POS0755 SAFETY, TOLERABILITY, PHARMACOKINETICS, AND PHARMACODYNAMICS OF A SINGLE ORALLY ADMINISTERED DOSE OF ENPATORAN IN A PHASE I STUDY OF HEALTHY JAPANESE AND CAUCASIAN PARTICIPANTS

Background

Enpatoran, a novel, highly selective and potent dual toll-like receptor (TLR) 7 and TLR8 inhibitor, is in development for the treatment of autoimmune disorders including systemic and cutaneous lupus erythematosus. A first-in-human study in healthy participants has shown that enpatoran is well-tolerated and has a linear pharmacokinetic (PK) profile.

Objectives

To compare the PK parameters, safety, and tolerability of single ascending oral doses of enpatoran in a Phase I study in Japanese and Caucasian participants, and to explore a potential PK/pharmacodynamic (PD) relationship.

Methods

A single-centre, open-label, sequential dose group study enrolled healthy Japanese and Caucasian participants into three dose cohorts. Each Caucasian participant was matched by body weight (± 20%), height (± 15%) and sex to a Japanese participant. Participants received a single orally administered enpatoran dose of 100 mg, 200 mg, or 300 mg as a film-coated tablet under fasting conditions. PK parameters, (maximum plasma concentration [Cmax]; area under the plasma concentration–time curve (AUC) from time 0 to infinity [AUC0-inf]; AUC from time 0 to the last sampling time [AUC0-tlast]) determined using noncompartmental analysis, were estimated post-dose from Day 1–3. Safety was assessed from Day -1 to 8. PK (exposure) between the two ethnic groups was compared using an analysis of covariance (ANCOVA) model including ethnic group, natural log-transformed dose, and ethnic group by natural log dose interaction. Ex vivo secretion of cytokines (PD) under stimulated (using the TLR7/8 agonist, R848) and unstimulated conditions, was assessed pre- and post-dose. A panel of cytokines was analysed by multiplex immunoassay; IL-6 was considered the primary PD biomarker.

Results

The study included 36 male participants (18 Japanese and 18 Caucasian) with a mean (± SD) age of 35.1 (± 10.8) years and mean (± SD) body mass index of 23.1 (± 2.1) kg/m2. Each dose group included six Japanese and six Caucasian participants. The geometric mean enpatoran plasma exposure parameters (Cmax, AUC0-inf, and AUC0-tlast) were consistent between the two ethnic groups for each dose level (Table 1) and indicated dose proportionality. ANCOVA modeling demonstrated comparable exposure between the two groups (geometric least square mean ratio [Japanese/Caucasian;90% CI] of Cmax: 0.9409 [0.7855–1.1270]; AUC0-inf: 0.8959 [0.7497–1.0704] and AUC0-tlast: 0.8963 [0.7511–1.0695]). Treatment-emergent adverse events (TEAEs) were observed in six Japanese (n = 0, 100 mg; n = 3, 200 mg; n = 3, 300 mg) and four Caucasian (n = 1, 100 mg; n = 0, 200 mg; n = 3, 300 mg) participants. There we no serious TEAEs; most were mild and not dose dependent. Treatment-related TEAEs were mild diarrhoea, mild flatulence, and moderate headache. There were no deaths, withdrawals, or early terminations due to TEAEs. Administering enpatoran effectively reduced ex vivo stimulated cytokine release, with maximal inhibition observed at 2 hours post-dose (IL-6: mean ≥99%). High inhibition levels were sustained through 24 hours in a dose-dependent manner (IL-6: mean ~76–97%). The pattern of cytokine release inhibition was consistent across doses and ethnic groups.

Table 1.

PK parameters in Japanese and Caucasian participants at the three enpatoran dose levels

Parameter100 mg200 mg300 mgJapaneseCaucasianJapaneseCaucasianJapaneseCaucasianN = 6N = 6N = 6N = 6N = 6N = 6Cmax139175260245486490(ng/mL)AUC0-inf7749481910185028403330(h*ng/mL)AUC0-tlast7589311880183028103270(h*ng/mL)

All values are Geometric mean.

