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von Samson-Himmelstjerna FA, Kakavand N, Gleske C, Schraml F, Basta AA, Braunisch MC, Bräsen JH, Schmitz J, Kraus D, Weinmann-Menke J, Zacharias HU, Vaulet T, Naesens M, Krautter M, Schwenger V, Esser G, Kolbrink B, Amann K, Holzmann-Littig C, Echterdiek F, Kunzendorf U, Renders L, Schulte K, Heemann U. Potential and Uncertainties of RejectClass in Acute Kidney Graft Dysfunction: An Independent Validation Study. Transplantation 2024; 108:1228-1238. [PMID: 38196094 DOI: 10.1097/tp.0000000000004906] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Kidney graft rejections are classified based on the Banff classification. The RejectClass algorithm, initially derived from a cohort comprising mostly protocol biopsies, identifies data-driven phenotypes of acute rejection and chronic pathology using Banff lesion scores. It also provides composite scores for inflammation activity and chronicity. This study independently evaluates the performance of RejectClass in a cohort consisting entirely of indication biopsies. METHODS We retrospectively applied RejectClass to 441 patients from the German TRABIO (TRAnsplant BIOpsies) cohort who had received indication biopsies. The primary endpoint was death-censored graft failure during 2 y of follow-up. RESULTS The application of RejectClass to our cohort demonstrated moderately comparable phenotypic features with the derivation cohort, and most clusters indicated an elevated risk of graft loss. However, the reproduction of all phenotypes and the associated risks of graft failure, as depicted in the original studies, was not fully accomplished. In contrast, adjusted Cox proportional hazards analyses substantiated that both the inflammation score and the chronicity score are independently associated with graft loss, exhibiting hazard ratios of 1.7 (95% confidence interval, 1.2-2.3; P = 0.002) and 2.2 (95% confidence interval, 1.8-2.6; P < 0.001), respectively, per 0.25-point increment (scale: 0.0-1.0). CONCLUSIONS The composite inflammation and chronicity scores may already have direct utility in quantitatively assessing the disease stage. Further refinement and validation of RejectClass clusters are necessary to achieve more reliable and accurate phenotyping of rejection.
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Affiliation(s)
| | - Nassim Kakavand
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Charlotte Gleske
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Florian Schraml
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Agathe A Basta
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jan H Bräsen
- Nephropathology Unit, Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Jessica Schmitz
- Nephropathology Unit, Department of Pathology, Hannover Medical School, Hannover, Germany
| | - Daniel Kraus
- Department of Nephrology, Department of Internal Medicine 1, University Medical Center Mainz, Mainz, Germany
| | - Julia Weinmann-Menke
- Department of Nephrology, Department of Internal Medicine 1, University Medical Center Mainz, Mainz, Germany
| | - Helena U Zacharias
- Peter L. Reichertz Institute for Medical Informatics of TU Braunschweig and Hannover Medical School, Hannover, Germany
| | - Thibaut Vaulet
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Naesens
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Markus Krautter
- Department of Nephrology, Transplant Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Vedat Schwenger
- Department of Nephrology, Transplant Center, Klinikum Stuttgart, Stuttgart, Germany
| | - Grit Esser
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Christopher Holzmann-Littig
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Fabian Echterdiek
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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Kolbrink B, Schüssel K, von Samson-Himmelstjerna FA, Esser G, Floege J, Kunzendorf U, Schulte K. Patient-focused outcomes after initiation of dialysis for ESRD: mortality, hospitalization and functional impairment. Nephrol Dial Transplant 2023; 38:2528-2536. [PMID: 37202223 PMCID: PMC10615626 DOI: 10.1093/ndt/gfad099] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Outcome data regarding clinically relevant endpoints after starting dialysis for end-stage renal disease (ESRD) are sparse, and early events after starting dialysis are particularly underestimated. The aim of this study was to describe patient-focused outcomes in ESRD patients starting from first dialysis. METHODS The data basis for this retrospective observational study were anonymized healthcare data from Germany's largest statutory health insurer. We identified ESRD patients who initiated dialysis in 2017. Deaths, hospitalizations and occurrence of functional impairment within 4 years after starting dialysis were recorded starting from first treatment. Hazard ratios in dialysis patients compared with an age- and sex-matched reference population without dialysis were generated, stratified by age. RESULTS The dialysis cohort included 10 328 ESRD patients who started dialysis in 2017. First dialysis was performed in-hospital for 7324 patients (70.9%), and 865 of these died during the same hospitalization. One-year mortality for ESRD patients initiating dialysis was 33.8%. Functional impairment occurred in 27.1% of patients, while 82.8% of patients required hospitalization within 1 year. Hazard ratios of dialysis patients compared with the reference population for mortality, functional impairment and hospitalization at 1-year were 8.6, 4.3 and 6.2. Dialysis patients <50 years were disproportionately affected, with >40-fold increased risk of adverse events compared with their peers. CONCLUSIONS The emergence of morbidity and mortality after starting dialysis for ESRD is significant, especially in younger patients. Patients have a right to be informed about the prognosis associated with their condition.
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Affiliation(s)
- Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
| | | | | | - Grit Esser
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
| | - Jürgen Floege
- Division of Nephrology and Immunology, Rheinisch Westfälische Technische Hochschule University of Aachen, Aachen, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein Campus Kiel, Christian-Albrechts-University, Kiel, Germany
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von Samson-Himmelstjerna FA, Messtorff ML, Kakavand N, Eisenberger U, Korth J, Lange U, Kolbrink B, Aldag L, Schulze Dieckhoff T, Feldkamp T, Kunzendorf U, Harth A, Schulte K. The Tacrolimus Concentration/Dose Ratio Does Not Predict Early Complications After Kidney Transplantation. Transpl Int 2023; 36:11027. [PMID: 37229240 PMCID: PMC10203205 DOI: 10.3389/ti.2023.11027] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/21/2023] [Indexed: 05/27/2023]
Abstract
Early-on post kidney transplantation, there is a high risk of graft rejection and opportunistic viral infections. A low tacrolimus concentration/dose (C/D) ratio as a surrogate marker of fast tacrolimus metabolism has been established for risk stratification 3 months post-transplantation (M3). However, many adverse events occurring earlier might be missed, and stratification at 1 month post-transplantation (M1) has not been investigated. We retrospectively analyzed case data from 589 patients who had undergone kidney transplantation between 2011 and 2021 at three German transplant centers. Tacrolimus metabolism was estimated by use of the C/D ratio at M1, M3, M6, and M12. C/D ratios increased substantially during the year, particularly between M1 and M3. Many viral infections and most graft rejections occurred before M3. Neither at M1 nor at M3 was a low C/D ratio associated with susceptibility to BKV viremia or BKV nephritis. A low C/D ratio at M1 could not predict acute graft rejections or impaired kidney function, whereas at M3 it was significantly associated with subsequent rejections and impairment of kidney function. In summary, most rejections occur before M3, but a low C/D ratio at M1 does not identify patients at risk, limiting the predictive utility of this stratification approach.
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Affiliation(s)
| | - Maja Lucia Messtorff
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Nassim Kakavand
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Ute Eisenberger
- Department of Nephrology, Essen University Hospital, Essen, Germany
| | - Johannes Korth
- Department of Nephrology, Essen University Hospital, Essen, Germany
| | - Ulrich Lange
- Department of Nephrology, Krankenhaus Köln-Merheim, Klinikum der Universität Witten/Herdecke, Cologne, Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Leon Aldag
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Tobias Schulze Dieckhoff
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Ana Harth
- Department of Nephrology, Krankenhaus Köln-Merheim, Klinikum der Universität Witten/Herdecke, Cologne, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
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Kuron D, Voran JC, von Samson‐Himmelstjerna FA, Baldus C, Kunzendorf U, Schulte K, Kolbrink B. Epidemiology of haemophagocytic lymphohistiocytosis at the population level in Germany. Br J Haematol 2022; 201:285-289. [PMID: 36535304 DOI: 10.1111/bjh.18617] [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] [Received: 09/28/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
We retrospectively analysed all German inpatient cases of haemophagocytic lymphohistiocytosis (HLH) from 2014 to 2020 to describe the epidemiology, clinical course, and underlying diseases of 4065 HLH patients. The age-standardized incidence rate of HLH in Germany was 0.52/100 000 people in 2014 and steadily increased by 10% per year to 0.97/100 000 in 2020 (mean 0.70/100 000). Inpatient deaths related to HLH increased from 0.84/1 000 000 people in 2014 to 2.32/1 000 000 people in 2020, caused by rising numbers of older HLH patients. Overall, HLH is more frequent than previously expected and incidence as well as HLH-related deaths increased significantly.
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Affiliation(s)
- David Kuron
- Department of Medicine II, Hematology and Oncology University Hospital Schleswig‐Holstein, Christian‐Albrechts‐University Kiel Germany
| | - Jakob Christoph Voran
- Department of Medicine III, Cardiology University Hospital Schleswig‐Holstein, Christian‐Albrechts‐University Kiel Germany
| | | | - Claudia Baldus
- Department of Medicine II, Hematology and Oncology University Hospital Schleswig‐Holstein, Christian‐Albrechts‐University Kiel Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension University Hospital Schleswig‐Holstein, Christian‐Albrechts‐University Kiel Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension University Hospital Schleswig‐Holstein, Christian‐Albrechts‐University Kiel Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension University Hospital Schleswig‐Holstein, Christian‐Albrechts‐University Kiel Germany
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Pfenning MB, Schmitz J, Scheffner I, Schulte K, Khalifa A, Tezval H, Weidemann A, Kulschewski A, Kunzendorf U, Dietrich S, Haller H, Kielstein JT, Gwinner W, Bräsen JH. High Macrophage Densities in Native Kidney Biopsies Correlate With Renal Dysfunction and Promote ESRD. Kidney Int Rep 2022; 8:341-356. [PMID: 36815108 PMCID: PMC9939427 DOI: 10.1016/j.ekir.2022.11.015] [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: 11/01/2022] [Accepted: 11/21/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Macrophages and monocytes are main players in innate immunity. The relevance of mononuclear phagocyte infiltrates on clinical outcomes remains to be determined in native kidney diseases. Methods Our cross-sectional study included 324 patients with diagnostic renal biopsies comprising 17 disease entities and normal renal tissues for comparison. All samples were stained for CD68+ macrophages. Selected groups were further subtyped for CD14+ monocytes and CD163+ alternatively activated macrophages. Using precise pixel-based digital measurements, we quantified cell densities as positively stained areas in renal cortex and medulla as well as whole renal tissue. Laboratory and clinical data of all cases at the time of biopsy and additional follow-up data in 158 cases were accessible. Results Biopsies with renal disease consistently revealed higher CD68+-macrophage densities and CD163+-macrophage densities in cortex and medulla compared to controls. High macrophage densities correlated with impaired renal function at biopsy and at follow-up in all diseases and in diseases analyzed separately. High cortical CD68+-macrophage densities preceded shorter renal survival, defined as requirement of permanent dialysis. CD14+ monocyte densities showed no difference compared to controls and did not correlate with renal function. Conclusion Precise quantification of macrophage densities in renal biopsies may contribute to risk stratification to identify patients with high risk for end-stage renal disease (ESRD) and might be a promising therapeutic target in renal disease.
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Affiliation(s)
- Maren B. Pfenning
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Lower Saxony, Germany,Medical Department I, Gastroenterology, Hepatology and Nephrology, Clinics Passau, Passau, Bavaria, Germany
| | - Jessica Schmitz
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Irina Scheffner
- Clinic for Kidney and Hypertension Diseases, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Kevin Schulte
- Clinic for Nephrology and Hypertension, Christian-Albrechts-University, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Abedalrazag Khalifa
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Hossein Tezval
- Department of Urology and Urological Oncology, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Alexander Weidemann
- Medical Clinic III – Nephrology and Dialysis, St. Vinzenz Hospital, Paderborn, North Rhine-Westphalia, Germany
| | - Anke Kulschewski
- Clinic for Nephrology and Hypertension, University Hospital Oldenburg, Oldenburg, Lower Saxony, Germany
| | - Ulrich Kunzendorf
- Clinic for Nephrology and Hypertension, Christian-Albrechts-University, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Sebastian Dietrich
- Clinic for Nephrology and Hypertension, Christian-Albrechts-University, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Hermann Haller
- Clinic for Kidney and Hypertension Diseases, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Jan T. Kielstein
- Medical Clinic V, Nephrology, Rheumatology and Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Lower Saxony, Germany
| | - Wilfried Gwinner
- Clinic for Kidney and Hypertension Diseases, Hannover Medical School, Hannover, Lower Saxony, Germany
| | - Jan H. Bräsen
- Nephropathology Unit, Institute of Pathology, Hannover Medical School, Hannover, Lower Saxony, Germany,Correspondence: Jan Hinrich Bräsen, Nephropathology Unit, Institute of Pathology, Hannover Medical School, OE 5110, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.
