Although recent pilot trials are available in both prediabetes and PTDM, further studies are warranted to elucidate the ideal timing of various antidiabetics as well as its long-term impact on safety, glucose metabolism and cardiovascular outcomes in kidney transplant recipients.
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Affiliation(s)
- Johannes Werzowa
- Department of Medicine 3, Division of Nephrology and Dialysis, Medical University of Vienna, Austria.
| | - Marcus Säemann
- Department of Medicine 3, Division of Nephrology and Dialysis, Medical University of Vienna, Austria
| | - Michael Haidinger
- Department of Medicine 3, Division of Nephrology and Dialysis, Medical University of Vienna, Austria
| | - Michael Krebs
- Department of Medicine 3, Division of Endocrinology and Metabolism, Medical University of Vienna, Austria
| | - Manfred Hecking
- Department of Medicine 3, Division of Nephrology and Dialysis, Medical University of Vienna, Austria
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Kovarik JJ, Antlanger M, Domenig O, Kaltenecker CC, Hecking M, Haidinger M, Werzowa J, Kopecky C, Säemann MD. Molecular regulation of the renin-angiotensin system in haemodialysis patients. Nephrol Dial Transplant 2014; 30:115-23. [PMID: 25107336 DOI: 10.1093/ndt/gfu265] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Blockade of the renin-angiotensin system (RAS) exerts beneficial effects in patients with mild-to-moderate chronic kidney disease, yet evidence suggesting a similar benefit in haemodialysis (HD) patients is not available. Furthermore, knowledge of the effects of RAS blockade on systemic RAS components in HD patients is limited. Analysis of the quantity and dynamics of all known peripheral constituents of the RAS may yield important pathomechanistic information of a widespread therapeutic measure in HD patients. METHODS Fifty-two HD patients from the following groups were analysed cross-sectionally: patients without RAS blockade (n = 16), angiotensin-converting enzyme inhibitor (ACEi) users (n = 8), angiotensin receptor blocker (ARB) users (n = 11), patients on ACEi plus ARB (dual blockade, n = 8) and anephric patients (n = 9). Ten healthy volunteers served as controls. Angiotensin metabolites were quantified by mass spectrometry. RESULTS In general, HD patients showed a broad variability of RAS activity. Patients without RAS blockade displayed angiotensin metabolite patterns similar to healthy controls. ACEi therapy increased plasma Ang 1-10 and Ang 1-7 concentrations, whereas ARB treatment increased both Ang 1-8 and Ang 1-5, while suppressing Ang 1-7 to minimal levels. Dual RAS blockade resulted in high levels of Ang 1-10 and suppressed levels of other angiotensins. Anephric patients were completely devoid of detectable levels of circulating angiotensins. CONCLUSION In HD patients, the activity status of the systemic RAS is highly distorted with the emergence of crucial angiotensin metabolites upon distinct RAS blockade. The characterization of molecular RAS patterns associated with specific RAS interfering therapies may help to individualize future clinical studies and therapies.
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Affiliation(s)
- Johannes J Kovarik
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Marlies Antlanger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Oliver Domenig
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Christopher C Kaltenecker
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Manfred Hecking
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Michael Haidinger
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Johannes Werzowa
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Chantal Kopecky
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Marcus D Säemann
- Department of Internal Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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19
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Kopecky C, Haidinger M, Birner-Grünberger R, Darnhofer B, Kaltenecker CC, Marsche G, Holzer M, Weichhart T, Antlanger M, Kovarik JJ, Werzowa J, Hecking M, Säemann MD. Restoration of renal function does not correct impairment of uremic HDL properties. J Am Soc Nephrol 2014; 26:565-75. [PMID: 25071090 DOI: 10.1681/asn.2013111219] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Cardiovascular disease remains the leading cause of death in renal transplant recipients, but the underlying causative mechanisms for this important problem remain elusive. Recent work has indicated that qualitative alterations of HDL affect its functional and compositional properties in ESRD. Here, we systematically analyzed HDL from stable renal transplant recipients, according to graft function, and from patients with ESRD to determine whether structural and functional properties of HDL remain dysfunctional after renal transplantation. Cholesterol acceptor capacity and antioxidative activity, representing two key cardioprotective mechanisms of HDL, were profoundly suppressed in kidney transplant recipients independent of graft function and were comparable with levels in patients with ESRD. Using a mass spectroscopy approach, we identified specific remodeling of transplant HDL with highly enriched proteins, including α-1 microglobulin/bikunin precursor, pigment epithelium-derived factor, surfactant protein B, and serum amyloid A. In conclusion, this study demonstrates that HDL from kidney recipients is uniquely altered at the molecular and functional levels, indicating a direct pathologic role of HDL that could contribute to the substantial cardiovascular risk in the transplant population.
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Affiliation(s)
- Chantal Kopecky
- Division of Nephrology and Dialysis, Department of Internal Medicine III, and
| | - Michael Haidinger
- Division of Nephrology and Dialysis, Department of Internal Medicine III, and
| | | | | | | | - Gunther Marsche
- Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria; and
| | - Michael Holzer
- Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Graz, Austria; and
| | - Thomas Weichhart
- Institute of Medical Genetics, Medical University of Vienna, Vienna, Austria
| | - Marlies Antlanger
- Division of Nephrology and Dialysis, Department of Internal Medicine III, and
| | - Johannes J Kovarik
- Division of Nephrology and Dialysis, Department of Internal Medicine III, and
| | - Johannes Werzowa
- Division of Nephrology and Dialysis, Department of Internal Medicine III, and
| | - Manfred Hecking
- Division of Nephrology and Dialysis, Department of Internal Medicine III, and
| | - Marcus D Säemann
- Division of Nephrology and Dialysis, Department of Internal Medicine III, and
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Stadler M, Krššák M, Jankovic D, Göbl C, Winhofer Y, Pacini G, Bischof M, Haidinger M, Saemann M, Mühlbacher F, Korbonits M, Baumgartner-Parzer SM, Luger A, Prager R, Anderwald CH, Krebs M. Fasting and postprandial liver glycogen content in patients with type 1 diabetes mellitus after successful pancreas-kidney transplantation with systemic venous insulin delivery. Clin Endocrinol (Oxf) 2014; 80:208-13. [PMID: 23302039 DOI: 10.1111/cen.12146] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 12/04/2012] [Accepted: 01/07/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients with type 1 diabetes mellitus (T1DM), insulin is usually replaced systemically (subcutaneously) and not via the physiological portal route. According to previous studies, the liver's capacity to store glycogen is reduced in T1DM patients, but it remains unclear whether this is due to hyperglycaemia, or whether the route of insulin supply could contribute to this phenomenon. T1DM patients after successful pancreas-kidney transplantation with systemic venous drainage (T1DM-PKT) represent a suitable human model to further investigate this question, because they are normoglycaemic, but their liver receives insulin from the pancreas transplant via the systemic route. MATERIALS AND METHODS In nine T1DM-PKT, nine controls without diabetes (CON) and seven patients with T1DM (T1DM), liver glycogen content was measured at fasting and after two standardized meals employing (13) C-nuclear-magnetic-resonance-spectroscopy. Circulating glucose and glucoregulatory hormones were measured repeatedly throughout the study day. RESULTS The mean and fasting concentrations of peripheral plasma glucose, insulin, glucagon and C-peptide were comparable between T1DM-PKT and CON, whereas T1DM were hyperglycaemic and hyperinsulinaemic (P < 0·05 vs T1DM-PKT and CON). Total liver glycogen content at fasting and after breakfast did not differ in the three groups. After lunch, T1DM-PKT and T1DM had a 14% and 21% lower total liver glycogen content than CON (P < 0·02). CONCLUSION In spite of normalized glycaemic control, postprandial liver glycogen content was reduced in T1DM-PKT with systemic venous drainage. Thus, not even optimized systemic insulin substitution is able to resolve the defect in postprandial liver glycogen storage seen in T1DM patients.