Cmax, maximum plasma concentration AUC0-inf, area under the plasma concentration–time curve (AUC) from time 0 to infinity; AUC0-tlast, AUC from time 0 to the last sampling time.

Conclusion

There were no relevant ethnic differences in PK, PD, and safety between healthy Japanese and Caucasian participants across a range of single oral enpatoran doses, thus supporting the inclusion of Asian participants in future global Phase II studies.

Acknowledgements

We would like to thank those who took part in the study. This study was sponsored by the healthcare business of Merck KGaA, Darmstadt, Germany (CrossRef Funder ID: 10.13039/100009945), who funded medical writing support by Bioscript Stirling Ltd.

Disclosure of Interests

Sathej Gopalakrishnan Shareholder of: Merck Healthcare KGaA, Employee of: Merck Healthcare KGaA, Axel Krebs-Brown Employee of: Merck Healthcare KGaA, Marco Nogueira Filho Employee of: Merck Healthcare KGaA, Yoshihiro Kuroki Employee of: Merck Biopharma Co., Ltd., Angelika Bachmann Employee of: Merck Healthcare KGaA, Andreas Becker Shareholder of: Merck Healthcare KGaA, Employee of: Merck Healthcare KGaA, Frank Schippers Employee of: Merck Healthcare KGaA, Markus Fluck Shareholder of: Merck Healthcare KGaA, Employee of: Merck Healthcare KGaA, Özkan Yalkinoglu Employee of: Merck Healthcare KGaA, Lena Klopp-Schulze Employee of: Merck Healthcare KGaA

Development and Clinical Validation of the LymphMonitor Technology to Quantitatively Assess Lymphatic Function

Current diagnostic methods for evaluating the functionality of the lymphatic vascular system usually do not provide quantitative data and suffer from many limitations including high costs, complexity, and the need to perform them in hospital settings. In this work, we present a quantitative, simple outpatient technology named LymphMonitor to quantitatively assess lymphatic function. This method is based on the painless injection of the lymphatic-specific near-infrared fluorescent tracer indocyanine green complexed with human serum albumin, using MicronJet600^TM microneedles, and monitoring the disappearance of the fluorescence signal at the injection site over time using a portable detection device named LymphMeter. This technology was investigated in 10 patients with unilateral leg or arm lymphedema. After injection of a tracer solution into each limb, the signal was measured over 3 h and the area under the normalized clearance curve was calculated to quantify the lymphatic function. A statistically significant difference in lymphatic clearance in the healthy versus the lymphedema extremities was found, based on the obtained area under curves of the normalized clearance curves. This study provides the first evidence that the LymphMonitor technology has the potential to diagnose and monitor the lymphatic function in patients.

Evaluating the differences in the early laparoscopic donor nephrectomy learning curves of a Swiss high volume transplant program and a South African low volume transplant program after knowledge transfer

Background

To describe the retroperitoneoscopic donor nephrectomy learning curve differences between a high volume (training) hospital in Basel, Switzerland, and a low volume (trainee) hospital in Cape Town, South Africa, after knowledge transfer. The South African hospital is resource constraint in hospital and training equipment. Techniques for performing the surgery were near identical.

Methods

Both units maintained prospective databases. Comparisons were made of the first 74 cases in each database: Basel’s series were from 19 January 2001 until 28 June 2004, while the Cape Town Hospital were from 8 April 2008 until 15 July 2008. Four surgeons operated in the Basel group, while only one surgeon operated in the Cape Town group. Variables compared include operating time (first skin incision until kidney was extracted), warm ischaemic time (renal arterial occlusion until cold bench reperfusion), blood loss, graft function, and hospital stay. We also analysed the first and last 25 cases of each series. Subgroup analysis of a single Basel surgeon was conducted.

Results

Donor age (means: Basel vs. Cape Town 54 vs. 33 p < 0.0001) and gender (males vs. females Cape Town 57% male and Basel 31% male) differed widely. The Basel group did more left-sided operations (72% vs. 58%). Operative times, blood loss and donor creatinine did not differ. Warm ischaemic time was significantly shorter in the Basel group (Cape Town mean 204 s Basel mean 130 s P = 0.0023). There was double the number of early graft failures in the South African group (six vs. three)—not related to donor surgery. Both groups showed a decline in operating times, plateauing at 30–34 cases.