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Kolbrink B, von Samson-Himmelstjerna FA, Messtorff ML, Riebeling T, Nische R, Schmitz J, Bräsen JH, Kunzendorf U, Krautwald S. Vitamin K1 inhibits ferroptosis and counteracts a detrimental effect of phenprocoumon in experimental acute kidney injury. Cell Mol Life Sci 2022; 79:387. [PMID: 35763128 PMCID: PMC9239973 DOI: 10.1007/s00018-022-04416-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/04/2022] [Revised: 05/30/2022] [Accepted: 06/02/2022] [Indexed: 02/07/2023]
Abstract
Ferroptosis, a type of iron-dependent programmed cell death distinct from apoptosis, necroptosis, and other types of cell death, is characterized by lipid peroxidation, reactive oxygen species production, and mitochondrial dysfunction. Accumulating evidence has highlighted vital roles for ferroptosis in multiple diseases, including acute kidney injury. Therefore, ferroptosis has become a major focus for translational research. However, despite its involvement in pathological conditions, there are no pharmacologic inhibitors of ferroptosis in clinical use. In the context of drug repurposing, a strategy for identifying new uses for approved drugs outside the original medical application, we discovered that vitamin K1 is an efficient inhibitor of ferroptosis. Our findings are strengthened by the fact that the vitamin K antagonist phenprocoumon significantly exacerbated ferroptotic cell death in vitro and also massively worsened the course of acute kidney injury in vivo, which is of utmost clinical importance. We therefore assign vitamin K1 a novel role in preventing ferroptotic cell death in acute tubular necrosis during acute kidney injury. Since the safety, tolerability, pharmacokinetics, and pharmacodynamics of vitamin K1 formulations are well documented, this drug is primed for clinical application, and provides a new strategy for pharmacological control of ferroptosis and diseases associated with this mode of cell death.
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Affiliation(s)
- Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Fleckenstr. 4, 24105, Kiel, Germany
| | | | - Maja Lucia Messtorff
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Fleckenstr. 4, 24105, Kiel, Germany
| | - Theresa Riebeling
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Fleckenstr. 4, 24105, Kiel, Germany
| | - Raphael Nische
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Fleckenstr. 4, 24105, Kiel, Germany
| | - Jessica Schmitz
- Nephropathology Unit, Institute of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Jan Hinrich Bräsen
- Nephropathology Unit, Institute of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Fleckenstr. 4, 24105, Kiel, Germany
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Fleckenstr. 4, 24105, Kiel, Germany.
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von Samson-Himmelstjerna FA, Esser G, Schulte K, Kolbrink B, Krautter M, Schwenger V, Weinmann-Menke J, Matschkal J, Schraml F, Pahl A, Braunisch M, Amann K, Feldkamp T, Kunzendorf U, Renders L, Heemann U. Study protocol: the TRAnsplant BIOpsies (TRABIO) study - a prospective, observational, multicentre cohort study to assess the treatment of kidney graft rejections. BMJ Open 2022; 12:e048122. [PMID: 35450886 PMCID: PMC9024278 DOI: 10.1136/bmjopen-2020-048122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Despite continued efforts, long-term outcomes of kidney transplantation remain unsatisfactory. Kidney graft rejections are independent risk factors for graft failure. At the participating centres of the TRAnsplant BIOpsies study group, a common therapeutic standard has previously been defined for the treatment of graft rejections. The outcomes of this strategy will be assessed in a prospective, observational cohort study. METHODS AND ANALYSIS A total of 800 kidney transplantation patients will be enrolled who undergo a graft biopsy because of deteriorating kidney function. Patients will be stratified according to the Banff classification, and the influence of the treatment strategy on end points will be assessed using regression analysis. Primary end points will be all-cause mortality and graft survival. Secondary end points will be worsening of kidney function (≥30% decline of estimated Glomerular Filtration Rate [eGFR] or new-onset large proteinuria), recurrence of graft rejection and treatment response. Baseline data and detailed histopathology data will be entered into an electronic database on enrolment. During a first follow-up period (within 14 days) and subsequent yearly follow-ups (for 5 years), treatment strategies and clinical course will be recorded. Recruitment at the four participating centres started in September 2016. As of August 2020, 495 patients have been included. ETHICS AND DISSEMINATION Ethical approval for the study has been obtained from the ethics committee of Kiel (AZ B 278/16) and was confirmed by the committees of Munich, Mainz and Stuttgart. The results will be reported in a peer-reviewed journal, according to the Strengthening the Reporting of Observational Studies in Epidemiology criteria. TRIAL REGISTRATION NUMBER ISRCTN78772632; Pre-results.
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Affiliation(s)
| | - Grit Esser
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Kevin Schulte
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Benedikt Kolbrink
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Markus Krautter
- Transplant Center, Department of Nephrology, Klinikum Stuttgart, Stuttgart, Germany
| | - Vedat Schwenger
- Transplant Center, Department of Nephrology, Klinikum Stuttgart, Stuttgart, Germany
| | - Julia Weinmann-Menke
- Department of Nephrology, University Medical Center Mainz, Department of Internal Medicine I, Mainz, Germany
| | - Julia Matschkal
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Florian Schraml
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Anne Pahl
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Matthias Braunisch
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Kerstin Amann
- Department of Nephropathology, University Hospital Erlangen, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Thorsten Feldkamp
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology & Hypertension, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - Lutz Renders
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
| | - Uwe Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, München, Germany
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Pfenning MB, Schmitz J, Schulte K, Hafer C, Khalifa AA, Kulschewski A, Feldkamp T, Kielstein JT, Gwinner W, Kunzendorf U, Dietrich S, Bräsen JH. MO444MACROPHAGE DENSITIES CORRELATE WITH LONG-TERM FUNCTION IN PAUCI-IMMUNE AND MEMBRANOUS GLOMERULONEPHRITIS AS WELL AS IN HYPERTENSIVE NEPHROPATHY. Nephrol Dial Transplant 2021. [DOI: 10.1093/ndt/gfab090.006] [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: 11/14/2022] Open
Abstract
Abstract
Background and Aims
Macrophages and monocytes are main players in innate immunity. In renal diseases, their role is poorly understood. Our multicentric cross-sectional study aimed to study the prevalence of macrophages and monocytes in various human native kidney diseases. For this, we used precise pixel-based digital quantification of their densities in renal biopsies and correlated our findings with clinical data.
Method
We included 324 patients, who underwent a diagnostic renal biopsy. Additional normal kidney samples from 16 tumour nephrectomies were used as controls. According to the diagnosed diseases, we established 17 patient groups. Biopsies were stained for CD68+-macrophages using automated immunohistochemistry (Ventana Ultra) and selected groups were further subtyped for CD14+-monocytes and CD163+-M2-macrophages (67 cases, pauci-immune glomerulonephritis (PIGN), IgA-nephropathy (IgAN) and control samples). Digitized sections (Leica) were analysed using the open-source software QuPath to quantify cell densities (positively stained areas displayed as percentages of ROI) in renal cortex, medulla and extrarenal tissue, respectively. Detailed clinical and laboratory data at timepoint of biopsy were available for all patients. Additional data for follow-up were achievable in 158 cases.
Results
Renal disease samples presented higher mean macrophage densities compared to control cases (CD68: cortex 1.2 vs. 0.2%, p<0.001, medulla 0.8 vs. 0.04%, p<0.001; CD163: cortex 3.2 vs. 0.5%, p<0.001, medulla 2.3 vs. 0.6%, p<0.05), but CD14+-density did not differ between patients and control samples. The highest cortical CD68+-density occurred in PIGN (1.98%) and in medulla in ascending infections (1.86%). The lowest cortical CD68+-densities were measured in thin basal membrane syndrome / Alport-syndrome (0.56%) and in medulla in immunotactoid and fibrillary glomerulopathy (0.26%). Chronic kidney disease displayed lower percentages of CD68+-densities (cortex: 1.15%; medulla: 0.49%) compared to acute kidney injury (cortex: 1.84%, p<0.001; medulla: 1.08%, p<0.001) and acute on chronic kidney injury (cortex: 1.81%, p<0.001; medulla: 1.43%, p<0.001). We detected a correlation of CD68+- and CD163+-infiltration with kidney function (eGFR) in cortex and medulla at the time of biopsy (CD68: r=-0.51 for cortex, r=-0.60 for medulla; CD163: r=-0.71 for cortex, r=-0.73 for medulla; p<0.001) and follow up (CD68: r=-0.41 for cortex, r=-0.34 for medulla, p<0.001; CD163: r=-0.46 for cortex, r=-0.50 for medulla, p<0.05). Older patients (>64 years) showed a higher medullary M2-infiltration (1.81% vs. 4.34%, p<0.005). The eGFR at the time of biopsy inversely correlated (p<0.05) with cortical CD68+-density in IgAN (r=-0.39), PIGN (r=-0.53), membranous glomerulonephritis (MGN; r=-0.70), focal segmental glomerulonephritis (r=-0.63), and hypertensive nephropathy (HNP; r=-0.44). At follow-up, this correlation (p<0.05) was still present in PIGN (r=-0.43), MGN (r=-0.58), and HNP (r=-0.77). In PIGN, cortical CD163+-density and eGFR were associated (p<0.001) at timepoint of biopsy (r=-0.51) and follow-up (r=-0.51). Particularly, cANCA-vasculitis showed a strong correlation between eGFR and cortical CD68+- as well as CD163+-densities at time of biopsy (CD68: r=-0.78; CD163: r=-0.75, p<0.001) and also for follow-up (CD68: r=-0.48; CD163: r=-0.68, p<0.05).
Conclusion
Macrophages may promote progression of human renal diseases, whereas monocytes do not correlate with eGFR-decline. Especially, in cANCA- vasculitis CD163+- infiltration is associated with renal outcome. Additional studies are needed to investigate, whether macrophages can serve as predictive markers or therapeutical targets in native renal diseases.
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Affiliation(s)
- Maren Bettina Pfenning
- Hannover Medical School (MHH), Nephropathology Unit, Institute of Pathology, Hannover, Germany
| | - Jessica Schmitz
- Hannover Medical School (MHH), Nephropathology Unit, Institute of Pathology, Hannover, Germany
| | - Kevin Schulte
- University Hospital Schleswig-Holstein, Christian-Albrechts-University, Department of Nephrology and Hypertension, Kiel, Germany
| | - Carsten Hafer
- Academic Teaching Hospital Braunschweig, Medical Clinic V, Nephrology, Rheumatology and Blood Purification, Braunschweig, Germany
| | | | - Anke Kulschewski
- University Hospital Oldenburg, Clinic for Nephrology and Hypertension, Oldenburg, Germany
| | - Thorsten Feldkamp
- Nephological Center of Lower Saxony, Klinikum Hann. Münden, Department of Internal Medicine and Nephrology, Kidney Transplant Center, Hann. Münden
| | - Jan T Kielstein
- Academic Teaching Hospital Braunschweig, Medical Clinic V, Nephrology, Rheumatology and Blood Purification, Braunschweig, Germany
| | - Wilfried Gwinner
- Hannover Medical School (MHH), Department of Nephrology, Hannover, Germany
| | - Ulrich Kunzendorf
- University Hospital Schleswig-Holstein, Christian-Albrechts-University, Department of Nephrology and Hypertension, Kiel, Germany
| | - Sebastian Dietrich
- University Hospital Schleswig-Holstein, Christian-Albrechts-University, Department of Nephrology and Hypertension, Kiel, Germany
| | - Jan Hinrich Bräsen
- Hannover Medical School (MHH), Nephropathology Unit, Institute of Pathology, Hannover, Germany
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9
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Riebeling T, Jamal K, Wilson R, Kolbrink B, von Samson-Himmelstjerna FA, Moerke C, Ramos Garcia L, Dahlke E, Michels F, Lühder F, Schunk D, Doldi P, Tyczynski B, Kribben A, Flüh C, Theilig F, Kunzendorf U, Meier P, Krautwald S. Primidone blocks RIPK1-driven cell death and inflammation. Cell Death Differ 2021; 28:1610-1626. [PMID: 33273695 PMCID: PMC7712602 DOI: 10.1038/s41418-020-00690-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/21/2022] Open
Abstract
The receptor-interacting serine/threonine protein kinase 1 (RIPK1) is a key mediator of regulated cell death and inflammation. Recent studies suggest that RIPK1 inhibition would fundamentally improve the therapy of RIPK1-dependent organ damage in stroke, myocardial infarction, kidney failure, and systemic inflammatory response syndrome. Additionally, it could ameliorate or prevent multi-organ failure induced by cytokine release in the context of hyperinflammation, as seen in COVID-19 patients. Therefore, we searched for a RIPK1 inhibitor and present the aromatic antiepileptic and FDA-approved drug primidone (Liskantin®) as a potent inhibitor of RIPK1 activation in vitro and in a murine model of TNFα-induced shock, which mimics the hyperinflammatory state of cytokine release syndrome. Furthermore, we detected for the first time RIPK1 activation in the respiratory tract epithelium of hospitalized patients who tested positive for SARS-CoV-2 infection. Our data provide a strong rationale for evaluating the drug primidone in conditions of hyperinflammation in humans.
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Affiliation(s)
- Theresa Riebeling
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Kunzah Jamal
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
- DDR Biology, Bioscience, Oncology R&D, AstraZeneca, Cambridge, UK
| | - Rebecca Wilson
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | | | - Caroline Moerke
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Laura Ramos Garcia
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
| | - Eileen Dahlke
- Institute of Anatomy, Christian-Albrechts-University Kiel, 24118, Kiel, Germany
| | - Friederike Michels
- Department of Neurosurgery, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Fred Lühder
- Institute for Neuroimmunology and Multiple Sclerosis Research, University Medical Center Göttingen, 37075, Göttingen, Germany
| | - Domagoj Schunk
- Department of Emergency Medicine, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Philipp Doldi
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-University Munich, 81377, Munich, Germany
| | - Bartosz Tyczynski
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147, Essen, Germany
| | - Charlotte Flüh
- Department of Neurosurgery, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Franziska Theilig
- Institute of Anatomy, Christian-Albrechts-University Kiel, 24118, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Pascal Meier
- The Breast Cancer Now Toby Robins Research Centre, The Institute of Cancer Research, Fulham Road, London, SW3 6JB, UK
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany.