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Affiliation(s)
- M Stadler
- 3rd Medical Department of Metabolic Diseases and Nephrology, Hietzing Hospital, Vienna, Austria; Karl Landsteiner Institute of Metabolic Diseases and Nephrology, Vienna, Austria; Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
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Haidinger M, Werzowa J, Hecking M, Antlanger M, Stemer G, Pleiner J, Kopecky C, Kovarik JJ, Döller D, Pacini G, Säemann MD. Efficacy and safety of vildagliptin in new-onset diabetes after kidney transplantation--a randomized, double-blind, placebo-controlled trial. Am J Transplant 2014; 14:115-23. [PMID: 24279801 DOI: 10.1111/ajt.12518] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 09/04/2013] [Accepted: 09/17/2013] [Indexed: 01/25/2023]
Abstract
New-onset diabetes after transplantation (NODAT) is a serious complication after kidney transplantation, but therapeutic strategies remain underexplored. Dipeptidyl peptidase-4 (DPP-4) inhibitors selectively foster insulin secretion without inducing hypoglycemia, which might be advantageous in kidney transplant recipients (KTRs) with NODAT. We conducted a randomized, double-blind, placebo-controlled, phase II trial to assess safety and efficacy of the DPP-4 inhibitor vildagliptin. Intraindividual differences in oral glucose tolerance test (OGTT)-derived 2-h plasma glucose (2HPG) from baseline to 3 months after treatment served as primary endpoint. Among secondary outcomes, we evaluated HbA1c, metabolic and safety parameters, as well as OGTTs at 1 month after drug discontinuation. Of 509 stable KTRs who were screened in our outpatient clinic, 63 (12.4%) had 2HPG ≥ 200 mg/dL, 33 of them were randomized and 32 completed the study. In the vildagliptin group 2HPG and HbA1c were profoundly reduced in comparison to placebo (vildagliptin: 2HPG = 182.7 mg/dL, HbA1c = 6.1%; placebo: 2HPG = 231.2 mg/dL, HbA1c = 6.5%; both p ≤ 0.05), and statistical significance was achieved for the primary endpoint (vildagliptin: 2HPG-difference -73.7 ± 51.3 mg/dL; placebo: -5.7 ± 41.4 mg/dL; p < 0.01). Adverse events were generally mild and occurred at similar rates in both groups. In conclusion, DPP-4 inhibition in KTRs with overt NODAT was safe and efficient, providing a novel treatment alternative for this specific form of diabetes.
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Affiliation(s)
- M Haidinger
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Antlanger M, Hecking M, Haidinger M, Werzowa J, Kovarik JJ, Paul G, Eigner M, Bonderman D, Hörl WH, Säemann MD. Fluid overload in hemodialysis patients: a cross-sectional study to determine its association with cardiac biomarkers and nutritional status. BMC Nephrol 2013; 14:266. [PMID: 24295522 PMCID: PMC4219439 DOI: 10.1186/1471-2369-14-266] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 11/26/2013] [Indexed: 12/30/2022] Open
Abstract
Background Chronic fluid overload is associated with higher mortality in dialysis patients; however, the link with cardiovascular morbidity has not formally been established and may be influenced by subclinical inflammation. We hypothesized that a relationship exists between fluid overload and [i] cardiovascular laboratory parameter as well as between fluid overload and [ii] inflammatory laboratory parameters. In addition, we aimed to confirm whether volume status correlates with nutritional status. Methods We recorded baseline characteristics of 244 hemodialysis patients at three hemodialysis facilities in Vienna (Austria) and determined associations with volume measurements using the body composition monitor (Fresenius/Germany). In one facility comprising 126 patients, we further analyzed cardiovascular, inflammatory and nutritional parameters. Results We detected predialysis fluid overload (FO) in 39% of all patients (n = 95) with FO defined as ≥15% of extracellular water (ECW). In this subgroup, the absolute FO was 4.4 +/-1.5 L or 22.9 ± 4.8% of ECW. A sub-analysis of patients from one center showed that FO was negatively associated with body mass index (r = -0.371; p = <0.001), while serum albumin was significantly lower in fluid overloaded patients (p = 0.001). FO was positively associated with D-Dimer (r = 0.316; p = 0.001), troponin T (r = 0.325; p < 0.001), and N-terminal pro-B-type natriuretic peptide (r = 0.436; p < 0.001), but not with investigated inflammatory parameters. Conclusions Fluid overload in HD patients was found to be lower in patients with high body mass index, indicating that dry weight was inadequately prescribed and/or difficult to achieve in overweight patients. The association with parameters of cardiovascular compromise and/or damage suggests that fluid overload is a biomarker for cardiovascular risk. Future studies should determine if this applies to patients prior to end-stage renal disease.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Marcus D Säemann
- Department of Internal Medicine III - Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna Austria.
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Hecking M, Kainz A, Werzowa J, Haidinger M, Döller D, Tura A, Karaboyas A, Hörl WH, Wolzt M, Sharif A, Roden M, Moro E, Pacini G, Port FK, Säemann MD. Glucose metabolism after renal transplantation. Diabetes Care 2013; 36:2763-71. [PMID: 23656979 PMCID: PMC3747896 DOI: 10.2337/dc12-2441] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We determined prevalence, risk factors, phenotype, and pathophysiological mechanism of new-onset diabetes after transplantation (NODAT) to generate strategies for optimal pharmacological management of hyperglycemia in NODAT patients. RESEARCH DESIGN AND METHODS Retrospective cohort study comparing demographics, laboratory data, and oral glucose tolerance test (OGTT)-derived metabolic parameters from kidney transplant recipients versus subjects not receiving transplants. RESULTS Among 1,064 stable kidney transplant recipients (≥ 6 months posttransplantation), 113 (11%) had a history of NODAT and 132 (12%) had pretransplant diabetes. In the remaining patients, randomly assigned OGTTs showed a high prevalence of abnormal glucose metabolism (11% diabetes; 32% impaired fasting glucose, impaired glucose tolerance, or both), predominantly in older patients who received tacrolimus as the primary immunosuppressant. Compared with 1,357 nontransplant subjects, stable kidney transplant recipients had lower basal glucose, higher glycated hemoglobin, lower insulin secretion, and greater insulin sensitivity in each of the three subgroups, defined by OGTT 2-h glucose (<140, 140-199, ≥ 200 mg/dL). These findings were reinforced in linear spline interpolation models of insulin secretion and sensitivity (all P < 0.001) and in another regression model in which the estimated oral glucose insulin sensitivity index was substantially higher (by 79-112 mL/min m(2)) for transplant versus nontransplant subjects despite adjustments for age, sex, and BMI (all P < 0.001). CONCLUSIONS Glucose metabolism differs substantially between kidney transplant recipients and nontransplant controls. Because impaired insulin secretion appears to be the predominant pathophysiological feature after renal transplantation, early therapeutic interventions that preserve, maintain, or improve β-cell function are potentially beneficial in this population.