Conclusions

There are statistically significant differences in some aspects of the learning curves of the Swiss (training) and South African (trainee) hospitals. These differences are clinically not pronounced, and the knowledge transfer was worth the effort.

P–723 Ovarian reserve parameters and ovarian stimulation outcome for IVF/ICSI are influenced by ethnicity

Study question

Are the ovarian reserve parameters and the outcome of ovarian stimulation for IVF / ICSI influenced by ethnicity?

Summary answer

Ethnicity influences ovarian reserve parameters and the outcome of ovarian stimulation for IVF / ICSI

What is known already

Infertility affects couples worldwide and due to a lack of a standardized reporting system, the real number, especially in developing countries, might be underestimated. The etiology of infertility may differ around the world and is often subjected not only to social, cultural and religious peculiarities, but also to different genetic influences. Published data suggest that ethnicity influences the ovarian reserve as well as the outcome of Assisted-Reproductive-Techniques (ART)-treatments. Key players of a successful ART outcome are the ovarian reserve and consequently the number of oocytes retrieved. Until today, the impact of ethnical differences is not sufficiently addressed in research.

Study design, size, duration

Prospective observational study, performed in 10 infertility centers worldwide (Europe (4 centers), Middle East North Africa (MENA) region (2 centers), Iran (2 centers), South America (1 center), India (1 center)) between May 2019 and September 2020, evaluating ovarian reserve and outcome parameters of ovarian stimulation treatments for IVF/ICSI. The study was approved by the Ethical Committee of each participating center.

Participants/materials, setting, methods

Couples with primary / secondary infertility and an indication for an IVF/ICSI treatment were included into this study. Besides anamnestic data regarding the history of the infertility and self-reported ethnicity (Arab, Caucasian, Hispanic, Ohters, Persian and South Asian), data obtained during the basic fertility assessment on the ovarian reserve parameters (Antral follicle count (AFC) and Anti-Muellerian-Hormone (AMH)) as well as stimulation parameters from the ovarian stimulation treatment were collected and analyzed.

Main results and the role of chance

This study comprised 1032 couples with the following distribution of the ethnicities: Arab 21.5%, Caucasian 15.9%, Hispanic 5%, Others 1.2%, Persian 33.4%, and South Asian 23%. The unadjusted means, SD and 95%CI (Confidence Interval) of AMH (ng/ml) for the groups were 3.33±0.19 [2.95–3.71]; 2.03±0.25 [1.55–2.52]; 2.43±0.74 [0.97–3.88]; 2.76±0.96 [0.88–4.64]; 3.10±0.16 [2.79–3.41]; 3.62±0.19 [3.25–3.98], for AFC 15.52±0.53 [14.49–16.55]; 12.00±0.67 [10.69–13.31]; 12.69±1.08 [10.57–14.81]; 15.11±2.60 [10.01–20.21]; 13.58±0.42 [12.75–14.41]; 13.49±0.51 [12.49–14.48] and for the number of retrieved oocytes (rCOC) 14.08±0.61 [12.88–15.27]; 9.84±0.71 [8.44–11.24]; 7.94±1.26 [5.48–10.41]; 9.92±2.62 [4.78–15.05]; 10.83±0.49 [9.87–11.79]; 17.06±0.59 [15.90–18.21], respectively. Univariate analysis of AMH, AFC and rCOC with the ethnicities revealed highly statistically significant differences for AMH and rCOC (p &lt; 0.001, respectively) and significant differences for AFC (p = 0.0014).

As age is a major confounder for the ovarian reserve, multivariate analyses were performed. After adjusting for age, AMH was significantly different between Arab-Persian, Arab-South Asian and Arab-Caucasian (p &lt; 0.001, p &lt; 0.001, p = 0.002) and AFC statistically significant between Arab and all other ethnicities. For rCOC, besides age, also the stimulation-dosage and -duration was taken into account. Highly statistically significant differences were found for the groups Arab-Persian and Arab-Caucasian and no differences towards the other ethnical groups.