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10
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Esser G, Kolbrink B, Borzikowsky C, Kunzendorf U, Feldkamp T, Schulte K. Evaluation of underidentification of potential organ donors in German hospitals. PLoS One 2020; 15:e0242724. [PMID: 33211776 PMCID: PMC7676668 DOI: 10.1371/journal.pone.0242724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 07/03/2020] [Accepted: 11/06/2020] [Indexed: 11/18/2022] Open
Abstract
Background Since 2010, the number of organ donations in Germany has decreased by one third, mostly due to undetected organ donors. It is unclear, how the undetected potential donor pool is distributed among the different German hospital categories (A = university hospital, B = hospitals with neurosurgery, C = hospitals without neurosurgery) and region types. Methods We performed a nationwide secondary data analysis of all German inpatient cases of the year 2016 (n = 20,063,689). All fatalities were regarded as potential organ donors, in which primary or secondary brain damage was encoded and organ donation was not excluded by a contraindication or a lack of ventilation therapy. Results In 2016, 28,087 potential organ donors were identified. Thereof 21% were found in category A, 28% in category B and 42% in category C hospitals. The contact rate (= organ donation related contacts/ potential organ donors) and realization rate (= realized organ donations/ potential organ donors) of category A, B and C hospitals was 10.6% and 4.6%, 10.9% and 4.8% and 6.0% and 1.7%, respectively. 58.2% of the donor potential of category C hospitals was found in the largest quartile of category C hospitals. 51% (n = 14,436) of the potential organ donors were treated in hospitals in agglomeration areas, 28% (n = 7,909) in urban areas and 21% (n = 5,742) in rural areas. The contact- and realization rate did not significantly differ between these areas. Conclusions The largest proportion of potential organ donors and the lowest realization rate are found in category C hospitals. Reporting and donation practice do not differ between urban and rural regions.
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Affiliation(s)
- Grit Esser
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Christian-Albrechts-University, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
- * E-mail:
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11
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Abstract
Necroptosis and pyroptosis are two forms of regulated cell death. They are executed by the proteins mixed-lineage kinase domain-like (MLKL) and gasdermin D (GSDMD), respectively. Once activated by numerous pathways, these proteins form membrane pores that allow the influx and efflux of various ions, proteins, and water, ultimately resulting in the death of the cell. These modalities of cell death are considered highly inflammatory because of the release of inflammatory cytokines and damage-associated molecular patterns, and are thereby not only deleterious for the dying cell itself, but also its environment or the entire organism. The relevance for these processes has been observed in various physiological and pathophysiological conditions, ranging from viral and bacterial infections over autoimmune and chronic inflammatory diseases to ischemic organ damage. In recent years, initial in vitro experiments have shed light on a range of connections between necroptosis and pyroptosis. Initial in vivo studies also indicate that, in many disease models, these two forms of cell death cannot be considered individually, as they demonstrate a complex interaction. In this article, we provide an overview of the currently known structure, pathways of activation, and functions of MLKL and GSDMD. With emerging evidence for an interconnection between necroptosis and pyroptosis in not only in vitro, but also in vivo models of disease, we highlight in particular the clinical relevance of the crosslinks between these two forms of inflammatory cell death and their implications for novel therapeutic strategies in a variety of diseases.
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Affiliation(s)
- Benedikt Kolbrink
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Theresa Riebeling
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
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12
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Schulte K, Esser G, Borzikowsky C, Kolbrink B, Kunzendorf U, Feldkamp T. Organ Donor Potential Increases Despite Rising Numbers of Decompressive Craniectomies. Dtsch Arztebl Int 2020; 117:542-543. [PMID: 33087243 DOI: 10.3238/arztebl.2020.0542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/20/2020] [Accepted: 05/07/2020] [Indexed: 11/27/2022]
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13
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Schulte K, Schierke H, Tamayo M, Hager L, Engehausen R, Raspe M, Hübner RH, Schlieper G, Borzikowsky C, Urbschat A, Auerswald S, Kunzendorf U, Feldkamp T. Strategies for Improving Influenza Vaccination Rates in Patients with Chronic Renal Disease. Dtsch Arztebl Int 2020; 116:413-419. [PMID: 31366435 DOI: 10.3238/arztebl.2019.0413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 12/15/2018] [Accepted: 04/04/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The influenza vaccination rate among older and chronically ill patients in Germany has declined in the past decade in spite of vaccination campaigns. METHODS The influenza vaccination rate among persons with chronic renal disease was studied with the aid of billing data from various Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, ASHIPs) in Germany. It was tested in a randomized controlled trial whether a written vaccination appeal, sent by physicians to patients, led to an increase in the vaccination rate. It was tested in a further such trial whether the vaccination rate among patients with renal disease could be improved by an appeal for vaccination that was sent by the ASHIPs to the treating nephrologists. Finally, it was also tested in a prospective interventional study whether the vaccination rate could be improved by an appeal for vaccination sent by a health- insurance carrier directly to the patients. RESULTS In 2012-2017, the vaccination rate among persons with chronically impaired renal function ranged from 41.1% to 46.9%; it ranged from 31.7% to 33.7% in kidney transplant recipients and from 42.7% to 44.7% in dialysis patients. An appeal for vaccination that was sent from physicians to patients raised the vaccination rate by 8.3% in the intervention group compared to the control group (p = 0.03; number needed to treat [NNT]: 13). On the other hand, an appeal for vaccination that was sent to the nephrologists lowered the vaccination rate by 0.8% in the intervention group compared to the control group. Finally, an appeal for vaccination that was sent by the health-insurance fund to the patients raised the vaccination rate by 3.2% (p<0.001; NNT: 32). CONCLUSION Fewer than half of all patients with chronic renal failure in Germany are vaccinated against influenza. The vaccination rate was found to be increased only after an appeal for vaccination that was sent directly to the patients. A letter sent to the treating physicians had no positive effect at all.
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Affiliation(s)
- Kevin Schulte
- Department of Nephrology and Hypertension. University Hospital Schleswig-Holstein; Department of Strategic Data Analysis and Health Policy North Rhine-Westphalia, North Rhine Association of Statutory Health Insurance Physicians, Düsseldorf; IKK Südwest, Saarbrücken; Medical Department, Division of Infectiology and Pneumology, Faculty of Medicine, Charite Berlin; Center for Renal, Hypertensive, and Metabolic Diseases, Hanover; Institute of Medical Informatics and Statistics, University of Kie; Division of Information Technology-Analysis and Development, Schleswig-Holstein Association of Statutory Health Insurance Physicians, Bad Segeberg; Thuringia Association of Statutory Health Insurance Physicians, Weimar
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14
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Sawitzki B, Harden PN, Reinke P, Moreau A, Hutchinson JA, Game DS, Tang Q, Guinan EC, Battaglia M, Burlingham WJ, Roberts ISD, Streitz M, Josien R, Böger CA, Scottà C, Markmann JF, Hester JL, Juerchott K, Braudeau C, James B, Contreras-Ruiz L, van der Net JB, Bergler T, Caldara R, Petchey W, Edinger M, Dupas N, Kapinsky M, Mutzbauer I, Otto NM, Öllinger R, Hernandez-Fuentes MP, Issa F, Ahrens N, Meyenberg C, Karitzky S, Kunzendorf U, Knechtle SJ, Grinyó J, Morris PJ, Brent L, Bushell A, Turka LA, Bluestone JA, Lechler RI, Schlitt HJ, Cuturi MC, Schlickeiser S, Friend PJ, Miloud T, Scheffold A, Secchi A, Crisalli K, Kang SM, Hilton R, Banas B, Blancho G, Volk HD, Lombardi G, Wood KJ, Geissler EK. Regulatory cell therapy in kidney transplantation (The ONE Study): a harmonised design and analysis of seven non-randomised, single-arm, phase 1/2A trials. Lancet 2020; 395:1627-1639. [PMID: 32446407 PMCID: PMC7613154 DOI: 10.1016/s0140-6736(20)30167-7] [Citation(s) in RCA: 231] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Use of cell-based medicinal products (CBMPs) represents a state-of-the-art approach for reducing general immunosuppression in organ transplantation. We tested multiple regulatory CBMPs in kidney transplant trials to establish the safety of regulatory CBMPs when combined with reduced immunosuppressive treatment. METHODS The ONE Study consisted of seven investigator-led, single-arm trials done internationally at eight hospitals in France, Germany, Italy, the UK, and the USA (60 week follow-up). Included patients were living-donor kidney transplant recipients aged 18 years and older. The reference group trial (RGT) was a standard-of-care group given basiliximab, tapered steroids, mycophenolate mofetil, and tacrolimus. Six non-randomised phase 1/2A cell therapy group (CTG) trials were pooled and analysed, in which patients received one of six CBMPs containing regulatory T cells, dendritic cells, or macrophages; patient selection and immunosuppression mirrored the RGT, except basiliximab induction was substituted with CBMPs and mycophenolate mofetil tapering was allowed. None of the trials were randomised and none of the individuals involved were masked. The primary endpoint was biopsy-confirmed acute rejection (BCAR) within 60 weeks after transplantation; adverse event coding was centralised. The RTG and CTG trials are registered with ClinicalTrials.gov, NCT01656135, NCT02252055, NCT02085629, NCT02244801, NCT02371434, NCT02129881, and NCT02091232. FINDINGS The seven trials took place between Dec 11, 2012, and Nov 14, 2018. Of 782 patients assessed for eligibility, 130 (17%) patients were enrolled and 104 were treated and included in the analysis. The 66 patients who were treated in the RGT were 73% male and had a median age of 47 years. The 38 patients who were treated across six CTG trials were 71% male and had a median age of 45 years. Standard-of-care immunosuppression in the recipients in the RGT resulted in a 12% BCAR rate (expected range 3·2-18·0). The overall BCAR rate for the six parallel CTG trials was 16%. 15 (40%) patients given CBMPs were successfully weaned from mycophenolate mofetil and maintained on tacrolimus monotherapy. Combined adverse event data and BCAR episodes from all six CTG trials revealed no safety concerns when compared with the RGT. Fewer episodes of infections were registered in CTG trials versus the RGT. INTERPRETATION Regulatory cell therapy is achievable and safe in living-donor kidney transplant recipients, and is associated with fewer infectious complications, but similar rejection rates in the first year. Therefore, immune cell therapy is a potentially useful therapeutic approach in recipients of kidney transplant to minimise the burden of general immunosuppression. FUNDING The 7th EU Framework Programme.
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Affiliation(s)
- Birgit Sawitzki
- Institute of Medical Immunology, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Paul N Harden
- Oxford Transplantation Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Petra Reinke
- BeCAT, BCRT, and Department of Nephrology & Intensive Care, Charité Universitätsmedizin Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Aurélie Moreau
- Centre de Recherche en Transplantation et Immunologie, Nantes Université, Inserm, Nantes, France; Institute of Transplantation Urology Nephrology, Nantes, France
| | - James A Hutchinson
- Department of Surgery, University of Regensburg, University Hospital Regensburg, Regensburg, Germany
| | - David S Game
- Guy's & St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Qizhi Tang
- Division of Transplantation, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Eva C Guinan
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston MA, USA
| | - Manuela Battaglia
- Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Milan, Italy
| | - William J Burlingham
- Division of Transplantation, Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ian S D Roberts
- Department of Cellular Pathology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mathias Streitz
- Institute of Medical Immunology, Charité, Universitätsmedizin Berlin, Berlin, Germany; BIH Center for Regenerative Therapies, Charité and Berlin Institute of Health, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Régis Josien
- Centre de Recherche en Transplantation et Immunologie, Nantes Université, Inserm, Nantes, France; Institute of Transplantation Urology Nephrology, Nantes, France; Laboratoire d'Immunologie, Cimna, Centre Hospitalier Universitaire, Nantes, France
| | - Carsten A Böger
- Department of Nephrology, University of Regensburg, University Hospital Regensburg, Regensburg, Germany
| | - Cristiano Scottà
- MRC Centre for Transplantation, Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - James F Markmann
- Center for Transplantation Sciences, Mass General Hospital, Boston, MA, USA
| | - Joanna L Hester
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Karsten Juerchott
- BIH Center for Regenerative Therapies, Charité and Berlin Institute of Health, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Cecile Braudeau
- Centre de Recherche en Transplantation et Immunologie, Nantes Université, Inserm, Nantes, France; Institute of Transplantation Urology Nephrology, Nantes, France; Laboratoire d'Immunologie, Cimna, Centre Hospitalier Universitaire, Nantes, France
| | - Ben James
- Department of Surgery, University of Regensburg, University Hospital Regensburg, Regensburg, Germany; Division of Personalized Tumor Therapy, Fraunhofer Institute for Experimental Medicine and Toxicology, Regensburg, Germany
| | | | - Jeroen B van der Net
- Oxford Transplantation Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Tobias Bergler
- Department of Nephrology, University of Regensburg, University Hospital Regensburg, Regensburg, Germany
| | - Rossana Caldara
- Transplant Medicine, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Milan, Italy
| | - William Petchey
- Oxford Transplantation Centre, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Matthias Edinger
- Department of Internal Medicine III, University of Regensburg, University Hospital Regensburg, Regensburg, Germany; Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany
| | - Nathalie Dupas
- Beckman Coulter Life Sciences, Immunotech, Marseille, France
| | | | - Ingrid Mutzbauer
- Department of Surgery, University of Regensburg, University Hospital Regensburg, Regensburg, Germany; Division of Personalized Tumor Therapy, Fraunhofer Institute for Experimental Medicine and Toxicology, Regensburg, Germany
| | - Natalie M Otto
- BeCAT, BCRT, and Department of Nephrology & Intensive Care, Charité Universitätsmedizin Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Robert Öllinger
- Department of Surgery, Charité Campus Mitte, Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Germany
| | - Maria P Hernandez-Fuentes
- MRC Centre for Transplantation, Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Fadi Issa
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Norbert Ahrens
- Institute for Clinical Chemistry and Laboratory Medicine, Transfusion Medicine, University of Regensburg, University Hospital Regensburg, Regensburg, Germany
| | | | | | - Ulrich Kunzendorf
- Clinic for Nephrology and Hypertension, Christian Albrechts University, University Clinic Schleswig-Holstein, Kiel, Germany
| | - Stuart J Knechtle
- Department of Surgery, Duke Transplant Center, Duke University Medical Center, Durham, NC, USA
| | - Josep Grinyó
- Kidney Transplant Unit, Nephrology Department, Bellvitge University Hospital, IDIBELL, Barcelona University, Barcelona, Spain
| | - Peter J Morris
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Leslie Brent
- St Mary's Hospital Transplant Unit, Paddington, London, UK
| | - Andrew Bushell
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Laurence A Turka
- Center for Transplantation Sciences, Mass General Hospital, Boston, MA, USA
| | - Jeffrey A Bluestone
- UCSF Diabetes Center, University of California, San Francisco, San Francisco, CA, USA
| | - Robert I Lechler
- MRC Centre for Transplantation, Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Hans J Schlitt
- Department of Surgery, University of Regensburg, University Hospital Regensburg, Regensburg, Germany
| | - Maria C Cuturi
- Centre de Recherche en Transplantation et Immunologie, Nantes Université, Inserm, Nantes, France; Institute of Transplantation Urology Nephrology, Nantes, France
| | - Stephan Schlickeiser
- Institute of Medical Immunology, Charité, Universitätsmedizin Berlin, Berlin, Germany; BIH Center for Regenerative Therapies, Charité and Berlin Institute of Health, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Peter J Friend
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Tewfik Miloud
- Beckman Coulter Life Sciences, Immunotech, Marseille, France
| | - Alexander Scheffold
- Institute for Immunology, Christian Albrechts University, University Clinic Schleswig-Holstein, Kiel, Germany
| | - Antonio Secchi
- Vita-Salute San Raffaele University Milan, Istituto di Ricovero e Cura a Carattere Scientifico, San Raffaele Scientific Institute, Milan, Italy
| | - Kerry Crisalli
- Center for Transplantation Sciences, Mass General Hospital, Boston, MA, USA
| | - Sang-Mo Kang
- Division of Transplantation, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Rachel Hilton
- Guy's & St Thomas' NHS Foundation Trust, Guy's Hospital, London, UK
| | - Bernhard Banas
- Department of Nephrology, University of Regensburg, University Hospital Regensburg, Regensburg, Germany
| | - Gilles Blancho
- Centre de Recherche en Transplantation et Immunologie, Nantes Université, Inserm, Nantes, France; Institute of Transplantation Urology Nephrology, Nantes, France
| | - Hans-Dieter Volk
- Institute of Medical Immunology, Charité, Universitätsmedizin Berlin, Berlin, Germany; BIH Center for Regenerative Therapies, Charité and Berlin Institute of Health, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Giovanna Lombardi
- MRC Centre for Transplantation, Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Kathryn J Wood
- Transplantation Research and Immunology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Edward K Geissler
- Department of Surgery, University of Regensburg, University Hospital Regensburg, Regensburg, Germany; Division of Personalized Tumor Therapy, Fraunhofer Institute for Experimental Medicine and Toxicology, Regensburg, Germany; Regensburg Center for Interventional Immunology, University of Regensburg, Regensburg, Germany.