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Affiliation(s)
- Manfred Hecking
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
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Haidinger M, Werzowa J, Kain R, Antlanger M, Hecking M, Pfaffenberger S, Mascherbauer J, Gremmel T, Gilbertson JA, Rowczenio D, Weichhart T, Kopecky C, Hörl WH, Hawkins PN, Säemann MD. Hereditary amyloidosis caused by R554L fibrinogen Aα-chain mutation in a Spanish family and review of the literature. Amyloid 2013; 20:72-9. [PMID: 23551149 DOI: 10.3109/13506129.2013.781998] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Hereditary amyloidosis with predominant renal disease can be caused by mutations in the gene encoding the fibrinogen Aα-chain (AFib). Here, we describe the clinical course of AFib amyloidosis associated with the rare R554L mutation, and the significance of extrarenal amyloid deposits and their possible influence on cardiovascular morbidity. METHODS We report on 101 members of a family after having conducted patient interviews, chart review, genetic testing, renal biopsies and assessment for extrarenal amyloid deposition. RESULTS Ten family members had chronic kidney disease with late-onset gross proteinuria and a variable course of declining renal function, starting in the fourth decade of life. In two affected living members, we identified the AFib R554L mutation. Renal biopsies from two affected members revealed almost complete obliteration of the mesangial glomerular architecture, although kidney function was only moderately impaired. There was neither evidence of extrarenal amyloidosis nor accelerated atherosclerosis. CONCLUSIONS Renal amyloidosis associated with the R554L AFib variant dominated the clinical picture in this family, which was similar to that associated with the much more prevalent E526V mutation. Although it has been hypothesized that vascular deposits of fibrinogen amyloid may be associated with accelerated atherosclerosis, there was no suggestion of this in this particular kindred.
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Affiliation(s)
- Michael Haidinger
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Porrini E, Silva I, Ibernon M, Rocio B, Diaz JM, Delgado Mallen P, Osorio JM, Moreso F, Torres A, Haidinger M, Werzowa J, Hecking M, Stemer G, Pleiner J, Kopecky C, Pacini G, Antlanger M, Saemann MD. Management of diabetes in advanced CKD. Nephrol Dial Transplant 2013. [DOI: 10.1093/ndt/gft190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Power A, Duncan N, Pusey C, Usvyat L, Marcelli D, Marelli C, Kotanko P, Li Z, Wang J, Yuan X, Wang J, Wang L, Ozkayar N, Altun B, Yildirim T, Yilmaz R, Dede F, Hayran M, Arici M, Aki T, Erdem Y, Vink EE, Siddiqi L, Verloop WL, van Schelven LJ, Liam Oey P, Blankestijn PJ, Vink EE, Verloop WL, Voslkuil M, Spiering W, Vonken EJ, Blankestijn PJ, Branco PQ, Gaspar AC, Sousa HS, Martins AR, Dores H, Goncalves P, Almeida M, Mendes M, Barata JD, Shi X, Xia P, Wen Y, Jiang L, Li H, Li X, Li X, Chen L, Quiroz YJ, Franco M, Tapia E, Bautista R, Pacheco U, Santamaria J, Johnson RJ, Rodriguez-Iturbe B, Suttorp MM, Hoekstra T, Dekker FW, Lin L, Zhang W, Yang J, He Y, Maciorkowska D, Zbroch E, Koc-Zorawska E, Malyszko JS, Mysliwiec MC, Malyszko J, Sala N, Navarro Diaz M, Serra A, Lopez D, Bonet J, Romero R, Qiu L, Li Y, Chen L, Zhu G, Schiller A, Bob F, Enache A, Jurca-Simina F, Mociar D, Bozdog G, Munteanu M, Petrica L, Velciov S, Bansal V, Timar R, Branco PQ, Gaspar AC, Sousa HS, Martins AR, Goncalves PA, Dores H, Mendes A, Mendes M, Barata JD, Calderon C, Lavilla FJ, Mora JM, Lopez D, Garcia-Fernandez N, Martin PL, Errasti P, David C, Ciocalteu A, Niculae A, Checherita AI, Otowa T, Yasuda T, Uehara K, Kawarazaki H, Shibagaki Y, Kimura K, Hasegawa H, Kanozawa K, Asakura J, Takayanagi K, Tayama Y, Okazaki S, Hara H, Kiba T, Mitani T, Iwanaga M, Ogawa T, Matsuda A, Mitarai T, Yilmaz Z, Yildirim T, Yilmaz R, Aybal-Kutlugun A, Altun B, Kucukozkan T, Erdem Y, Abbss SR, Zhu F, Flores-Gama C, Williams C, Podesta MA, Cartagena C, Carter M, Levin NW, Kotanko P, Gerasimovska Kitanovska B, Bogdanovska S, Severova Andreevska G, Gerasimovska V, Sikole A, Zafirovska K, Boubaker K, Kheder A, Kaaroud H, Lee SM, Park HE, Kim M, Heo NJ, Choi SY, Joo KW, Han JS, Shah S, Pandya B, Schiller A, Munteanu M, Enache A, Bob F, Jurca-Simina F, Mociar D, Timar R, Karanovic S, Fistrek Prlic M, Kos J, Premuzic V, Abramovic Baric M, Matijevic V, Fucek M, Vrdoljak A, Cvitkovic A, Leko N, Bitunjac M, Laganovic M, Jelakovic B, Antlanger M, Kovarik JJ, Domenig O, Kaltenecker C, Hecking M, Haidinger M, Werzowa J, Kopecky C, Heinzl H, Poglitsch M, Saemann MD, Bartmanska M, Wyskida K, Baba M, Tarski M, Adamczak M, Wiecek A, Szotowska M, Fistrek Prlic M, Karanovic S, Pecin I, Laganovic M, Vedran P, Vrdoljak A, Fucek M, Cvitkovic A, Bitunjac M, Abramovic Baric M, Matijevic V, Jelakovic B, Margulis F, Golglid V, Castro C, Ramallo S, Martinez M, Schiavelli R, Demikhova N, Prikhodko O, Vazquez Jimenez LC, Bancu IE, Troya Saborido MI, Bonet Sol J, Tasdemir M, Canpolat N, Caliskan S, Pehlivan G, Sever L, Sasaki K, Kimura T, Sakai S, Iwahashi E, Fujimoto T, Minami S, Oka T, Yokoyama K. Hypertension - human studies. Nephrol Dial Transplant 2013. [DOI: 10.1093/ndt/gft106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Yildirim T, Yilmaz R, Altindal M, Turkmen E, Arici M, Altun B, Erdem Y, Guliyev O, Erkmen Uyar M, Tutal E, Bal Z, Sezer S, Erkmen Uyar M, Bal U, Bal Z, Tutal E, Say n B, Guliyev O, Erdemir B, Sezer S, O'Rourke-Potowki A, Gauge N, Penny H, Cronin A, Frame S, Goldsmith DJ, Yagan JA, Chandraker A, Velickovic Radovanovic RM, Catic Djordjevic A, Mitic B, Stefanovic N, Cvetkovic T, Serpieri N, Grosjean F, Sileno G, Torreggiani M, Esposito V, Mangione F, Abelli M, Castoldi F, Catucci D, Esposito C, Dal Canton A, Vatazin AV, Zulkarnaev AB, Borst C, Liu Y, Thoning J, Tepel M, Libetta C, Margiotta E, Borettaz I, Canevari M, Martinelli C, Lainu E, Abelli M, Meloni F, Sepe V, Dal Canton A, Miguel Costa R, Vasquez Martul E, Reboredo J, Rivera C, Simonato F, Tognarelli G, Daidola G, Gallo E, Burdese M, Cantaluppi V, Biancone L, Segoloni GP, Burdese M, Priora M, Messina M, Tamagnone M, Daidola G, Linsalata A, Lavacca A, Biancone L, Segoloni G, Zuidema W, Erdman R, van de Wetering J, Dor F, Roodnat J, Massey E, Timmerman L, IJzermans J, Weimar W, Goldsmith DJ, Sibley-Allen C, Hilton R, Moghul M, Burnapp L, Blake G, Koo TY, Park JS, Park HC, Kim GH, Lee CH, Oh IH, Kang CM, Hwang JK, Park SC, Choi BS, Chun HJ, Kim JI, Yang CW, Moon IS, Van Laecke S, Van Biesen W, Nagler EV, Taes Y, Peeters P, Vanholder R, Pruthi R, Ravanan R, Casula A, Harber M, Roderick P, Fogarty D, Cho