Limitations, reasons for caution

Limitations of the study are an unequal number of included patients per ethnicity and that the data for the ovarian reserve parameters and the stimulation outcome were not available for all of the included patients.

Wider implications of the findings: Counselling of couples with infertility have to take, besides all other factors, also the ethnicity of the couple into account as ethnicity influences the ovarian reserve parameters as well as the number of retrieved oocytes in ovarian stimulation cycles for IVF/ICSI.

Trial registration number

ClinicalTrials.gov Identifier: NCT03927417

[Surgical positioning techniques in urology : Tips and tricks]

Correct positioning of patients during preoperative preparations is essential for success of the intervention to avoid any positioning trauma and to provide the best access to the targeted structures. The appropriate positioning (and optimal performance) means that complications are avoided and also makes an essential contribution to the smooth course of the surgical intervention. A correct position is essential particularly in urology because the organs assigned to the discipline of urology are anatomically mostly difficult to reach. A further important function of the correct positioning technique is the avoidance of injuries to the patient. This article summarizes the most common positioning techniques in urological interventions with special emphasis on the explanation of practical advice, helpful tips and possible complications that can enable even junior surgeons to correctly perform the appropriate positioning technique.

A Comparison of Two Types of Rabbit Antithymocyte Globulin Induction Therapy in Immunological High-Risk Kidney Recipients: A Prospective Randomized Control Study

Background

Induction treatment with rabbit polyclonal antithymocyte globulins (ATGs) is frequent used in kidney transplant recipients with donorspecific HLA antibodies and shows acceptable outcomes. The two commonly used ATGs, Thymoglobulin and ATG-F have slightly different antigen profile and antibody concentrations. The two compounds have never been directly compared in a prospective trial in immunological high-risk recipients. Therefore we performed a prospective randomized controlled study comparing the two compounds in immunological high-risk kidney recipients in terms of safety and efficacy.

Methods

Immunological high-risk kidney recipients, defined as the presence of HLA DSA but negative CDC-B and T-cell crossmatches were randomized 1:1 to receive ATG-F or Thymoglobulin. Maintenance immunosuppressive therapy consisted of tacrolimus, mycophenolate mofetil and steroids.

Results

The per-protocol analysis included 35 patients. There was no immediate infusion reaction observed with both compounds. No PTLD or malignancy occurred during the follow-up in both groups. The incidence of viral and bacterial infections was similar in both groups (p = 0.62). The cumulative incidence of clinical and subclinical antibody mediated allograft rejection as well as T-cell mediated allograft rejection during the first year between ATG-F and Thymoglobulin was similar (35% versus 19%; p = 0.30 and 11% versus 18%; 0.54 respectively). The two-year graft function was similar with a median eGFR of 56 ml/min/1.73m² (range 21–128) (ATG-F-group) and 51 ml/min/1.73m² (range 22–132) (Thymo-group) (p = 0.69).

Conclusion

We found no significant differences between the compared study drugs for induction treatment in immunological high-risk patients regarding safety and efficacy during follow-up with good allograft function at 2 years after transplantation.

[Urinary Tract Infections--Current Innovations in Urine Diagnostics]

Urine culture (UC) confirms the diagnosis of urinary tract infection (UTI) and is still considered the diagnostic 'gold standard' for pathogen identification, quantification and resistance testing. However, up to 80% of samples will not yield bacterial growth. Different techniques are currently approved for resistance testing. However, all of them are culture based and have the disadvantage of being very slow. In the field of urology, the development of drug resistance of uropathogens complicates the optimal administration of antimicrobial agents not only in the treatment, but also in the prevention of UTI before endourological and open surgical procedures. In this context, rapid identification of microbiological agents, including timely antimicrobial resistance testing (ART) is desirable. This overview presents alternative techniques (flow cytometry, PCR-based techniques, MALDI-TOF MS and microcalorimetry) to urine culture and discusses their advantages and disadvantages.