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15
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Moerke C, Jaco I, Dewitz C, Müller T, Jacobsen AV, Gautheron J, Fritsch J, Schmitz J, Bräsen JH, Günther C, Murphy JM, Kunzendorf U, Meier P, Krautwald S. The anticonvulsive Phenhydan ® suppresses extrinsic cell death. Cell Death Differ 2019; 26:1631-1645. [PMID: 30442947 PMCID: PMC6748113 DOI: 10.1038/s41418-018-0232-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/30/2018] [Accepted: 10/30/2018] [Indexed: 12/27/2022] Open
Abstract
Different forms of regulated cell death-like apoptosis and necroptosis contribute to the pathophysiology of clinical conditions including ischemia-reperfusion injury, myocardial infarction, sepsis, and multiple sclerosis. In particular, the kinase activity of the receptor-interacting serine/threonine protein kinase 1 (RIPK1) is crucial for cell fate in inflammation and cell death. However, despite its involvement in pathological conditions, no pharmacologic inhibitor of RIPK1-mediated cell death is currently in clinical use. Herein, we screened a collection of clinical compounds to assess their ability to modulate RIPK1-mediated cell death. Our small-scale screen identified the anti-epilepsy drug Phenhydan® as a potent inhibitor of death receptor-induced necroptosis and apoptosis. Accordingly, Phenhydan® blocked activation of necrosome formation/activation as well as death receptor-induced NF-κB signaling by influencing the membrane function of cells, such as lipid raft formation, thus exerting an inhibitory effect on pathophysiologic cell death processes. By targeting death receptor signaling, the already FDA-approved Phenhydan® may provide new therapeutic strategies for inflammation-driven diseases caused by aberrant cell death.
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Affiliation(s)
- Caroline Moerke
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Isabel Jaco
- Toby Robins Research Centre, Institute of Cancer Research, London, SW3 6JB, UK
| | - Christin Dewitz
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Tammo Müller
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Annette V Jacobsen
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Jérémie Gautheron
- Université Pierre et Marie Curie, UMR_S 938, Inserm, 75012, Paris, France
| | - Jürgen Fritsch
- Institute for Clinical Microbiology and Hygiene, University of Regensburg, 93053, Regensburg, Germany
| | - Jessica Schmitz
- Department of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Jan Hinrich Bräsen
- Department of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Claudia Günther
- Department of Medicine 1, Friedrich-Alexander-University, 91052, Erlangen, Germany
| | - James M Murphy
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia
- Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany
| | - Pascal Meier
- Toby Robins Research Centre, Institute of Cancer Research, London, SW3 6JB, UK
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105, Kiel, Germany.
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16
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Schulte K, Borzikowsky C, Rahmel A, Kolibay F, Polze N, Fränkel P, Mikle S, Alders B, Kunzendorf U, Feldkamp T. Decline in Organ Donation in Germany. Dtsch Arztebl Int 2019; 115:463-468. [PMID: 30064626 DOI: 10.3238/arztebl.2018.0463] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 02/20/2018] [Accepted: 06/11/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND The annual number of post-mortem organ donations in Germany has declined by more than 30% since 2010. The causes of this development have not yet been adequately determined. METHODS All patients hospitalized in Germany between 2010 and 2015 (112 172 869 hospitalizations in total) were included in this nationwide secondary analysis. Among the deceased patients we identified those who had died in the presence of a brain damage and for whom organ donation was not excluded either by a medical contraindication or by the patient's not having been artificially ventilated. The analysis was also conducted separately for six German university hospitals. RESULTS Over the period 2010-2015, the number of potential organ donors per year in Germany rose by 13.9%, from 23 937 to 27 258. This development was due to an increase in the number of deaths with severe brain damage as well as an increase in the percentage of patients who were treated with invasive ventilation before death. The contact quotient, i.e., the percentage of potential donors for whom contact was made with the German Foundation for Organ Transplantation (Deutsche Stiftung Organtransplantation, DSO) fell over this period from 11.4% to 8.2%. At the same time, the realization quotient (the percentage of potential donors who became actual donors) fell from 5.4% to 3.2%, and the conversion quotient (the percentage of potential donors for whom contact was made who became actual donors) fell from 47% to 39.1%. From 2010 to 2012, the falling realization quotient was accounted for mainly by the falling conversion quotient; from 2012 to 2015, it was accounted for mainly by the falling contact quotient. The contact and realization quotients among the six university hospitals studied differed markedly (by factors of 17.5 and 23.3, respectively), while the conversion quotients differed only minimally (by a factor of 1.3). CONCLUSION The decline in post-mortem organ donation is due to a deficiency in the recognition and reporting of potential organ donors in hospital. If this process were better supported on the organizational and political level, far more organs could be transplanted.
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Affiliation(s)
- Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel; Institute of Medical Informatics and Statistics, Christian-Albrechts University, Kiel; German Organ Transplantation Foundation (DSO), Frankfurt am Main; The Medical Director's Staff Division of Clinical Affairs, University Hospital of Cologne; Department of Quality and Risk Management, University Hospital Leipzig; Department of Quality and Risk Management, University Hospital RWTH Aachen; Department of Quality Management, University Hospital of the Ruhr University Bochum, Knappschaft Hospital; Department of Anesthesiology, Surgical Intensive Care Medicine and Pain Therapy, University Hospital of the Ruhr University Bochum, Knappschaft Hospital
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17
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Moerke C, Bleibaum F, Kunzendorf U, Krautwald S. Combined Knockout of RIPK3 and MLKL Reveals Unexpected Outcome in Tissue Injury and Inflammation. Front Cell Dev Biol 2019; 7:19. [PMID: 30842945 PMCID: PMC6391322 DOI: 10.3389/fcell.2019.00019] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [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: 11/13/2018] [Accepted: 02/05/2019] [Indexed: 11/21/2022] Open
Abstract
Necroptosis, initially identified as a backup cell death program when apoptosis is hindered, is a prominent feature in the etiology and progression of many human diseases, such as ischemic injury and sepsis. Receptor-interacting protein kinase 3 (RIPK3) is the cardinal regulator of this cell death modality, recruiting and phosphorylating the executioner mixed lineage kinase domain-like protein (MLKL) to signal necroptosis, which is terminated by a cellular plasma membrane rupture and the leakage of intracellular contents from dying cells. Experimental data to date indicate that RIPK3 and MLKL is the core machinery essential for all necroptotic cell death responses. By using CRISPR/Cas9 (clustered regularly interspaced short palindromic repeat/CRISPR-associated protein 9) technology, we showed that Ripk3 and Mlkl knockout and Ripk3/Mlkl double-knockout in necroptosis-sensitive cell lines extensively block susceptibility to necroptosis, in each case to an indistinguishable degree. In vivo studies using Ripk3- or Mlkl-deficient mice validated kidney ischemia reperfusion injury and high-dose tumor necrosis factor (TNF) availability, as druggable targets in necroptotic-mediated pathologies. Here, we demonstrated that Ripk3 or Mlkl-deficient mice are protected to a similar extent from kidney ischemia reperfusion injury and TNF-induced toxicity. Remarkably, in contrast to each single knockout, Ripk3/Mlkl double-deficient mice did not have appreciable protection from either of the above necroptotic-mediated pathologies. Paradoxically, the double-knockout mice resembled, in each case, the vulnerable wild-type mice, revealing novel complexities in the mechanisms of inflammation-driven diseases, due to aberrant cell death.
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Affiliation(s)
- Caroline Moerke
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Florian Bleibaum
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Kiel, Germany
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18
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Schulte K, Klasen V, Vollmer C, Borzikowsky C, Kunzendorf U, Feldkamp T. Analysis of the Eurotransplant Kidney Allocation Algorithm: How Should We Balance Utility and Equity? Transplant Proc 2018; 50:3010-3016. [PMID: 30577160 DOI: 10.1016/j.transproceed.2018.08.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/29/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Since 2014, expected graft and recipient survival are matched by the U.S. kidney allocation system to improve organ utility. This mechanism is based on the kidney donor profile index (KDPI) and the estimated posttransplant survival score (EPTS). Here we analyzed 1. the transferability of these scores into the Eurotransplant (ET) region and 2. the extent to which the ET kidney allocation algorithm promotes utility. METHODS We studied data of 262 kidney transplantations performed at the University Hospital Kiel between 2000 and 2009 (median follow-up, 9.94 years). RESULTS Multivariable Cox regression analysis revealed that only the variables donor age of the KDPI and recipient's age of the EPTS have a significant value as predictors of posttransplant graft and recipient survival. The other variables showed no additional predictive value. Analyzing all kidneys allocated in the ET kidney allocation system and the European Senior Program, we found that donor and recipient's age and KDPI and EPTS were weakly correlated (rage-age = 0.5, P < .001; rKDPI-EPTS = 0.4, P < .01). If both programs were analyzed separately, no correlation between donor and recipient's age and between KDPI and EPTS was detected. CONCLUSION The ET kidney allocation algorithm poorly matched predicted graft and recipient survival at our center. A better age-matching may improve organ utility.
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Affiliation(s)
- K Schulte
- Clinic for Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany.
| | - V Klasen
- Clinic for Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany
| | - C Vollmer
- Clinic for Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany
| | - C Borzikowsky
- Institute of Medical Informatics and Statistics, Christian-Albrechts University, Kiel, Germany
| | - U Kunzendorf
- Clinic for Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany
| | - T Feldkamp
- Clinic for Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany
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19
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Ros U, Peña-Blanco A, Hänggi K, Kunzendorf U, Krautwald S, Wong WWL, García-Sáez AJ. Necroptosis Execution Is Mediated by Plasma Membrane Nanopores Independent of Calcium. Cell Rep 2017; 19:175-187. [PMID: 28380356 PMCID: PMC5465952 DOI: 10.1016/j.celrep.2017.03.024] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/22/2016] [Accepted: 03/06/2017] [Indexed: 01/14/2023] Open
Abstract
Necroptosis is a form of regulated necrosis that
results in cell death and content release after plasma membrane permeabilization.