A, Shin JH, Jang HR, Lee JE, Huh W, Kim DJK, Oh HY, Kim YG, Sancho Calabuig A, Gavela Martinez E, Kanter Berga J, Beltran Catalan S, Avila Bernabeu AI, Pallardo Mateu LM, Gonzalez E, Polanco N, Molina M, Gutierrez E, Garcia Puente L, Sevillano A, Morales E, Praga M, Andres A, Banasik M, Boratynska M, Koscielska-Kasprzak K, Bartoszek D, Myszka M, Zmonarski S, Nowakowska B, Wawrzyniak E, Halon A, Chudoba P, Klinger M, Rojas-Rivera J, Gonzalez E, Polanco N, Morales E, Andres A, Morales JM, Egido J, Praga M, Kopecky CM, Haidinger M, Kaltenecker C, Antlanger M, Marsche G, Holzer M, Kovarik J, Werzowa J, Hecking M, Saemann MD, Hwang JK, Kim JM, Koh ES, Chung BH, Park SC, Choi BS, Kim JI, Yang CW, Kim YS, Moon IS, Banasik M, Boratynska M, Koscielska-Kasprzak K, Krajewska M, Mazanowska O, Kaminska D, Bartoszek D, Zabinska M, Halon A, Malkiewicz B, Patrzalek D, Klinger M, Sulowicz J, Szostek S, Wojas-Pelc A, Ignacak E, Sulowicz W, Bellizzi V, Calella P, Cupisti A, Capitanini A, D'Alessandro C, Giannese D, Camocardi A, Conte G, Barsotti M, Bilancio G, Luciani R, Locsey L, Seres I, Kovacs D, Asztalos L, Paragh G, Wohlfahrtova M, Balaz P, Rokosny S, Wohlfahrt P, Bartonova A, Viklicky O, Kers J, Geskus RB, Meijer LJ, Bemelman F, ten Berge IJM, Florquin S, Hwang JC, Jiang MY, Lu YH, Weng SF, Testa A, Porto G, Sanguedolce M, Spoto B, Parlongo R, Pisano A, Enia G, Tripepi G, Zoccali C, Zuidema W, Mamode N, Lennerling A, Citterio F, Massey E, Van Assche K, Sterckx S, Frunza M, Jung H, Pascalev A, Johnson R, Loven C, Weimar W, Dor F, Soleymanian T, Keyvani H, Jazayeri SM, Fazeli Z, Ghamari S, Mahabadi M, Chegeni V, Najafi I, Ganji MR, Meys KME, Groothoff JW, Jager K, Schaefer F, Tonshoff B, Mota C, Cransberg K, van Stralen K, Gurluler E, Gures N, Alim A, Gurkan A, Cakir U, Berber I, Van Laecke S, Caluwe R, Nagler E, Van Biesen W, Peeters P, Van Vlem B, Vanholder R, Sulowicz J, Wojas-Pelc A, Ignacak E, Betkowska-Prokop A, Kuzniewski M, Krzanowski M, Sulowicz W, Masson I, Flamant M, Maillard N, Cavalier E, Moranne O, Alamartine E, Mariat C, Delanaye P, Canas Sole LL, Iglesias Alvarez E, Pastor MCMC, Moreno Flores FF, Abujder VV, Graterol FF, Bonet Sol JJ, Lauzurica Valdemoros RR, Yoshikawa M, Kitamura K, Nakai K, Goto S, Fujii H, Ishimura T, Takeda M, Fujisawa M, Nishi S, Prasad N, Gurjer D, Bhadauria D, Gupta A, Sharma R, Kaul A, Cybulla M, West M, Nicholls K, Torras J, Sunder-Plassmann G, Feriozzi S, Lo S, Wong PYH, Ip D, Wong CK, Chow VCC, Mo SKL, Molnar M, Ujszaszi A, Czira ME, Novak M, Mucsi I, Cruzado JM, Coelho S, Porta N, Bestard O, Melilli E, Taco O, Rivas I, Grinyo J, Pouteau LM, N'Guyen JM, Hami A, Hourmant M, Ghahramani N, Karparvar Z, Shadrou S, Ghahramani M, Fauvel JP, Hadj-Aissa A, Buron F, Morelon E, Ducher M, Heine C, Glander P, Neumayer HH, Budde K, Liefeldt L, Montero N, Webster AC, Royuela A, Zamora J, Crespo M, Pascual J, Adema AY, van Dorp WTH, Mallat MJK, de Fijter HW, Kim YS, Hong YA, Chung BH, Park CW, Yang CW, Kim YS, Choi BS, Suleymanlar G, Uzundurukan Z, Kapuagas A, Sencan I, Akdag R, Pascual J, Torio A, Mas V, Perez-Saez MJ, Mir M, Faura A, Montes-Ares O, Checa MD, Crespo M, Sawinski D, Trofe-Clark J, Sparkes T, Patel P, Goral S, Bloom R, Kim HJ, Park SJ, Kim TH, Kim YW, Kim YH, Kang SW, Abdel Halim M, Gheith O, Al-Otaibi T, Mosaad A, Awadeen W, Said T, Nair P, Nampoory MRN. Transplantation: clinical studies - A. Nephrol Dial Transplant 2013. [DOI: 10.1093/ndt/gft123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hecking M, Werzowa J, Haidinger M, Hörl WH, Pascual J, Budde K, Luan FL, Ojo A, de Vries APJ, Porrini E, Pacini G, Port FK, Sharif A, Säemann MD. Novel views on new-onset diabetes after transplantation: development, prevention and treatment. Nephrol Dial Transplant 2013; 28:550-66. [PMID: 23328712 DOI: 10.1093/ndt/gfs583] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
New-onset diabetes after transplantation (NODAT) is associated with increased risk of allograft failure, cardiovascular disease and mortality, and therefore, jeopardizes the success of renal transplantation. Increased awareness of NODAT and the prediabetic states (impaired fasting glucose and impaired glucose tolerance, IGT) has fostered previous and present recommendations, based on the management of type 2 diabetes mellitus (T2DM). Unfortunately, the idea that NODAT merely resembles T2DM is potentially misleading, because the opportunity to initiate adequate anti-hyperglycaemic treatment early after transplantation might be given away for 'tailored' immunosuppression in patients who have developed NODAT or carry personal risk factors. Risk factor-independent mechanisms, however, seem to render postoperative hyperglycaemia with subsequent development of overt or 'full-blown' NODAT, the unavoidable consequence of the transplant and immunosuppressive process itself, at least in many cases. A proof of the concept that timely preventive intervention with exogenous insulin against post-transplant hyperglycaemia may decrease NODAT was recently provided by a small clinical trial, which is awaiting confirmation from a multicentre study. However, because early insulin therapy aimed at beta-cell protection seems to contrast the currently recommended, stepwise approach of 'watchful waiting' prior to pancreatic decompensation, we here aim at reviewing recent concepts regarding the development, prevention and treatment of NODAT, some of which seem to challenge the traditional view on T2DM and NODAT. In summary, we suggest a novel, risk factor-independent management approach to NODAT, which includes glycaemic monitoring and anti-hyperglycaemic treatment in virtually everybody after transplantation. This approach has widespread implications for future research and is intended to tackle NODAT and also ultimately cardiovascular disease.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