[Structural lag and room for possibilities in old age exemplified by central transitions. Initial results of a novel discipline trialogue between diaconal studies, psychology and theology]

BACKGROUND

Although the need for interdisciplinary research is generally accepted in gerontology, such interdisciplinary communication is often limited to various combinations of psychological, sociological and biomedical scientific approaches. We argue that gerontology requires a continuous examination of novel disciplinary constellations to obtain a better understanding of aging in its complexity and to further develop this scientific field in its entirety.

OBJECTIVE

The present study introduced and tested for the first time an innovative disciplinary trialogue, i.e. the combination of psychology, theology and diaconal studies. In particular, it is assumed that this combination can contribute to a more profound interpretation of the prominent concept of structural lag which is underresearched in gerontology.

MATERIAL AND METHODS

The analysis of structural lag with another overarching concept, "room for possibilities", can provide a synergy-rich interpretation category for a range of challenges connected with old age. In this respect, three major transitions were selected to shed light on these concepts and examined by means of three focus group interviews: transition to retirement, need for long-term care in the private home context and transition to nursing home life. The data were evaluated using qualitative content analysis.

RESULTS

The interdisciplinary-oriented evaluation of the interviews and the qualitative data analysis revealed the relevance of different perceptions of time in all three transitions. In addition, different dynamics in terms of the interplay of gains and losses as well as participation were found to be important for a better understanding of the three transitions. In particular, the subjective interpretation of the time remaining for living and the predetermined or self-selected time structuring of the daily routine were important factors for the perception of one's own potential. The results also underline a range of unused room for possibilities and the existence of structural lag for each transition.

CONCLUSION

By the cooperation of the participating disciplines aspects of aging and their interdependence became visible. At the same time this pilot-like disciplinary trialogue revealed the challenges in combining interdisciplinary perspectives by the combination of empirical and hermeneutical methods.

Circulating angiopoietin-like protein 8 is independently associated with fasting plasma glucose and type 2 diabetes mellitus

OBJECTIVE

Angiopoietin-like protein 8 (Angptl8) has recently been introduced as a novel adipokine/hepatokine that promotes pancreatic β-cell proliferation and improves glucose tolerance in mouse models of insulin resistance. However, regulation of Angptl8 in human type 2 diabetes mellitus (T2DM) and renal dysfunction has not been determined.

RESEARCH DESIGN AND METHODS

Serum Angptl8 levels were quantified by ELISA in 62 patients with T2DM as compared with 58 nondiabetic subjects in vivo. Within both groups, about half of the patients were on chronic hemodialysis or had an estimated glomerular filtration rate above 50 mL/min/1.73 m(2). Furthermore, we investigated the effect of insulin and differentiation on Angptl8 mRNA expression in 3T3-L1 adipocytes in vitro.

RESULTS

Median [interquartile range] serum Angptl8 levels were higher in patients with T2DM (1.19 [0.37] μg/L) as compared with nondiabetic subjects (1.03 [0.47] μg/L) (P = .005). Furthermore, the adipokine/hepatokine was significantly higher in women (1.21 [0.47] μg/L) as compared with men (1.05 [0.44] μg/L]) (P = .013). In multivariate analysis, fasting glucose and T2DM but not renal function remained independent and positive predictors of circulating Angptl8 even after adjustment for markers of obesity, lipid status, and inflammation (P < .05). Furthermore, Angptl8 mRNA expression was induced by insulin and during adipogenesis in 3T3-L1 adipocytes in vitro.

CONCLUSIONS

Circulating Angptl8 is positively and independently associated with T2DM and fasting glucose in vivo. Furthermore, Angptl8 mRNA expression is induced by insulin and during adipogenesis in 3T3-L1 adipocytes in vitro.