However, little is known about the molecular events responsible for the disruption of
the plasma membrane. Here, we find that early increase in cytosolic calcium in
TNF-induced necroptosis is mediated by treatment with a Smac mimetic via the
TNF/RIP1/TAK1 survival pathway. This does not require the activation of the necrosome
and is dispensable for necroptosis. Necroptosis induced by the activation of TLR3/4
pathways does not trigger early calcium flux. We also demonstrate that necroptotic
plasma membrane rupture is mediated by osmotic forces and membrane pores around 4 nm
in diameter. This late permeabilization step represents a hallmark in necroptosis
execution that is cell and treatment independent and requires the RIP1/RIP3/MLKL
core. In support of this, treatment with osmoprotectants reduces cell damage in an
in vivo necroptosis model of ischemia-reperfusion injury. Early calcium signaling in TSZ necroptosis correlates with
cellular levels of cIAP1/2 Calcium flux is induced by a Smac mimetic and is
dispensable for necroptosis execution Pores ∼4 nm in diameter mediate final plasma membrane
disruption in necroptosis
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Affiliation(s)
- Uris Ros
- Interfaculty Institute of Biochemistry, Tübingen University, 72076 Tübingen, Germany.
| | - Aida Peña-Blanco
- Interfaculty Institute of Biochemistry, Tübingen University, 72076 Tübingen, Germany
| | - Kay Hänggi
- Institute of Experimental Immunology, University of Zürich, 8057 Zürich, Switzerland
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, 24105 Kiel, Germany
| | - W Wei-Lynn Wong
- Institute of Experimental Immunology, University of Zürich, 8057 Zürich, Switzerland
| | - Ana J García-Sáez
- Interfaculty Institute of Biochemistry, Tübingen University, 72076 Tübingen, Germany; Max-Planck Institute for Intelligent Systems, 70569 Stuttgart, Germany.
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20
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Feldkamp T, Luedemann M, Spehlmann ME, Freitag-Wolf S, Gaensbacher J, Schulte K, Bajrovic A, Hinzmann D, Hippe HJ, Kunzendorf U, Frey N, Luedde M. Radial access protects from contrast media induced nephropathy after cardiac catheterization procedures. Clin Res Cardiol 2017; 107:148-157. [PMID: 28939956 DOI: 10.1007/s00392-017-1166-2] [Citation(s) in RCA: 23] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 09/19/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess, whether cardiac catheterization via radial access prevents contrast-induced nephropathy. BACKGROUND Contrast-induced nephropathy (CIN) is a major clinical problem which accounts for more than 10% of acute kidney injury cases in hospitalized patients. Protective measures such as the infusion of isotonic saline solution or acetylcysteine have not consistently been proven to prevent acute kidney injury (AKI). However, there is growing evidence that radial access for coronary angiography and coronary intervention is associated with a lower incidence of AKI compared to femoral access. METHODS AND RESULTS In a retrospective monocentric analysis, 2937 patients that had undergone cardiac catheterization were examined. Up to 2013, coronary intervention was performed primarily via the femoral artery in our hospital; thereafter, interventions were primarily done via the radial artery. In the cohort under study, 1141 patients had received catheterization using the radial access while 1796 were examined via the femoral artery. No significant differences were found in the two groups regarding the amount of iodinated contrast medium applied [femoral group: 180 (120-260) ml; radial group: 180 (120-250) ml; P = 0.438]. A total of 400 (13.6%) patients developed acute kidney injury (AKI) after cardiac catheterization (85.3% AKI stage 1; 12.8% AKI stage 2; 2% AKI stage 3). AKI was significantly less frequent in patients that had received radial access compared to patients with femoral access (10.1 vs. 15.9%, P < 0.001). Multivariate regression analysis showed that patient age (1.03/year; 95% CI 1.02-1.04/year; P < 0.001), the amount of contrast media applied (OR 1.003/ml; 95% CI 1.002-1.004/ml; P < 0.001), acute coronary syndrome (OR 2.01, 95% CI 1.52-2.66; P < 0.001), CKD (OR 1.62, 95% CI 1.50-1.70; P < 0.001), pre-existing heart failure (OR 1.27, 95% CI 1.00-1.42 P = 0.007), previous myocardial infarction (OR 1.34, 95% CI 1.15-1.49; P = 0.001), diabetes (OR 1.25, 95% CI 1.04-1.41; P = 0.020) and serum creatinine before the procedure (1.45/mg/dl; 95% CI 1.24-1.69/mg/dl; P < 0.001) were important risk factors for the occurrence of AKI. Our analysis points to a significant risk reduction using radial access (OR 0.65; 95% CI 0.51-0.83; P < 0.001). Interestingly, this reduction in risk was also evident in patients with CKD (OR 0.59; 95% CI 0.41-0.87; P = 0.007). The superiority of radial access was particularly obvious in the subgroup of patients with acute coronary syndrome (13.1% AKI in the radial access group vs. 23.6% AKI in the femoral access group, OR 0.52; 95% CI 0.34-0.81; P = 0.003). CONCLUSION Our study shows that cardiac catheterization using radial access bears significantly lower risk of AKI than cardiac catheterization via femoral access. The advantage of radial access in acute coronary syndrome regarding morbidity and mortality could partly be explained by the here demonstrated reduced risk for AKI. Thus, radial access should be preferred in patients at risk for AKI.
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Affiliation(s)
- Thorsten Feldkamp
- Internal Medicine IV, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Maya Luedemann
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany
| | - Martina E Spehlmann
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany
| | - Sandra Freitag-Wolf
- Institute for Medical Information Technology and Statistics, Christian Albrechts University Kiel, Kiel, Germany
| | - Julia Gaensbacher
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany
| | - Kevin Schulte
- Internal Medicine IV, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Amer Bajrovic
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany
| | - Dieter Hinzmann
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany
| | - Hans-Joerg Hippe
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany
| | - Ulrich Kunzendorf
- Internal Medicine IV, University Hospital of Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - Norbert Frey
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Mark Luedde
- Internal Medicine III, University Hospital of Schleswig Holstein, Campus Kiel, Rosalind-Franklin-Str.12, 24105, Kiel, Germany.
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21
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Kronjäger C, Aits I, Schreiber S, Kunzendorf U, Lieb W, Plachta-Danielzik S. Prävalenz von Spätfolgen 6 Monate und 4 Jahre nach Infektion mit Escherichia coli O104:H4 im Jahr 2011. Das Gesundheitswesen 2017. [DOI: 10.1055/s-0037-1605994] [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: 10/18/2022]
Affiliation(s)
- C Kronjäger
- Christian-Albrechts-Universität zu Kiel, Institut für Epidemiologie, Kiel
| | - I Aits
- Christian-Albrechts-Universität zu Kiel, Institut für Epidemiologie, Kiel
| | - S Schreiber
- Universitätsklinikum Schleswig-Holstein, Klinik für Innere Medizin I, Kiel
| | - U Kunzendorf
- Universitätsklinikum Schleswig-Holstein, Klinik für Innere Medizin IV, Klinik für Nieren- und Hochdruckkrankheiten, Kiel
| | - W Lieb
- Christian-Albrechts-Universität zu Kiel, Institut für Epidemiologie, Kiel
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22
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Müller T, Dewitz C, Schmitz J, Schröder AS, Bräsen JH, Stockwell BR, Murphy JM, Kunzendorf U, Krautwald S. Necroptosis and ferroptosis are alternative cell death pathways that operate in acute kidney failure. Cell Mol Life Sci 2017; 74:3631-3645. [PMID: 28551825 PMCID: PMC5589788 DOI: 10.1007/s00018-017-2547-4] [Citation(s) in RCA: 240] [Impact Index Per Article: 34.3] [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: 02/07/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 01/19/2023]
Abstract
Ferroptosis is a recently recognized caspase-independent form of regulated cell death that is characterized by the accumulation of lethal lipid ROS produced through iron-dependent lipid peroxidation. Considering that regulation of fatty acid metabolism is responsible for the membrane-resident pool of oxidizable fatty acids that undergo lipid peroxidation in ferroptotic processes, we examined the contribution of the key fatty acid metabolism enzyme, acyl-CoA synthetase long-chain family member 4 (ACSL4), in regulating ferroptosis. By using CRISPR/Cas9 technology, we found that knockout of Acsl4 in ferroptosis-sensitive murine and human cells conferred protection from erastin- and RSL3-induced cell death. In the same cell types, deletion of mixed lineage kinase domain-like (Mlkl) blocked susceptibility to necroptosis, as expected. Surprisingly, these studies also revealed ferroptosis and necroptosis are alternative, in that resistance to one pathway sensitized cells to death via the other pathway. These data suggest a mechanism by which one regulated necrosis pathway compensates for another when either ferroptosis or necroptosis is compromised. We verified the synergistic contributions of ferroptosis and necroptosis to tissue damage during acute organ failure in vivo. Interestingly, in the course of pathophysiological acute ischemic kidney injury, ACSL4 was initially upregulated and its expression level correlated with the severity of tissue damage. Together, our findings reveal ACSL4 to be a reliable biomarker of the emerging cell death modality of ferroptosis, which may also serve as a novel therapeutic target in preventing pathological cell death processes.
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Affiliation(s)
- Tammo Müller
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Georges-Köhler-Haus, Fleckenstr. 4, 24105, Kiel, Germany
| | - Christin Dewitz
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Georges-Köhler-Haus, Fleckenstr. 4, 24105, Kiel, Germany
| | - Jessica Schmitz
- Department of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Anna Sophia Schröder
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Georges-Köhler-Haus, Fleckenstr. 4, 24105, Kiel, Germany
| | - Jan Hinrich Bräsen
- Department of Pathology, University of Hannover, 30625, Hannover, Germany
| | - Brent R Stockwell
- Department of Biological Sciences and Department of Chemistry, Columbia University of New York, New York, NY, 10027, USA
| | - James M Murphy
- The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, 3052, Australia.,Department of Medical Biology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Georges-Köhler-Haus, Fleckenstr. 4, 24105, Kiel, Germany
| | - Stefan Krautwald
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Georges-Köhler-Haus, Fleckenstr. 4, 24105, Kiel, Germany.
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23
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Schulte K, Vollmer C, Klasen V, Bräsen JH, Püchel J, Borzikowsky C, Kunzendorf U, Feldkamp T. Late conversion from tacrolimus to a belatacept-based immuno-suppression regime in kidney transplant recipients improves renal function, acid-base derangement and mineral-bone metabolism. J Nephrol 2017; 30:607-615. [PMID: 28540602 DOI: 10.1007/s40620-017-0411-0] [Citation(s) in RCA: 23] [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] [Received: 03/02/2017] [Accepted: 05/12/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Calcineurin inhibitor (CNI)-induced nephrotoxicity and chronic graft dysfunction with deteriorating glomerular filtration rate (GFR) are common problems of kidney transplant recipients. The aim of this study was to analyze the role of belatacept as a rescue therapy in these patients. METHODS In this retrospective, observational study we investigated 20 patients (10 females, 10 males) who were switched from a CNI (tacrolimus) to a belatacept-based immunosuppression because of CNI intolerance or marginal transplant function. Patient follow-up was 12 months. RESULTS Patients were converted to belatacept in mean 28.8 months after transplantation. Reasons for conversion were CNI intolerance (14 patients) or marginal transplant function (6 patients). Mean estimated GFR (eGFR) before conversion was 22.2 ± 9.4 ml/min at baseline and improved significantly to 28.3 ± 10.1 ml/min at 4 weeks and to 32.1 ± 12.6 ml/min at 12 months after conversion. Serum bicarbonate significantly increased from 24.4 ± 3.2 mmol/l at baseline to 28.7 ± 2.6 mmol/l after 12 months. Conversion to belatacept decreased parathyroid hormone and phosphate concentrations significantly, whereas albumin levels significantly increased. In 6 cases an acute rejection preceded clinically relevant CNI toxicity; only two patients suffered from an acute rejection after conversion. Belatacept was well tolerated and there was no increase in infectious or malignant side effects. CONCLUSION A late conversion from a tacrolimus-based immunosuppression to belatacept is safe, effective and significantly improves renal function in kidney transplant recipients. Additionally, the conversion to belatacept has a beneficial impact on acid-base balance, mineral-bone and protein metabolism, independently of eGFR.
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Affiliation(s)
- Kevin Schulte
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany.
| | - Clara Vollmer
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Vera Klasen
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Jan Hinrich Bräsen
- Nephropathology, Institute for Pathology, Hannover Medical School, Hanover, Germany
| | - Jodok Püchel
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Christian-Albrechts University, Kiel, Germany
| | - Ulrich Kunzendorf
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
| | - Thorsten Feldkamp
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Christian-Albrechts University Kiel, Schittenhelmstr. 12, 24105, Kiel, Germany
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Beneke J, Sartison A, Kielstein JT, Haller H, Nitschke M, Kunzendorf U, Loos S, Kemper MJ, Stahl RAK, Menne J. Clinical and Laboratory Consequences of Platelet Transfusion in Shiga Toxin-Mediated Hemolytic Uremic Syndrome. Transfus Med Rev 2016; 31:51-55. [PMID: 27468945 DOI: 10.1016/j.tmrv.2016.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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: 09/08/2015] [Revised: 06/02/2016] [Accepted: 06/10/2016] [Indexed: 11/25/2022]
Abstract
Recent studies suggest that platelet transfusions are harmful in patients with thrombotic thrombocytopenic purpura, an entity of thrombotic microangiopathies. As the typical or Shiga toxin-producing Escherichia coli-induced hemolytic uremic syndrome (STEC-HUS) is also classified as thrombotic microangiopathy, we complement these data with an analysis of 250 patients from the German O104:H4 STEC-HUS outbreak. The effect of platelet transfusion in 44 patients who received platelet transfusions vs 206 control patients was investigated. Criteria for both groups were severe thrombocytopenia less than 50/nL, severe hemolysis with administration of packed red blood cells, and a complicated clinical course with admission to intensive care units. Readouts were clinical complications and changes in routine clinical chemistry and whole blood count. Chemistry values at admission and demographic parameters were comparable. Platelet transfusions were administered in 44 cases a median of 7 (interquartile range, 6-9) days after diarrhea onset. After platelet transfusion, we observed a transient and slight increase in inflammation parameters. No significant difference in major complications such as seizures, or requirement for ventilation or renal replacement therapy could be observed. Thrombotic events such as thrombosis or embolism were comparably rare in both groups (2.3% in platelet transfused vs 4.4% in controls, P=not significant). The mortality was not significantly different (0% vs 2.6%, P=not significant) in our study cohort, but overall in the outbreak, 6 of 711 STEC-HUS patients in Germany died of a procedural-related bleeding complications. In conclusion, platelet transfusions seem comparably safe in adult STEC-HUS patients, considering both the possible necessity for invasive procedures and potential risk for severe bleeding.