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Hecking M, Antlanger M, Winnicki W, Reiter T, Werzowa J, Haidinger M, Weichhart T, Polaschegg HD, Josten P, Exner I, Lorenz-Turnheim K, Eigner M, Paul G, Klauser-Braun R, Hörl WH, Sunder-Plassmann G, Säemann MD. Blood volume-monitored regulation of ultrafiltration in fluid-overloaded hemodialysis patients: study protocol for a randomized controlled trial. Trials 2012; 13:79. [PMID: 22682149 PMCID: PMC3493292 DOI: 10.1186/1745-6215-13-79] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Accepted: 06/08/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Data generated with the body composition monitor (BCM, Fresenius) show, based on bioimpedance technology, that chronic fluid overload in hemodialysis patients is associated with poor survival. However, removing excess fluid by lowering dry weight can be accompanied by intradialytic and postdialytic complications. Here, we aim at testing the hypothesis that, in comparison to conventional hemodialysis, blood volume-monitored regulation of ultrafiltration and dialysate conductivity (UCR) and/or regulation of ultrafiltration and temperature (UTR) will decrease complications when ultrafiltration volumes are systematically increased in fluid-overloaded hemodialysis patients. METHODS/DESIGN BCM measurements yield results on fluid overload (in liters), relative to extracellular water (ECW). In this prospective, multicenter, triple-arm, parallel-group, crossover, randomized, controlled clinical trial, we use BCM measurements, routinely introduced in our three maintenance hemodialysis centers shortly prior to the start of the study, to recruit sixty hemodialysis patients with fluid overload (defined as ≥15% ECW). Patients are randomized 1:1:1 into UCR, UTR and conventional hemodialysis groups. BCM-determined, 'final' dry weight is set to normohydration weight -7% of ECW postdialysis, and reached by reducing the previous dry weight, in steps of 0.1 kg per 10 kg body weight, during 12 hemodialysis sessions (one study phase). In case of intradialytic complications, dry weight reduction is decreased, according to a prespecified algorithm. A comparison of intra- and post-dialytic complications among study groups constitutes the primary endpoint. In addition, we will assess relative weight reduction, changes in residual renal function, quality of life measures, and predialysis levels of various laboratory parameters including C-reactive protein, troponin T, and N-terminal pro-B-type natriuretic peptide, before and after the first study phase (secondary outcome parameters). DISCUSSION Patients are not requested to revert to their initial degree of fluid overload after each study phase. Therefore, the crossover design of the present study merely serves the purpose of secondary endpoint evaluation, for example to determine patient choice of treatment modality. Previous studies on blood volume monitoring have yielded inconsistent results. Since we include only patients with BCM-determined fluid overload, we expect a benefit for all study participants, due to strict fluid management, which decreases the mortality risk of hemodialysis patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT01416753.
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Affiliation(s)
- Manfred Hecking
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Marlies Antlanger
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Wolfgang Winnicki
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Thomas Reiter
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Johannes Werzowa
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Michael Haidinger
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Thomas Weichhart
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | | | - Peter Josten
- Nikkiso Europe GmbH, Beneckealle 30, Hanover, 30419, Germany
| | - Isabella Exner
- Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef Spital, 1st Medical Department, Dialysis, Kundratstrasse 3, Vienna, 1100, Austria
| | - Katharina Lorenz-Turnheim
- Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef Spital, 1st Medical Department, Dialysis, Kundratstrasse 3, Vienna, 1100, Austria
| | - Manfred Eigner
- Sozialmedizinisches Zentrum Süd, Kaiser-Franz-Josef Spital, 1st Medical Department, Dialysis, Kundratstrasse 3, Vienna, 1100, Austria
| | - Gernot Paul
- Sozialmedizinisches Zentrum Ost, Donauspital, 3rd Medical Department, Dialysis, Langobardenstrasse 122, Vienna, 1220, Austria
| | - Renate Klauser-Braun
- Sozialmedizinisches Zentrum Ost, Donauspital, 3rd Medical Department, Dialysis, Langobardenstrasse 122, Vienna, 1220, Austria
| | - Walter H Hörl
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Gere Sunder-Plassmann
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
| | - Marcus D Säemann
- Department of Internal Medicine III, Nephrology and Dialysis, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria
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Hecking M, Kainz A, Werzowa J, Haidinger M, Tura A, Karaboyas A, Hörl WH, Wolzt M, Pacini G, Port FK, Säemann MD. Impaired Glucose Metabolism Despite Decreased Insulin Resistance After Renal Transplantation. Kidney Res Clin Pract 2012. [DOI: 10.1016/j.krcp.2012.04.399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Hecking M, Haidinger M, Döller D, Werzowa J, Tura A, Zhang J, Tekoglu H, Pleiner J, Wrba T, Rasoul-Rockenschaub S, Mühlbacher F, Schmaldienst S, Druml W, Hörl WH, Krebs M, Wolzt M, Pacini G, Port FK, Säemann MD. Early basal insulin therapy decreases new-onset diabetes after renal transplantation. J Am Soc Nephrol 2012; 23:739-49. [PMID: 22343119 DOI: 10.1681/asn.2011080835] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
No effective interventions to reduce risk for new-onset diabetes after transplantation (NODAT), a condition associated with postoperative hyperglycemia and reduced patient and graft survival, have been established. In this 1-year, proof-of-concept clinical trial, we randomly assigned 50 renal transplant recipients to immediate-postoperative isophane insulin for evening blood glucose ≥140 mg/dl (treatment group) or short-acting insulin and/or oral antidiabetic agents for blood glucose ≥180-250 mg/dl (standard-of-care control group). We included only patients without a history of diabetes who received tacrolimus. By the third postoperative evening, all patients in the treatment group had blood glucose ≥140 mg/dl and were subsequently treated with basal insulin; during the first 3 weeks after transplantation, the mean ± SD daily insulin dosage was 17±11 IU/d. Among controls, 23 (92%) of 25 had blood glucose ≥200 mg/dl and 18 (72%) of 25 received standard-of-care antihyperglycemic treatment. Asymptomatic hypoglycemia occurred five times in the treatment group and once in the control group. Throughout follow-up, the treatment group had 73% lower odds of NODAT (odds ratio, 0.27) than the control group, and hemoglobin A1c was on average 0.38% lower in the treatment group than the control group. Twelve months after transplantation, all patients in the treatment group were insulin-independent, whereas 7 (28%) of 25 controls required antidiabetic agents. The groups did not differ for insulin sensitivity, but the treatment group showed better β-cell function throughout the 1-year follow-up. In conclusion, this study suggests regimens that include basal insulin significantly reduce the odds for NODAT after renal transplantation, presumably via insulin-mediated protection of β cells.