A novel Nrf2-miR-29-desmocollin-2 axis regulates desmosome function in keratinocytes

The Nrf2 transcription factor controls the expression of genes involved in the antioxidant defense system. Here, we identified Nrf2 as a novel regulator of desmosomes in the epidermis through the regulation of microRNAs. On Nrf2 activation, expression of miR-29a and miR-29b increases in cultured human keratinocytes and in mouse epidermis. Chromatin immunoprecipitation identified the Mir29ab1 and Mir29b2c genes as direct Nrf2 targets in keratinocytes. While binding of Nrf2 to the Mir29ab1 gene activates expression of miR-29a and -b, the Mir29b2c gene is silenced by DNA methylation. We identified desmocollin-2 (Dsc2) as a major target of Nrf2-induced miR-29s. This is functionally important, since Nrf2 activation in keratinocytes of transgenic mice causes structural alterations of epidermal desmosomes. Furthermore, the overexpression of miR-29a/b or knockdown of Dsc2 impairs the formation of hyper-adhesive desmosomes in keratinocytes, whereas Dsc2 overexpression has the opposite effect. These results demonstrate that a novel Nrf2-miR-29-Dsc2 axis controls desmosome function and cutaneous homeostasis.

Circulating adipocyte fatty acid binding protein is increased in chronic and acute renal dysfunction

BACKGROUND AND AIMS

The adipokine adipocyte fatty acid binding protein (AFABP) is positively associated with the development of the metabolic syndrome, diabetes mellitus, and cardiovascular disease. We hypothesized that AFABP also increases with deteriorating renal function.

METHODS AND RESULTS

Serum AFABP levels were quantified by enzyme linked immunosorbent assay in 532 patients with chronic kidney disease (CKD) covering the whole spectrum of estimated glomerular filtration rate (eGFR) categories from G1 to G5 (study population 1). Furthermore, AFABP was measured in 32 patients before and within 30 h after elective unilateral nephrectomy, a model of acute kidney dysfunction (AKD) (study population 2). Moreover, circulating AFABP was investigated in rats undergoing bilateral nephrectomy (BNE) as compared to sham-operated animals. Median serum AFABP levels adjusted for age, gender, and body mass index significantly increased with increasing eGFR category (G1: 22.0 μg/l; G2: 34.6 μg/l; G3: 56.7 μg/l; G4: 95.2 μg/l; and G5: 173.9 μg/l). Furthermore, renal dysfunction remained positively associated with AFABP in multivariate analysis in this cohort. In patients undergoing unilateral nephrectomy, AFABP increased significantly after surgery (42.1 μg/l) as compared to pre-surgical values (29.3 μg/l). Furthermore, relative changes of post-to-pre-surgical AFABP levels were independently associated with relative changes of post-to-pre-surgical creatinine concentrations. After BNE in rats, AFABP increased significantly as compared to sham-operated animals.

CONCLUSIONS

We show that AFABP is significantly elevated in CKD and AKD patients. Furthermore, measures of renal function are associated with circulating AFABP. Moreover, animal experiments indicate that AFABP levels strongly depend on renal function.

ERG rearrangement and protein expression in the progression to castration-resistant prostate cancer

BACKGROUND

Approximately half of the prostate carcinomas are characterized by a chromosomal rearrangement fusing the androgen-regulated gene TMPRSS2 to the oncogenic ETS transcription factor ERG. Aim of this study was to comprehensively analyze the role and impact of the ERG rearrangement and protein expression on the progression to castration-resistant (CR) disease.

METHODS

We used a tissue microarray (TMA) constructed from 114 hormone naive (HN) and 117 CR PCs. We analyzed the ERG rearrangement status by fluorescence in situ hybridization and the expression profiles of ERG, androgen receptor (AR) and the proliferation marker Ki67 by immunohistochemistry.

RESULTS

Nearly half of the PC tissue specimens (HN: 38%, CR: 46%) harbored a TMPRSS2-ERG gene fusion. HN PCs with positive translocation status showed increased tumor cell proliferation (P<0.05). As expected, TMPRSS2-ERG gene fusion was strongly associated with increased ERG protein expression in HN and CR PCs (both P<0.0001). Remarkably, the study revealed a subgroup (26%) of CR PCs with ERG rearrangement but without any detectable ERG protein expression. This subgroup showed significantly lower levels of AR protein expression and androgen-regulated serum PSA (both P<0.05).