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Affiliation(s)
- Jan Beneke
- Department of Nephrology and Hypertension, Hanover Medical School, Hanover, Germany.
| | - Aleksej Sartison
- Department of Nephrology and Hypertension, Hanover Medical School, Hanover, Germany
| | - Jan T Kielstein
- Department of Nephrology and Hypertension, Hanover Medical School, Hanover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hanover Medical School, Hanover, Germany
| | | | | | - Sebastian Loos
- University Children's Hospital, Hamburg, Germany; University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus J Kemper
- University Children's Hospital, Hamburg, Germany; University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf A K Stahl
- 3rd Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Menne
- Department of Nephrology and Hypertension, Hanover Medical School, Hanover, Germany
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Krämer BK, Montagnino G, Krüger B, Margreiter R, Olbricht CJ, Marcen R, Sester U, Kunzendorf U, Dietl KH, Rigotti P, Ronco C, Hörsch S, Banas B, Mühlbacher F, Arias M. Efficacy and safety of tacrolimus compared with ciclosporin-A in renal transplantation: 7-year observational results. Transpl Int 2015; 29:307-14. [PMID: 26565071 DOI: 10.1111/tri.12716] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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: 05/03/2015] [Revised: 05/27/2015] [Accepted: 10/30/2015] [Indexed: 12/28/2022]
Abstract
The European Tacrolimus versus Ciclosporin-A Microemulsion (CsA-ME) Renal Transplantation Study demonstrated that tacrolimus decreased acute rejection rates at 6 months. Primary endpoints of this investigator-initiated, observational 7-year follow-up study were acute rejection rates, patient and graft survival rates, and a composite endpoint (BPAR, graft loss, and patient death). We analyzed data from the original intent-to-treat population (n = 557; 286 tacrolimus, 271 CsA-ME). A total of 237 tacrolimus and 208 CsA-ME patients provided data. At 7 years, Kaplan-Meier estimated rates of patients free from BPAR were 77.1% in the tacrolimus arm and 59.9% in the CsA-ME arm, graft survival rates amounted to 82.6% and 80.6%, and patient survival rates to 89.9% and 88.1%. Estimated combined endpoint-free survival rates were 60.2% in the tacrolimus arm and 47.0% in the CsA-ME arm (P = <0.0001). A higher number of patients from the CsA-ME arm crossed over to tacrolimus during 7 year follow-up: 19.7% vs. 7.9% (P = <0.002). More patients in the tacrolimus group stopped steroids and received immunosuppressive monotherapy. Significantly, more CsA-ME patients received lipid-lowering medication and experienced cosmetic and cardiovascular adverse events. Tacrolimus-treated renal transplant recipients had significantly higher combined endpoint-free survival rates mainly driven by lower acute rejection rates despite less immunosuppressive medication at 7 years.
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Affiliation(s)
- Bernhard K Krämer
- Universitätsmedizin Mannheim, Vth Department of Medicine, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | - Giuseppe Montagnino
- Division of Nephrology and Dialysis, Ospedale Maggiore di Milano IRCCS, Milano, Italy
| | - Bernd Krüger
- Universitätsmedizin Mannheim, Vth Department of Medicine, Medical Faculty of the University of Heidelberg, Mannheim, Germany
| | | | | | | | - Urban Sester
- Universitätsklinik des Saarlandes, Homburg, Germany
| | | | | | | | | | | | - Bernhard Banas
- Abteilung für Nephrologie, University of Regensburg, Regensburg, Germany
| | | | - Manuel Arias
- Hospital Marqués de Valdecilla, Santander, Spain
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26
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Zschiedrich S, Budde K, Nürnberger J, Wanner C, Sommerer C, Kunzendorf U, Banas B, Hoerl WH, Obermüller N, Arns W, Pavenstädt H, Gaedeke J, Lindner TH, Faerber L, Wimmer P, Stork R, Eckardt KU, Walz G. Secreted frizzled-related protein 4 predicts progression of autosomal dominant polycystic kidney disease. Nephrol Dial Transplant 2015; 31:284-9. [DOI: 10.1093/ndt/gfv077] [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] [Received: 12/13/2014] [Accepted: 03/01/2015] [Indexed: 01/28/2023] Open
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Affiliation(s)
- Andreas Linkermann
- Clinic for Nephrology and Hypertension; Christian-Albrechts-University; Kiel, Germany
| | - Ulrich Kunzendorf
- Clinic for Nephrology and Hypertension; Christian-Albrechts-University; Kiel, Germany
| | - Stefan Krautwald
- Clinic for Nephrology and Hypertension; Christian-Albrechts-University; Kiel, Germany
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Abstract
AKI is pathologically characterized by sublethal and lethal damage of renal tubules. Under these conditions, renal tubular cell death may occur by regulated necrosis (RN) or apoptosis. In the last two decades, tubular apoptosis has been shown in preclinical models and some clinical samples from patients with AKI. Mechanistically, apoptotic cell death in AKI may result from well described extrinsic and intrinsic pathways as well as ER stress. Central converging nodes of these pathways are mitochondria, which become fragmented and sensitized to membrane permeabilization in response to cellular stress, resulting in the release of cell death-inducing factors. Whereas apoptosis is known to be regulated, tubular necrosis was thought to occur by accident until recent work unveiled several RN subroutines, most prominently receptor-interacting protein kinase-dependent necroptosis and RN induced by mitochondrial permeability transition. Additionally, other cell death pathways, like pyroptosis and ferroptosis, may also be of pathophysiologic relevance in AKI. Combination therapy targeting multiple cell-death pathways may, therefore, provide maximal therapeutic benefits.
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Affiliation(s)
- Andreas Linkermann
- Clinic for Nephrology and Hypertension, Christian-Albrechts-University, Kiel, Germany;
| | - Guochun Chen
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; and
| | - Guie Dong
- Department of Cellular Biology and Anatomy, Charlie Norwood Veterans Affairs Medical Center and Medical College of Georgia at Georgia Regents University, Augusta, Georgia
| | - Ulrich Kunzendorf
- Clinic for Nephrology and Hypertension, Christian-Albrechts-University, Kiel, Germany
| | - Stefan Krautwald
- Clinic for Nephrology and Hypertension, Christian-Albrechts-University, Kiel, Germany
| | - Zheng Dong
- Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; and Department of Cellular Biology and Anatomy, Charlie Norwood Veterans Affairs Medical Center and Medical College of Georgia at Georgia Regents University, Augusta, Georgia
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Linkermann A, Hackl MJ, Kunzendorf U, Walczak H, Krautwald S, Jevnikar AM. Necroptosis in immunity and ischemia-reperfusion injury. Am J Transplant 2013; 13:2797-804. [PMID: 24103029 DOI: 10.1111/ajt.12448] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [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: 04/05/2013] [Revised: 05/14/2013] [Accepted: 05/16/2013] [Indexed: 01/25/2023]
Abstract
Transplantation is invariably associated with ischemia-reperfusion injury (IRI), inflammation and rejection. Resultant cell death has morphological features of necrosis but programmed cell death has been synonymous with apoptosis until pathways of regulated necrosis (RN) have been described. The best-studied RN pathway, necroptosis, is triggered by perturbation of caspase-8-mediated apoptosis and depends on receptor-interacting protein kinases 1 and 3 (RIPK1/RIPK3) as well as mixed linage kinase domain like to form the necroptosome. The release of cytosolic content and cell death-associated molecular patterns (CDAMPs) can trigger innate and promote adaptive immune responses. Thus, the form of cell death can substantially influence alloimmunity and graft survival. Necroptosis is a key element of IRI, and RIPK1 interference by RN-specific inhibitors such as necrostatin-1 protects from IRI in kidney, heart and brain. Necroptosis may be a general mechanism in response to other forms of inflammatory organ injury, and will likely emerge as a promising target in solid organ transplantation. As second-generation RIPK1 and RIPK3 inhibitors become available, clinical trials for the prevention of delayed graft function and attenuation of allograft rejection-mediated injury will emerge. These efforts will accelerate upon further identification of critical necroptosis-triggering receptor(s).
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Affiliation(s)
- A Linkermann
- Clinic for Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany
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30
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Koch T, Derer S, Staudinger M, Rossen K, Glorius P, Peipp M, Kellner C, Kunzendorf U, Valerius T, Dechant M. Antibody-dependent cellular cytotoxicity in patients on chronic hemodialysis. Am J Nephrol 2013; 38:379-87. [PMID: 24157422 DOI: 10.1159/000355972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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: 03/14/2013] [Accepted: 09/24/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Antibody (Ab)-dependent cellular cytotoxicity (ADCC) is considered to be a relevant mechanism of action of Ab-based tumor therapies. However, knowledge about ADCC capacity of dialysis patients (DP) is limited. The aim of our study was to investigate if ADCC capacity of effector cells obtained from DP differed from those of healthy individuals (HI). METHODS First, we performed ADCC assays with isolated polymorphonuclear cells (PMN) and peripheral blood mononuclear cells (PBMC), mediated by the epidermal growth factor receptor Ab cetuximab or panitumumab. As cetuximab is of human IgG1 and panitumumab of human IgG2 isotype, both Abs differ in their affinity to Fcγ receptors and effector cell recruitment. RESULTS Using PMN as effectors, ADCC levels via panitumumab proved to be higher than via cetuximab, but did not differ between DP and HI. In contrast, IgG2-mediated ADCC with PBMC from DP was significantly enhanced compared to HI. IgG2 Abs predominantly bind to FcγRIIa. Within the PBMC, monocytes are the only cytotoxic cells physiologically expressing this receptor. ADCC experiments with isolated monocytes confirmed them to be the pivotal cells for the observed effect. Analysis of monocytes' Fc receptor expression demonstrated no difference between DP and HI, but monocytes of DP proved to be numerically increased and appeared preactivated. CONCLUSION Our studies implicate that ADCC capacity is not impaired in DP and that it might particularly be reasonable to apply human IgG2 Abs as therapeutics for these patients.
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Affiliation(s)
- Till Koch
- Department of Internal Medicine IV, Nephrology and Hypertension, Christian Albrechts University, Kiel, Germany
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Linkermann A, Bräsen JH, Darding M, Jin MK, Sanz AB, Heller JO, De Zen F, Weinlich R, Ortiz A, Walczak H, Weinberg JM, Green DR, Kunzendorf U, Krautwald S. Two independent pathways of regulated necrosis mediate ischemia-reperfusion injury. Proc Natl Acad Sci U S A 2013; 110:12024-9. [PMID: 23818611 PMCID: PMC3718149 DOI: 10.1073/pnas.1305538110] [Citation(s) in RCA: 525] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Regulated necrosis (RN) may result from cyclophilin (Cyp)D-mediated mitochondrial permeability transition (MPT) and receptor-interacting protein kinase (RIPK)1-mediated necroptosis, but it is currently unclear whether there is one common pathway in which CypD and RIPK1 act in or whether separate RN pathways exist. Here, we demonstrate that necroptosis in ischemia-reperfusion injury (IRI) in mice occurs as primary organ damage, independent of the immune system, and that mice deficient for RIPK3, the essential downstream partner of RIPK1 in necroptosis, are protected from IRI. Protection of RIPK3-knockout mice was significantly stronger than of CypD-deficient mice. Mechanistically, in vivo analysis of cisplatin-induced acute kidney injury and hyperacute TNF-shock models in mice suggested the distinctness of CypD-mediated MPT from RIPK1/RIPK3-mediated necroptosis. We, therefore, generated CypD-RIPK3 double-deficient mice that are viable and fertile without an overt phenotype and that survived prolonged IRI, which was lethal to each single knockout. Combined application of the RIPK1 inhibitor necrostatin-1 and the MPT inhibitor sanglifehrin A confirmed the results with mutant mice. The data demonstrate the pathophysiological coexistence and corelevance of two separate pathways of RN in IRI and suggest that combination therapy targeting distinct RN pathways can be beneficial in the treatment of ischemic injury.
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Affiliation(s)
| | - Jan Hinrich Bräsen
- Institute for Pathology, Christian-Albrechts-University, 24105 Kiel, Germany
- Pathology Hamburg-West, Institute for Diagnostic Histopathology and Cytopathology, 22767 Hamburg, Germany
| | - Maurice Darding
- Cell Death and Inflammation Laboratory, Centre for Cell Death, Cancer and Inflammation, University College London Cancer Institute, London WC1E 6BT, United Kingdom
| | | | - Ana B. Sanz
- El Instituto de Investigación Sanitaria de la Fundacion Jimenez Diaz, Redinren, Fundación Renal Íñigo Álvarez de Toledo, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | | | | | - Ricardo Weinlich
- Department of Immunology, St. Jude Children’s Research Hospital, Memphis, TN 38105-3678; and
| | - Alberto Ortiz
- El Instituto de Investigación Sanitaria de la Fundacion Jimenez Diaz, Redinren, Fundación Renal Íñigo Álvarez de Toledo, Universidad Autónoma de Madrid, 28049 Madrid, Spain
| | - Henning Walczak
- Cell Death and Inflammation Laboratory, Centre for Cell Death, Cancer and Inflammation, University College London Cancer Institute, London WC1E 6BT, United Kingdom
| | - Joel M. Weinberg
- Division for Nephrology, University of Michigan Medical Center, Ann Arbor, MI 48109-5676
| | - Douglas R. Green
- Department of Immunology, St. Jude Children’s Research Hospital, Memphis, TN 38105-3678; and
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Abstract
Programmed cell death (PCD) had been widely used synonymously to caspase-mediated apoptosis until caspase-independent cell death was described. Identification of necrosis as a regulated process in ischaemic conditions has recently changed our understanding of PCD. At least three pathways of programmed necrosis (PN) have been identified. First, receptor-interacting protein kinase 3 (RIP3)-dependent necroptosis causes organ failure following stroke, myocardial infarction and renal ischaemia/reperfusion injury. Necroptosis can be mediated either by a large intracellular caspase-8-containing signalling complex called the ripoptosome or by the RIP1-/RIP3-containing necroptosome and is controlled by a caspase-8/FLICE inhibitory protein(long) heterodimer at least in the latter case. Second, mitochondrial permeability transition mediates apoptotic or necrotic stimuli and depends on the mitochondrial protein cyclophilin D. The third PN pathway involves the poly(ADP-ribose) polymerase-calpain axis that contributes to acute kidney injury (AKI). Preclinical interference with the PN pathways therefore raises expectations for the future treatment of ischaemic conditions. In this brief review, we aim to summarize the clinically relevant PCD pathways and to transfer the basic science data to settings of AKI. We conclude that pathologists were quite right to refer to ischaemic kidney injury as 'acute tubular necrosis'.