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Affiliation(s)
- Manfred Hecking
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
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Weichhart T, Kopecky C, Kubicek M, Haidinger M, Döller D, Katholnig K, Suarna C, Eller P, Tölle M, Gerner C, Zlabinger GJ, van der Giet M, Hörl WH, Stocker R, Säemann MD. Serum amyloid A in uremic HDL promotes inflammation. J Am Soc Nephrol 2012; 23:934-47. [PMID: 22282592 DOI: 10.1681/asn.2011070668] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Uremia impairs the atheroprotective properties of HDL, but the mechanisms underlying why this occurs are unknown. Here, we observed that HDL isolated from healthy individuals inhibited the production of inflammatory cytokines by peripheral monocytes stimulated with a Toll-like receptor 2 agonist. In contrast, HDL isolated from the majority of patients with ESRD did not show this anti-inflammatory property; many HDL samples even promoted the production of inflammatory cytokines. To investigate this difference, we used shotgun proteomics to identify 49 HDL-associated proteins in a uremia-specific pattern. Proteins enriched in HDL from patients with ESRD (ESRD-HDL) included surfactant protein B (SP-B), apolipoprotein C-II, serum amyloid A (SAA), and α-1-microglobulin/bikunin precursor. In addition, we detected some ESRD-enriched proteins in earlier stages of CKD. We did not detect a difference in oxidation status between HDL isolated from uremic and healthy patients. Regarding function of these uremia-specific proteins, only SAA mimicked ESRD-HDL by promoting inflammatory cytokine production. Furthermore, SAA levels in ESRD-HDL inversely correlated with its anti-inflammatory potency. In conclusion, HDL has anti-inflammatory activities that are defective in uremic patients as a result of specific changes in its molecular composition. These data suggest a potential link between the high levels of inflammation and cardiovascular mortality in uremia.
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Affiliation(s)
- Thomas Weichhart
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Austria.
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Abstract
BACKGROUND Low levels of plasma high-density lipoprotein (HDL) represent a major cardiovascular risk factor and therefore raising HDL has been proposed to positively affect patients with atherosclerotic heart disease. However, the current evidence that raising HDL per se will reduce atherosclerosis and thereby cardiovascular events still remains controversial. AIMS In this review, we discuss the diverse anti-atherogenic and anti-inflammatory properties of HDL in the light of recent findings indicating that the quality rather than the mere quantity of HDL determines its beneficial effects against atherosclerosis. More specifically, we will focus on the conspicuous anti-inflammatory properties of HDL as this might contribute to the overall beneficial effects of HDL in diseased patients such as modulation of costimulatory/adhesion molecule expression, cytokine production and inhibition of the prototypical proinflammatory transcription factor NF-κB. RESULTS A range of clinical disorders share permanent inflammation as a characteristic hallmark including coronary artery disease, chronic kidney disease, diabetes mellitus or rheumatoid arthritis and also display distinct qualitative changes in the HDL compartment. Loss of anti-inflammatory functions of HDL is emerging as an important risk factor for disease progression and survival in these clinical entities. CONCLUSIONS It will be important to define the anti-inflammatory effects of HDL at the molecular level and to dissect the manifold functional implications to develop both novel functional assays that enable meaningful outcome studies and foster new therapeutic concepts in patients with altered HDL function.
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Affiliation(s)
- Marcus D Säemann
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University Vienna, Währinger Gürtel, Vienna, Austria.
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Haidinger M, Werzowa J, Voigt HC, Pleiner J, Stemer G, Hecking M, Döller D, Hörl WH, Weichhart T, Säemann MD. A randomized, placebo-controlled, double-blind, prospective trial to evaluate the effect of vildagliptin in new-onset diabetes mellitus after kidney transplantation. Trials 2010; 11:91. [PMID: 20925938 PMCID: PMC2984585 DOI: 10.1186/1745-6215-11-91] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 10/06/2010] [Indexed: 11/18/2022] Open
Abstract
Background New-onset diabetes mellitus after transplantation (NODAT), a frequent and serious complication after transplantation, is associated with decreased graft and patient survival. Currently, it is diagnosed and treated primarily according to existing guidelines for type II diabetes. To date, only a few trials have studied antidiabetic drugs in patients with NODAT. Vildagliptin is a novel dipeptidyl peptidase-4 (DPP-4) inhibitor that improves pancreatic islet function by enhancing both α- and β-cell responsiveness to increased blood glucose. Experimental data show potential protective effects of DPP-4 inhibitors on islet function after exogenous stress stimuli including immunosuppressants. Therefore, the therapy of NODAT with this class of compounds seems attractive. At present, vildagliptin is used to treat type II diabetes as monotherapy or in combination with other antidiabetic drugs, since that it efficiently decreases glycated hemoglobin (HbA1c) values. Additionally, vildagliptin has been shown to be safe in patients with moderately impaired kidney function. This study will evaluate the safety and efficacy of vildagliptin monotherapy in renal transplant recipients with recently diagnosed NODAT. Methods/Design This study is a randomized, placebo-controlled, double-blind, prospective phase II trial. Using the results of routinely performed oral glucose tolerance tests (OGTT) in stable renal transplant patients at our center, we will recruit patients without a history of diabetes and a 2 h glucose value surpassing 200 mg/dl (11.1 mmol/l). They are randomized to receive either 50 mg vildagliptin or placebo once daily. A total of 32 patients with newly diagnosed NODAT will be included. The primary endpoint is the difference in the 2 h glucose value between baseline and the repeated OGTT performed 3 months after treatment start, compared between the vildagliptin- and the placebo-group. Secondary endpoints include changes in HbA1c and fasting plasma glucose (FPG). The safety of vildagliptin in renal transplant patients will be assessed by the number of symptomatic hypoglycemic episodes (glucose <72 mg/dl or 4 mmol/l), the number of adverse events, and possible medication-associated side-effects. Discussion NODAT is a severe complication after kidney transplantation. Few trials have assessed the safety and efficacy of antidiabetic drugs for these patients. The purpose of this study is to assess the safety and efficacy of vildagliptin in renal transplant patients with NODAT. Trial Registration ClinicalTrials.gov NCT00980356
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Affiliation(s)
- Michael Haidinger
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Austria