CONCLUSIONS

In this study, we identified a subgroup of ERG-rearranged CR PCs without detectable ERG protein expression. Our results suggest that this subgroup could represent CR PCs with a dispensed AR pathway. These tumors might represent a thus far unrecognized subset of patients with AR-independent CR PC who may not benefit from conventional therapy directed against the AR pathway.

Diabetes mellitus without metformin intake is associated with worse oncologic outcomes after radical nephroureterectomy for upper tract urothelial carcinoma

AIMS

Evidence suggests a detrimental effect of diabetes mellitus (DM) on cancer incidence and outcomes. To date, the effect of DM and its treatment on prognosis in upper tract urothelial carcinoma (UTUC) remains uninvestigated. We tested the hypothesis that DM and metformin use impact oncologic outcomes of patients treated with radical nephroureterectomy (RNU) for UTUC.

METHODS

Retrospective analysis of 2492 patients with UTUC treated at 23 institutions with RNU without neoadjuvant therapy. Cox regression models addressed the association of DM and metformin use with disease recurrence, cancer-specific mortality and any-cause mortality.

RESULTS

A total of 365 (14.3%) patients had DM and 194 (7.8%) patients used metformin. Within a median follow-up of 36 months, 663 (26.6%) patients experienced disease recurrence, 545 patients (21.9%) died of UTUC and 884 (35.5%) patients died from any cause. Diabetic patients who did not use metformin were at significantly higher risk of disease recurrence and cancer-specific death compared to non-diabetic patients and diabetic patients who used metformin. In multivariable Cox regression analyses, DM treated without metformin was associated with worse recurrence-free survival (HR: 1.44, 95% CI 1.10-1.90, p = 0.009) and cancer-specific mortality (HR: 1.49, 95% CI 1.11-2.00, p = 0.008).

CONCLUSIONS

Diabetic UTUC patients without metformin use have significantly worse oncologic outcomes than diabetics who used metformin and non-diabetics. The possible mechanism behind the impact of DM on UTUC biology and the potentially protective effect of metformin need further elucidation.

Hepatic 3D cultures but not 2D cultures preserve specific transporter activity for acetaminophen-induced hepatotoxicity

Primary human hepatocytes (PHH) are the "gold standard" for in vitro toxicity tests. However, 2D PHH cultures have limitations that are due to a time-dependent dedifferentiation process visible by morphological changes closely connected to a decline of albumin production and CYP450 activity. The 3D in vitro culture corresponds to in vivo-like tissue architecture, which preserves functional characteristics of hepatocytes, and therefore can at least partially overcome the restrictions of 2D cultures. Consequently, several drug toxicities observed in vivo cannot be reproduced in 2D in vitro models, for example, the toxic effects of acetaminophen. The objective of this study was to identify molecular differences between 2D and 3D cultivation which explain the observed toxicity response. Our data demonstrated an increase in cell death after treatment with acetaminophen in 3D, but not in 2D cultures. Additionally, an acetaminophen concentration-dependent increase in the CYP2E1 expression level in 3D cultures was detected. However, during the treatment with 10 mM acetaminophen, the expression level of SOD gradually decreased in 3D cultures and was undetectable after 24 h. In line with these findings, we observed higher import/export rates in the membrane transport protein, multidrug resistance-associated protein-1, which is known to be specific for acetaminophen transport. The presented data demonstrate that PHH cultured in 3D preserve certain metabolic functions. Therefore, they have closer resemblance to the in vivo situation than PHH in 2D cultures. In consequence, 3D cultures will allow for a more accurate hepatotoxicity prediction in in vitro models in the future.