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Linkermann A, Heller JO, Prókai A, Weinberg JM, De Zen F, Himmerkus N, Szabó AJ, Bräsen JH, Kunzendorf U, Krautwald S. The RIP1-kinase inhibitor necrostatin-1 prevents osmotic nephrosis and contrast-induced AKI in mice. J Am Soc Nephrol 2013; 24:1545-57. [PMID: 23833261 DOI: 10.1681/asn.2012121169] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The pathophysiology of contrast-induced AKI (CIAKI) is incompletely understood due to the lack of an appropriate in vivo model that demonstrates reduced kidney function before administration of radiocontrast media (RCM). Here, we examine the effects of CIAKI in vitro and introduce a murine ischemia/reperfusion injury (IRI)-based approach that allows induction of CIAKI by a single intravenous application of standard RCM after injury for in vivo studies. Whereas murine renal tubular cells and freshly isolated renal tubules rapidly absorbed RCM, plasma membrane integrity and cell viability remained preserved in vitro and ex vivo, indicating that RCM do not induce apoptosis or regulated necrosis of renal tubular cells. In vivo, the IRI-based CIAKI model exhibited typical features of clinical CIAKI, including RCM-induced osmotic nephrosis and increased serum levels of urea and creatinine that were not altered by inhibition of apoptosis. Direct evaluation of renal morphology by intravital microscopy revealed dilation of renal tubules and peritubular capillaries within 20 minutes of RCM application in uninjured mice and similar, but less dramatic, responses after IRI pretreatment. Necrostatin-1 (Nec-1), a specific inhibitor of the receptor-interacting protein 1 (RIP1) kinase domain, prevented osmotic nephrosis and CIAKI, whereas an inactive Nec-1 derivate (Nec-1i) or the pan-caspase inhibitor zVAD did not. In addition, Nec-1 prevented RCM-induced dilation of peritubular capillaries, suggesting a novel role unrelated to cell death for the RIP1 kinase domain in the regulation of microvascular hemodynamics and pathophysiology of CIAKI.
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Affiliation(s)
- Andreas Linkermann
- Division of Nephrology and Hypertension, Christian-Albrechts-University, Kiel, Germany
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Menne J, Nitschke M, Stingele R, Abu-Tair M, Beneke J, Bramstedt J, Bremer JP, Brunkhorst R, Busch V, Dengler R, Deuschl G, Fellermann K, Fickenscher H, Gerigk C, Goettsche A, Greeve J, Hafer C, Hagenmüller F, Haller H, Herget-Rosenthal S, Hertenstein B, Hofmann C, Lang M, Kielstein JT, Klostermeier UC, Knobloch J, Kuehbacher M, Kunzendorf U, Lehnert H, Manns MP, Menne TF, Meyer TN, Michael C, Münte T, Neumann-Grutzeck C, Nuernberger J, Pavenstaedt H, Ramazan L, Renders L, Repenthin J, Ries W, Rohr A, Rump LC, Samuelsson O, Sayk F, Schmidt BMW, Schnatter S, Schöcklmann H, Schreiber S, von Seydewitz CU, Steinhoff J, Stracke S, Suerbaum S, van de Loo A, Vischedyk M, Weissenborn K, Wellhöner P, Wiesner M, Zeissig S, Büning J, Schiffer M, Kuehbacher T. Validation of treatment strategies for enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome: case-control study. BMJ 2012; 345:e4565. [PMID: 22815429 PMCID: PMC3400392 DOI: 10.1136/bmj.e4565] [Citation(s) in RCA: 225] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effect of different treatment strategies on enterohaemorrhagic Escherichia coli O104:H4 induced haemolytic uraemic syndrome. DESIGN Multicentre retrospective case-control study. SETTING 23 hospitals in northern Germany. PARTICIPANTS 298 adults with enterohaemorrhagic E coli induced haemolytic uraemic syndrome. MAIN OUTCOME MEASURES Dialysis, seizures, mechanical ventilation, abdominal surgery owing to perforation of the bowel or bowel necrosis, and death. RESULTS 160 of the 298 patients (54%) temporarily required dialysis, with only three needing treatment long term. 37 patients (12%) had seizures, 54 (18%) required mechanical ventilation, and 12 (4%) died. No clear benefit was found from use of plasmapheresis or plasmapheresis with glucocorticoids. 67 of the patients were treated with eculizumab, a monoclonal antibody directed against the complement cascade. No short term benefit was detected that could be attributed to this treatment. 52 patients in one centre that used a strategy of aggressive treatment with combined antibiotics had fewer seizures (2% v 15%, P = 0.03), fewer deaths (0% v 5%, p = 0.029), required no abdominal surgery, and excreted E coli for a shorter duration. CONCLUSIONS Enterohaemorrhagic E coli induced haemolytic uraemic syndrome is a severe self limiting acute condition. Our findings question the benefit of eculizumab and of plasmapheresis with or without glucocorticoids. Patients with established haemolytic uraemic syndrome seemed to benefit from antibiotic treatment and this should be investigated in a controlled trial.
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Affiliation(s)
- Jan Menne
- Medical School Hannover, Hannover, Germany
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Linkermann A, Bräsen JH, De Zen F, Weinlich R, Schwendener RA, Green DR, Kunzendorf U, Krautwald S. Dichotomy between RIP1- and RIP3-mediated necroptosis in tumor necrosis factor-α-induced shock. Mol Med 2012; 18:577-86. [PMID: 22371307 DOI: 10.2119/molmed.2011.00423] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 02/17/2012] [Indexed: 01/03/2023] Open
Abstract
Tumor necrosis factor receptor (TNFR) signaling may result in survival, apoptosis or programmed necrosis. The latter is called necroptosis if the receptor-interacting protein 1 (RIP1) inhibitor necrostatin-1 (Nec-1) or genetic knockout of RIP3 prevents it. In the lethal mouse model of TNFα-mediated shock, addition of the pan-caspase inhibitor zVAD-fmk (zVAD) accelerates time to death. Here, we demonstrate that RIP3-deficient mice are protected markedly from TNFα-mediated shock in the presence and absence of caspase inhibition. We further show that the fusion protein TAT-crmA, previously demonstrated to inhibit apoptosis, also prevents necroptosis in L929, HT29 and FADD-deficient Jurkat cells. In contrast to RIP3-deficient mice, blocking necroptosis by Nec-1 or TAT-crmA did not protect from TNFα/zVAD-mediated shock, but further accelerated time to death. Even in the absence of caspase inhibition, Nec-1 application led to similar kinetics. Depletion of macrophages, natural killer (NK) cells, granulocytes or genetic deficiency for T lymphocytes did not influence this model. Because RIP3-deficient mice are known to be protected from cerulein-induced pancreatitis (CIP), we applied Nec-1 and TAT-crmA in this model and demonstrated the deterioration of pancreatic damage upon addition of these substances. These data highlight the importance of separating genetic RIP3 deficiency from RIP1 inhibition by Nec-1 application in vivo and challenge the current definition of necroptosis.
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Affiliation(s)
- Andreas Linkermann
- Division of Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany
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Linkermann A, Himmerkus N, Rölver L, Keyser KA, Steen P, Bräsen JH, Bleich M, Kunzendorf U, Krautwald S. Renal tubular Fas ligand mediates fratricide in cisplatin-induced acute kidney failure. Kidney Int 2010; 79:169-78. [PMID: 20811331 DOI: 10.1038/ki.2010.317] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cisplatin, a standard chemotherapeutic agent for many tumors, has an unfortunately common toxicity where almost a third of patients develop renal dysfunction after a single dose. Acute kidney injury caused by cisplatin depends on Fas-mediated apoptosis driven by Fas ligand (FasL) expressed on tubular epithelial and infiltrating immune cells. Since the role of FasL in T cells is known, we investigated whether its presence in primary kidney cells is needed for its toxic effect. We found that all cisplatin-treated wild-type (wt) mice died within 6 days; however, severe combined immunodeficiency (SCID)/beige mice (B-, T-, and natural killer-cell-deficient) displayed a significant survival benefit, with only 55% mortality while exhibiting significant renal failure. Treating SCID/beige mice with MFL3, a FasL-blocking monoclonal antibody, completely restored survival after an otherwise lethal cisplatin dose, suggesting another source of FasL besides immune cells. Freshly isolated primary tubule segments from wt mice were co-incubated with thick ascending limb (TAL) segments freshly isolated from mice expressing the green fluorescent protein (GFP) transgene (same genetic background) to determine whether FasL-mediated killing of tubular cells is an autocrine or paracrine mechanism. Cisplatin-stimulated primary segments induced apoptosis in the GFP-tagged TAL cells, an effect blocked by MFL3. Thus, our study shows that cisplatin-induced nephropathy is mediated through FasL, functionally expressed on tubular cells that are capable of inducing death of cells of adjacent tubules.
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Affiliation(s)
- Andreas Linkermann
- Division of Nephrology and Hypertension, Christian-Albrechts University, Kiel, Germany
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Walz G, Budde K, Mannaa M, Nürnberger J, Wanner C, Sommerer C, Kunzendorf U, Banas B, Hörl WH, Obermüller N, Arns W, Pavenstädt H, Gaedeke J, Büchert M, May C, Gschaidmeier H, Kramer S, Eckardt KU. Everolimus in patients with autosomal dominant polycystic kidney disease. N Engl J Med 2010; 363:830-40. [PMID: 20581392 DOI: 10.1056/nejmoa1003491] [Citation(s) in RCA: 415] [Impact Index Per Article: 29.6] [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] [Indexed: 12/17/2022]
Abstract
BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is a slowly progressive hereditary disorder that usually leads to end-stage renal disease. Although the underlying gene mutations were identified several years ago, efficacious therapy to curtail cyst growth and prevent renal failure is not available. Experimental and observational studies suggest that the mammalian target of rapamycin (mTOR) pathway plays a critical role in cyst growth. METHODS In this 2-year, double-blind trial, we randomly assigned 433 patients with ADPKD to receive either placebo or the mTOR inhibitor everolimus. The primary outcome was the change in total kidney volume, as measured on magnetic resonance imaging, at 12 and 24 months. RESULTS Total kidney volume increased between baseline and 1 year by 102 ml in the everolimus group, versus 157 ml in the placebo group (P=0.02) and between baseline and 2 years by 230 ml and 301 ml, respectively (P=0.06). Cyst volume increased by 76 ml in the everolimus group and 98 ml in the placebo group after 1 year (P=0.27) and by 181 ml and 215 ml, respectively, after 2 years (P=0.28). Parenchymal volume increased by 26 ml in the everolimus group and 62 ml in the placebo group after 1 year (P=0.003) and by 56 ml and 93 ml, respectively, after 2 years (P=0.11). The mean decrement in the estimated glomerular filtration rate after 24 months was 8.9 ml per minute per 1.73 m2 of body-surface area in the everolimus group versus 7.7 ml per minute in the placebo group (P=0.15). Drug-specific adverse events were more common in the everolimus group; the rate of infection was similar in the two groups. CONCLUSIONS Within the 2-year study period,as compared with placebo, everolimus slowed the increase in total kidney volume of patients with ADPKD but did not slow the progression of renal impairment [corrected]. (Funded by Novartis; EudraCT number, 2006-001485-16; ClinicalTrials.gov number, NCT00414440.)
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Affiliation(s)
- Gerd Walz
- Renal Division, University Hospital Freiburg, Hugstetter St., 55 79106 Freiburg, Germany.
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Abstract
Acute renal failure (ARF) comprises several syndromes that are associated with a sudden decrease in renal function. ARF is common among critically ill patients, is typically multifactorial and is of great prognostic significance. Indeed, even moderate changes in renal function significantly add to the morbidity and worsen mortality associated with ARF. Recent definitions, namely the renal Risk, Injury, Failure, Loss of renal function and End-stage kidney disease (RIFLE) classification or Acute Kidney Injury Network (AKIN) criteria, which incorporate the levels of oliguria in addition to fractional serum creatinine elevation, are important because the magnitude of kidney injury according to those definitions correlates very well with both short- and long-term patient survival. However, preventive strategies are most effective when started before oliguria or elevated serum creatinine is detectable, as those criteria already reflect established renal tubular cell injury. New biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty acid binding protein (L-FABP) or kidney injury molecule-1 (KIM-1) that increase prior to the serum creatinine elevation are promising and have been proven to be useful in this regard in a few clinical trials. In addition, genetic profiling may define patients at risk earlier and help to individualize preventive strategies. Well established strategies include limiting dehydration and hypotension by the use of intravenous isotonic fluids at an optimal and individualized rate, as well as avoiding exposure to nephrotoxins, which include aminoglycosides, amphotericin or non-ionic contrast. Generally accepted and evidence-based pharmacological preventive or therapeutic options have not yet been established, although many drugs (e.g. renal vasodilators, diuretics and HMG-CoA reductase inhibitors [statins]) have been tested. New promising agents interfere with the apoptotic signalling that can occur in the setting of toxin exposure or ischaemia-reperfusion injury, limit inflammatory responses or modulate endothelial cell activation. In the future, these new approaches will enable us to extend our therapeutic repertoire.