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Haidinger M, Poglitsch M, Geyeregger R, Kasturi S, Zeyda M, Zlabinger GJ, Pulendran B, Hörl WH, Säemann MD, Weichhart T. A versatile role of mammalian target of rapamycin in human dendritic cell function and differentiation. J Immunol 2010; 185:3919-31. [PMID: 20805416 DOI: 10.4049/jimmunol.1000296] [Citation(s) in RCA: 172] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The mammalian target of rapamycin (mTOR) regulates cell growth and survival and exists as rapamycin-sensitive mTOR complex (mTORC) 1 and as rapamycin-insensitive mTORC2. Although mTOR is a well-known regulator of diverse immune cells, its detailed role in human dendritic cell (DC) function and differentiation is only incompletely understood. In this study, we demonstrate divergent roles of mTOR during activation and differentiation of myeloid DCs (mDCs) and monocyte-derived DCs (moDCs). Inhibition of mTORC1 in mDCs activated with TLR-dependent or -independent stimuli increased proinflammatory cytokines and NF-κB, whereas IL-10 and STAT3 were blocked. Rapamycin regulated the costimulatory/surface molecules CD86, programmed death ligand-1, and CD25 on mDCs and significantly increased the T cell allostimulatory potential of mDCs. In contrast, rapamycin suppressed immunostimulatory molecules and the allostimulatory potential of LPS-stimulated moDCs by an inability to augment NF-κB signaling. In differentiating moDCs, the PI3K/Akt-dependent mTOR pathway was constitutively activated by GM-CSF to induce DC differentiation in an mTORC1-dependent manner. Inhibition of mTORC1 or mTORC1/2 during moDC differentiation decreased moDC survival and markedly hampered its immunostimulatory phenotype. Analyzing the fate of DCs in vivo, we found that kidney transplant patients treated with rapamycin displayed an increased immunostimulatory potential of mDCs compared with patients treated with calcineurin inhibitors. Furthermore, rapamycin did not interfere with mDC differentiation in these patients. Collectively, mTOR exerts divergent immunoregulatory functions during DC activation and differentiation depending on the DC type that lead to opposing T cell responses, which might be of clinical importance in transplantation, cancer, and also for novel vaccination strategies.
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Affiliation(s)
- Michael Haidinger
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Ritter M, Bolz M, Haidinger M, Deák G, Sacu S, Säemann M, Schmidt-Erfurth U. Functional and morphological macular abnormalities in membranoproliferative glomerulonephritis type II. Br J Ophthalmol 2010; 94:1112-4. [PMID: 20679091 DOI: 10.1136/bjo.2009.159475] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Haidinger M, Hecking M, Weichhart T, Poglitsch M, Enkner W, Vonbank K, Prayer D, Geusau A, Oberbauer R, Zlabinger GJ, Soleiman A, Hörl WH, Säemann MD. Sirolimus in renal transplant recipients with tuberous sclerosis complex: clinical effectiveness and implications for innate immunity. Transpl Int 2010; 23:777-85. [DOI: 10.1111/j.1432-2277.2009.01041.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Säemann MD, Haidinger M, Hecking M, Hörl WH, Weichhart T. The multifunctional role of mTOR in innate immunity: implications for transplant immunity. Am J Transplant 2009; 9:2655-61. [PMID: 19788500 DOI: 10.1111/j.1600-6143.2009.02832.x] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The mammalian target of rapamycin (mTOR) is an evolutionary conserved serine-threonine kinase that senses various environmental stimuli in most cells primarily to control cell growth. Restriction of cellular proliferation by mTOR inhibition led to the use of mTOR inhibitors as immunosuppressants in allogeneic transplantation as well as novel anticancer agents. However, distinct inflammatory side effects such as fever, pneumonitis, glomerulonephritis or anemia of chronic disease have been observed under this treatment regime. Apart from the mere cell-cycle regulatory effect of mTOR in dividing cells, recent data revealed a master regulatory role of mTOR in the innate immune system. Hence, inhibition of mTOR promotes proinflammatory cytokines such as IL-12 and IL-1beta, inhibits the anti-inflammatory cytokine IL-10 and boosts MHC antigen presentation via autophagy in monocytes/macrophages and dendritic cells. Moreover, mTOR regulates type I interferon production and the expression of chemokine receptors and costimulatory molecules. These results place mTOR in a complex immunoregulatory context by controlling innate and adaptive immune responses. In this review, we discuss the clinical consequences of mTOR-inhibitor therapy and aim to integrate this recent data into our current view of the molecular mechanisms of clinically employed mTOR inhibitors and discuss their relevance with special emphasis to transplantation.
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Affiliation(s)
- M D Säemann
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University Vienna, Vienna, Austria.
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Haidinger M, Schmaldienst S, Körmöczi G, Regele H, Soleiman A, Schwartz D, Derfler K, Steininger R, Mühlbacher F, Böhmig GA. Vienna experience of ABO-incompatible living-donor kidney transplantation. Wien Klin Wochenschr 2009; 121:247-55. [DOI: 10.1007/s00508-009-1161-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Accepted: 01/30/2009] [Indexed: 12/29/2022]
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Haidinger M, Hecking M, Memarsadeghi M, Weichhart T, Werzowa J, Hörl W, Säemann M. Late onsetPneumocystispneumonia in renal transplantation after long-term immunosuppression with belatacept. Transpl Infect Dis 2009; 11:171-4. [DOI: 10.1111/j.1399-3062.2009.00366.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Wahrmann M, Haidinger M, Drach J, Geyeregger R, Kikić Z, Raab R, Säemann MD, Böhmig GA. Proteasome inhibition for recipient desensitization? A report of two sensitized kidney transplant candidates subjected to bortezomib treatment. Clin Transpl 2009:415-420. [PMID: 20524307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The proteasome inhibitor bortezomib was recently shown to effectively downregulate donor-specific humoral alloimmunity in rejecting kidney transplant recipients. The anti-humoral efficiency of proteasome inhibition in wait-listed non-immunosuppressed high risk patients is less well established. This pilot study, which included two pre-sensitized hemodialysis patients, was designed to get first insights into the impact of bortezomib treatment on allosensitization. Treatment consistent in two subsequent cycles of bortezomib. In an effort to increase responsiveness to treatment the second cycle was combined with dexamethasone. During a half-year follow-up, levels of CDC-PRA reactivity slightly decreased (patient 1: 87% to 80%, patient 2: 35% to 13%). However, proportions and MFI levels of detected Luminex SA reactivities (patient 1: N = 74; patient 2: N = 22) were not affected in a meaningful way. In parallel, bortezbmib treatment had no considerable effect on total immunoglobulin and kappa/lambda light chain levels. Our data suggest that, in absence of basal immunosuppression or rejection therapy, bortezomib may not or only modestly affect levels of humoral allosensitization. Future studies will have to clarify if additional anti-humoral measures or intensified treatment enhance the efficiency of proteasome inhibition as a desensitization strategy in advance of transplantation.