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Affiliation(s)
- Ulrich Kunzendorf
- Division of Nephrology and Hypertension, University of Kiel, Kiel, Germany.
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Krautwald S, Ziegler E, Rölver L, Linkermann A, Keyser KA, Steen P, Wollert KC, Korf-Klingebiel M, Kunzendorf U. Effective blockage of both the extrinsic and intrinsic pathways of apoptosis in mice by TAT-crmA. J Biol Chem 2010; 285:19997-20005. [PMID: 20427266 DOI: 10.1074/jbc.m110.122127] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Evidence accumulates that in clinically relevant cell death, both the intrinsic and extrinsic apoptotic pathway synergistically contribute to organ failure. In search for an inhibitor of apoptosis that provides effective blockage of these pathways, we analyzed viral proteins that evolved to protect the infected host cells. In particular, the cowpox virus protein crmA has been demonstrated to be capable of blocking key caspases of both pro-apoptotic pathways. To deliver crmA into eukaryotic cells, we fused the TAT protein transduction domain of HIV to the N terminus of crmA. In vitro, the TAT-crmA fusion protein was efficiently translocated into target cells and inhibited apoptosis mediated through caspase-8, caspase-9, and caspase-3 after stimulation with alpha-Fas, etoposide, doxorubicin, or staurosporine. The extrinsic apoptotic pathway was investigated following alpha-Fas stimulation. In vivo 90% of TAT-crmA-treated animals survived an otherwise lethal dose of alpha-Fas and showed protection from Fas-induced organ failure. To examine the intrinsic apoptotic pathway, we investigated the survival of mice treated with an otherwise lethal dose of doxorubicin. Whereas all control mice died within 31 days, 40% of mice that concomitantly received intraperitoneal injections of TAT-crmA survived. To test the ability to comprehensively block both the intrinsic and extrinsic apoptotic pathway in a clinically relevant setting, we employed a murine cardiac ischemia-reperfusion model. TAT-crmA reduced infarction size by 40% and preserved left ventricular function. In summary, these results provide a proof of principle for the inhibition of apoptosis with TAT-crmA, which might provide a new treatment option for ischemia-reperfusion injuries.
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Affiliation(s)
- Stefan Krautwald
- Division of Nephrology and Hypertension, University of Kiel, 24105 Kiel, Germany
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Braun F, Schöcklmann H, Ziegler E, Kunzendorf U, Armstrong VW, Renders L. Increased Mycophenolic Acid Exposure in Stable Kidney Transplant Recipients on Tacrolimus as Compared With Those on Sirolimus: Implications for Pharmacokinetics. Clin Pharmacol Ther 2009; 86:411-5. [DOI: 10.1038/clpt.2009.129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Hutchinson JA, Gövert F, Riquelme P, Bräsen JH, Brem-Exner BG, Matthäi M, Schulze M, Renders L, Kunzendorf U, Geissler EK, Fändrich F. Administration of donor-derivedtransplant acceptance-inducing cellsto the recipients of renal transplants from deceased donors is technically feasible. Clin Transplant 2009; 23:140-5. [DOI: 10.1111/j.1399-0012.2008.00953.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Hutchinson JA, Riquelme P, Brem-Exner BG, Schulze M, Matthi M, Renders L, Kunzendorf U, Geissler EK, Fndrich F. Transplant acceptance-inducing cells as an immune-conditioning therapy in renal transplantation. Transpl Int 2008; 21:728-41. [DOI: 10.1111/j.1432-2277.2008.00680.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hutchinson JA, Roelen D, Riquelme P, Brem-Exner BG, Witzke O, Philipp T, Matthi M, Gvert F, Claas FHJ, Westphal E, Kunzendorf U, Geissler EK, Fndrich F. Preoperative treatment of a presensitized kidney transplant recipient with donor-derived transplant acceptance-inducing cells. Transpl Int 2008; 21:808-13. [DOI: 10.1111/j.1432-2277.2008.00712.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hutchinson JA, Brem-Exner BG, Riquelme P, Roelen D, Schulze M, Ivens K, Grabensee B, Witzke O, Philipp T, Renders L, Humpe A, Sotnikova A, Matthäi M, Heumann A, Gövert F, Schulte T, Kabelitz D, Claas FHJ, Geissler EK, Kunzendorf U, Fändrich F. A cell-based approach to the minimization of immunosuppression in renal transplantation. Transpl Int 2008; 21:742-54. [PMID: 18573141 DOI: 10.1111/j.1432-2277.2008.00692.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Five renal transplant recipients were preoperatively treated with transplant acceptance-inducing cells (TAICs) in a Phase-I safety study of TAICs as an adjunct immune-conditioning therapy in living-donor kidney transplantation. Initially, patients received anti-thymocyte globulin induction therapy in combination with tacrolimus and steroid immunosuppression. Over the course of 12 weeks, steroids were withdrawn and tacrolimus therapy was minimized. Three of the five patients were able to tolerate low-dose tacrolimus monotherapy and one patient was withdrawn from all immunosuppression for over 8 months. No acute or delayed adverse events were associated with the infusion of TAICs. Monitoring of the recipient anti-donor reactivity of TAIC-treated patients in mixed lymphocyte cultures demonstrated that, during periods of clinically stable graft function, recipient T-cell proliferation and cytokine secretion in response to stimulation with donor alloantigen was relatively suppressed. Therefore, although the TAIC-II trial did not provide conclusive evidence of a beneficial effect of preoperative TAIC treatment, the results were encouraging because they suggest that TAICs promote a state of alloantigen-specific unresponsiveness, which might allow safe minimization of pharmacological immunosuppression.
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Affiliation(s)
- James A Hutchinson
- Laboratory of Transplantation Research of the Clinic of General and Thoracic Surgery, University of Schleswig-Holstein, Kiel, Germany.
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Krämer BK, Del Castillo D, Margreiter R, Sperschneider H, Olbricht CJ, Ortuño J, Sester U, Kunzendorf U, Dietl KH, Bonomini V, Rigotti P, Ronco C, Tabernero JM, Rivero M, Banas B, Mühlbacher F, Arias M, Montagnino G. Efficacy and safety of tacrolimus compared with ciclosporin A in renal transplantation: three-year observational results. Nephrol Dial Transplant 2008; 23:2386-92. [PMID: 18258740 DOI: 10.1093/ndt/gfn004] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The European tacrolimus versus ciclosporin A microemulsion (CsA-ME) renal transplantation study showed that tacrolimus was significantly more effective in preventing acute rejection and had a superior cardiovascular risk profile at 6 months. METHODS The endpoints of this investigator-initiated, observational, 36-month follow-up were acute rejection incidence rates, rates of patient and graft survival and renal function. An additional analysis was performed using the combined endpoints BPAR, graft loss and patient death. Data available from the original ITT population (557 patients; 286 tacrolimus and 271 CsA-ME) were analysed. RESULTS A total of 231 tacrolimus and 217 CsA-ME patients participated. At 36 months, Kaplan-Meier-estimated BPAR-free survival rates were 78.8% in the tacrolimus group and 60.6% in the CsA-ME group, graft survival rates were 88.0% and 86.9% and patient survival rates were 96.6% and 96.7%, respectively. The estimated combined endpoint-free survival rate was 71.4% with tacrolimus and 55.4% with CsA-ME (P <or= 0.001, chi-square test). Significantly more CsA-ME patients crossed over to tacrolimus during the 3-year follow-up: 21.2% versus 2.6%, P <or= 0.0001, chi-square test. Most patients in the tacrolimus arm discontinued steroids and received monotherapy and fewer tacrolimus patients remained on a triple regimen. Mean serum creatinine concentration was 145.4 +/- 90.9 micromol/L with tacrolimus and 149.0 +/- 92.1 micromol/L with CsA-ME. Significantly more CsA-ME patients had a classified cholesterol value >6 mmol/L (26.3% versus 12.6%, P <or= 0.0003, chi-square test). CONCLUSIONS Patients treated with tacrolimus had significantly higher combined endpoint-free survival rates and lower acute rejection rates with less immunosuppressive medication at 36 months.
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Affiliation(s)
- Bernhard K Krämer
- Klinik und Poliklinik für Innere Medizin II--Nephrologie, Klinikum der Universität Regensburg, Germany.
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Ziegler E, Oberbarnscheidt M, Bulfone-Paus S, Förster R, Kunzendorf U, Krautwald S. CCR7 signaling inhibits T cell proliferation. J Immunol 2007; 179:6485-93. [PMID: 17982037 DOI: 10.4049/jimmunol.179.10.6485] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
CCR7 and its ligands, CCL19 and CCL21, are responsible for directing the migration of T cells and dendritic cells into lymph nodes, where these cells play an important role in the initiation of the immune response. Recently, we have shown that systemic application of CCL19-IgG is able to inhibit the colocalization of T cells and dendritic cells within secondary lymphoid organs, resulting in pronounced immunosuppression with reduced allograft rejection after organ transplantation. In this study, we demonstrate that the application of sustained high concentrations of either soluble or immobilized CCL19 and CCL21 elicits an inhibitory program in T cells. We show that these ligands specifically interfere with cell proliferation and IL-2 secretion of CCR7(+) cells. This could be demonstrated for human and murine T cells and was valid for both CD4(+) and CD8(+) T cells. In contrast, CCL19 had no inhibitory effect on T cells from CCR7 knockout mice, but CCR7(-/-) T cells showed a proliferative response upon TCR-stimulation similar to that of CCL19-treated wild-type cells. Furthermore, the inhibition of proliferation is associated with delayed degradation of the cyclin-dependent kinase (CDK) inhibitor p27(Kip1) and the down-regulation of CDK1. This shows that CCR7 signaling is linked to cell cycle control and that sustained engagement of CCR7, either by high concentrations of soluble ligands or by high density of immobilized ligands, is capable of inducing cell cycle arrest in TCR-stimulated cells. Thus, CCR7, a chemokine receptor that has been demonstrated to play an essential role during activation of the immune response, is also competent to directly inhibit T cell proliferation.
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Affiliation(s)
- Ekkehard Ziegler
- Department of Nephrology and Hypertension, University of Kiel, Kiel, Germany
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Kunzendorf U, Kramer BK, Arns W, Braun J, Grossmann J, Pietruck F, Schmidt-Gayk H, Schwarz A, Ziegler E, Sperschneider H, Wuthrich RP, Nonnast-Daniel B, Schindler R, Renders L. Bone disease after renal transplantation. Nephrol Dial Transplant 2007; 23:450-8. [DOI: 10.1093/ndt/gfm816] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [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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Abstract
Kidney transplantation is the best option for all patients with terminal renal failure. Kidney transplantation is not only associated with an improved quality of life in comparison to all other renal replacement therapies, this method also offers a significantly extended lifespan. Therefore, the option for transplantation has to be verified for every patient with renal failure. Graft and patient survival is best when transplantation is carried out just before starting dialysis treatment. Realistically, only living donor transplantation offers the option of sparing the recipient a long waiting period on dialysis. Although transplantation from living donors is superior to cadaveric kidney transplantation, a small risk remains for the donor. Kidney transplantation and the immunosuppressive therapy are associated with an increased risk for certain types of infection, an increased tumour risk and an increased risk for cardiovascular complications. To address these problems, specific recommendations for patient surveillance have been provided by different transplantation societies.
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Affiliation(s)
- U Kunzendorf
- Klinik für Nieren- und Hochdruckkrankheiten, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Schittenhelmstrasse 12, 24105 Kiel.
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Renders L, Frisman M, Ufer M, Mosyagin I, Haenisch S, Ott U, Caliebe A, Dechant M, Braun F, Kunzendorf U, Cascorbi I. CYP3A5 genotype markedly influences the pharmacokinetics of tacrolimus and sirolimus in kidney transplant recipients. Clin Pharmacol Ther 2006; 81:228-34. [PMID: 17192769 DOI: 10.1038/sj.clpt.6100039] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It is currently not clear whether the concentration-time curves of the immunosuppressants differ with respect to the CYP3A5, MDR1, or MRP2 genotype in dose-adapted stable kidney transplant patients. Dose/trough concentration ratios were obtained in 134 tacrolimus and 20 sirolimus-treated patients, and plasma concentration-time profiles were obtained from 16 (tacrolimus) and 10 (sirolimus) patients. Genotyping was carried out for CYP3A5 6986A>G; ABCB1 2677G>T/A, 3435C>T and ABCC2 -24C>T; 1249G>A; 3972C>T. Dose/trough concentration ratios were 0.67+/-0.3 and 1.36+/-0.73 x 10(3) l (P<0.00001) for tacrolimus and 0.42+/-0.17 and 0.84+/-0.46 x 10(3) l (P=0.18) for sirolimus in CYP3A5 non-expressors and expressors. The unadjusted tacrolimus area under curve (AUC)(0-12) was 106.8+/-17.5 ng/ml x h compared with 133.3+/-42.2 ng/ml x h (P=0.37) without affecting serum creatinine. Mean unadjusted AUC(0-24) of sirolimus did not differ significantly either. Therefore, CYP3A5 expressor status and not transporter variants is a main determinant of oral clearance, particularly for tacrolimus. Dose adaptation according to trough levels, however, appears to be sufficient to maintain similar concentration-time profiles.
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Affiliation(s)
- L Renders
- Department of Nephrology and Hypertension, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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