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Affiliation(s)
- Markus Wahrmann
- Division of Nephrology and Dialysis, Department of Medicine II, Medical University of Vienna, Vienna, Austria
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Abstract
Mucosal tissues such as the gastrointestinal tract are typically exposed to a tremendous number of microorganisms and many of them are potentially dangerous to the host. In contrast, the urogenital tract is rather infrequently colonized with bacterial organisms and also devoid of physical barriers as a multi-layered mucus or ciliated epithelia, thereby necessitating separate host defence mechanisms. Recurrent urinary tract infection (UTI) represents the successful case of microbial host evasion and poses a major medical and economic health problem. During recent years considerable advances have been made in our understanding of the mechanisms underlying the immune homeostasis of the urogenital tract. Hence, the system of pathogen-recognition receptors including the Toll-like receptors (TLRs) is able to sense danger signalling and thus activate the host immune system of the genitourinary tract. Additionally, various soluble antimicrobial molecules including iron-sequestering proteins, defensins, cathelicidin and Tamm-Horsfall protein (THP), as well as their role for the prevention of UTI by modulating innate and adaptive immunity, have been more clearly defined. Furthermore, signalling mediators like cyclic adenosine monophosphate (cAMP) or the circulatory hormone vasopressin were shown to be involved in the defence of uropathogenic microbes and maintenance of mucosal integrity. Beyond this, specific receptors e.g. CD46 or beta1/beta 3-integrins, have been elucidated that are hijacked by uropathogenic E. coli to enable invasion and survival within the urogenital system paving the way for chronic forms of urinary tract infection. Collectively, the majority of these findings offer novel avenues for basic and translational research implying effective therapies against the diverse forms of acute and chronic UTI.
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Affiliation(s)
- T Weichhart
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria
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Haidinger M, Geyeregger R, Poglitsch M, Weichhart T, Zeyda M, Vodenik B, Stulnig TM, Böhmig GA, Hörl WH, Säemann MD. Antithymocyte globulin impairs T-cell/antigen-presenting cell interaction: disruption of immunological synapse and conjugate formation. Transplantation 2007; 84:117-21. [PMID: 17627247 DOI: 10.1097/01.tp.0000266677.45428.80] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Antithymocyte globulin (ATG) is employed for the treatment and prevention of acute organ rejection after transplantation. However, the mechanisms underlying its immunomodulatory capacities beyond cellular depletion remains ill defined. A stable interaction between T-cells and professional antigen-presenting cells (APC) and full T-cell stimulation requires a complex molecular rearrangement at the T-cell/APC interface, the so called immunological synapse. Here we investigated, whether ATG affects T-cell/APC interactions. ATG concentration and time-dependently inhibited relocalization of the T-cell receptor/CD3 complex as well as adhesion molecules and cytoskeletal proteins of human peripheral blood T-cells and a human T-cell line towards the APC contact site. Moreover, ATG-treated peripheral blood T-cells were incapable to form conjugates with APCs. In conclusion, ATG impairs T-cell/APC conjugate formation, a mechanism that may help to understand the functional inactivation of peripheral blood T-cells that have escaped cellular depletion after ATG treatment.
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Affiliation(s)
- Michael Haidinger
- Clinical Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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Kirsch BM, Haidinger M, Zeyda M, Böhmig GA, Tombinsky J, Mühlbacher F, Watschinger B, Hörl WH, Säemann MD. Alemtuzumab (Campath-1H) induction therapy and dendritic cells: Impact on peripheral dendritic cell repertoire in renal allograft recipients. Transpl Immunol 2006; 16:254-7. [PMID: 17138063 DOI: 10.1016/j.trim.2006.09.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 08/10/2006] [Accepted: 09/08/2006] [Indexed: 11/18/2022]
Abstract
Dendritic cells (DC) are the most potent antigen-presenting cells (APC) and are pivotal for initiating allograft immunity. Recently, particular DC subsets have been implicated also in allogeneic T cell hyporesponsiveness. Alemtuzumab (anti-CD52, Campath-1H) is a novel T cell depleting antibody that is currently under investigation for the use in allogeneic organ transplantation. While recent studies demonstrated a conspicuous effect of alemtuzumab on peripheral DC in clinical graft-versus-host disease, its efficiency in patients receiving allogeneic organ transplants is still undefined. In the present study we assessed the peripheral DC repertoire in kidney transplant recipients after either alemtuzumab induction therapy followed by FK506 monotherapy or after conventional immunosuppression (FK506, mycophenolate mofetil and steroids) without any induction agent. Induction with alemtuzumab caused a strong and sustained reduction of the total number of peripheral DC and a significant shift from myeloid to plasmacytoid DC subsets (mDC/pDC ratio) as early as 1 month post-transplantation. These data show that alemtuzumab induction targets the peripheral DC repertoire, which might add another mechanism allowing immunosuppressive drug minimization. Further studies are warranted to further elucidate the functional significance of these finding in the setting of allogeneic organ transplantation.
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Affiliation(s)
- Bernhard M Kirsch
- Department of Medicine III, Clinical Division of Nephrology and Dialysis, Medical University of Vienna, Austria
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Neumann I, Haidinger M, Jäger H, Grützmacher H, Griesmacher A, Müller MM, Bayer PM, Meisl FT. Pharmacokinetics of mycophenolate mofetil in patients with autoimmune diseases compared renal transplant recipients. J Am Soc Nephrol 2003; 14:721-7. [PMID: 12595508 DOI: 10.1097/01.asn.0000051598.12824.da] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Mycophenolate mofetil (MMF), being effectively used as immunosuppressant in transplant medicine, has recently attracted interest as therapeutic agent for autoimmune diseases (AID). For these patients, no pharmacokinetic (PK) data are available. This study is an investigation of single-dose concentration-time profiles of 1 g off MMF in 16 patients with AID, including 10 patients with ANCA-associated vasculitis and 6 patients with systemic lupus erythematosus, and compares them with profiles of 16 renal transplant recipients (RTX). Mycophenolic acid (MPA) blood levels were measured by both HPLC and EMIT, and MPA-glucuronide was determined by HPLC. In AID, mean MPA concentrations at 12 h were significantly higher compared with RTX (4.1 +/- 3.27 versus 1.8 +/- 1.15 mg/L; P = 0.018), whereas peak concentrations were lower (P = 0.017). However, mean MPA-AUC at 12 h as well as at 24 h were comparable between both groups. In contrast to RTX, there was an association in AID between MPA trough levels at 12 h and at 24 h with AUC(0-12) (P < 0.05 and P < 0.01). MPA trough concentrations at 24 h provided an estimation of AUC(0-24 h) in both patient groups (P < 0.001 and P < 0.01; AID and RTX, respectively). Compared with RTX, MPA-PK seems to be less affected in AID by renal function. Inter-individual variability of PK parameters was high in both groups. These data indicate that there are differences of MPA-PK between RTX and AID. The use of therapeutic drug monitoring in patients with AID appears to be clinically practicable and may be valuable to optimize individual immunosuppressive therapy.
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Affiliation(s)
- Irmgard Neumann
- Department of Nephrology, Wilhelminenspital, Vienna, Austria.
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