High incidence of rejection episodes and poor tolerance of sirolimus in a protocol with early steroid withdrawal and calcineurin inhibitor-free maintenance therapy in renal transplantation: experiences of a randomized prospective single-center study

Immunosuppressive maintenance therapy after kidney transplantation leads to various undesired side effects such as calcineurin inhibitor (CNI)-associated nephrotoxicity or elevated cardiovascular risk due to posttransplantation diabetes and hypertension. These effects show negative impacts on long-term allograft function as well as patient morbidity and mortality. Therefore, we used an immunosuppressive regimen with early corticosteroid withdrawal (ESW), maintenance therapy containing tacrolimus, sirolimus (SRL), and mycophenolate sodium for 3 months followed by a prospective randomized trial comparing a CNI free versus a low-dose CNI therapy. The primary endpoint was 6-month graft function. Among 75 patients, ESW was performed after 4 days in 65 patients. Over the following 3 months before randomization to CNI-free maintenance therapy, we experienced a high number (25%) of SRL discontinuations due to adverse events, including leukopenia, anemia, arthritis, and pneumonitis. In addition there were significantly more allograft rejection episodes in the CNI-free group (P = .017) during the study period leading to a switch from SRL to a CNI. Despite the higher rate of rejection episodes in the CNI-free groups, glomerular filtration rates (GFR) at 6 months were comparable between the study groups (P = .25). After 1 year only 9.2% (6/65) of all patients treated with SRL remained on this drug. Conclusion, there was an unacceptably high rate of SRL intolerance using an ESW and CNI-free immunosuppressive regimen combined with a significantly higher rate of rejection episodes.

[Laservaporization of the prostate: current status of the greenlight and diode laser]

In the last decade laser vaporization of the prostate has emerged as a safe and effective alternative to transurethral resection of the prostate (TURP). This was facilitated in particular by the introduction of photoselective vaporization of the prostate (PVP) with a 532 nm 80 W KTP laser in 2002. Prospective randomized trials comparing PVP and TURP with a maximum follow-up of 3 years mostly demonstrated comparable functional results. Cohort studies showed a safe application of PVP in patients under oral anticoagulation and with large prostates. Systems from various manufacturers with different maximum power output and wavelengths are now available for diode laser vaporization of the prostate. Prospective randomized trials comparing diode lasers and TURP are not yet available. In cohort studies and comparative studies PVP diode lasers are characterized by excellent hemostatic properties but functional results vary greatly with some studies reporting high reoperation rates.

Comparison of the roll-plate and sonication techniques in the diagnosis of microbial ureteral stent colonisation: results of the first prospective randomised study

BACKGROUND

Microbial ureteral stent colonisation (MUSC) is one leading risk factor for complications associated with ureteral stent placement. As MUSC remains frequently undetected by standard urine cultures, its definitive diagnosis depends on microbiological investigation of the stent. However, a standard reference laboratory technique for studying MUSC is still lacking.

MATERIALS AND METHODS

A total of 271 ureteral stents removed from 199 consecutive patients were investigated. Urine samples were obtained prior to device removal. Stents were divided into four parts. Each part was separately processed by the microbiology laboratory within 6 h. Ureteral stents were randomly allocated to roll-plate or sonication, respectively, and analysed using standard microbiological techniques. Demographic and clinical data were prospectively collected using a standard case-report form.

RESULTS

Overall, roll-plate showed a higher detection rate of MUSC compared with sonication (35 vs. 28 %, p < 0.05) and urine culture (35 vs. 8 %, p < 0.05). No inferiority of Maki's technique was observed even when stents were stratified according to indwelling time below or above 30 days. Compared with roll-plate, sonication commonly failed to detect Enterococcus spp., coagulase-negative staphylococci (CoNS) and Enterobacteriaceae. In addition, sonication required more hands-on time, more equipment and higher training than roll-plate in the laboratory.

CONCLUSIONS

This prospective randomised study demonstrates the superiority of Maki's roll-plate technique over sonication in the diagnosis of MUSC and that urine culture is less sensitive than both methods. The higher detection rate, simplicity and cost-effectiveness render roll-plate the methodology of choice for routine clinical investigation as well as basic laboratory research.

Abstract A27: Comprehensive analysis of the TMPRSS2-ERG translocation during prostate cancer progression

Introduction: Approximately half of the diagnosed prostate carcinomas (PC) are characterized by a chromosomal rearrangement fusing the androgen regulated gene TMPRSS2 to the oncogenic ETS transcription factor ERG. Aim of this study was to comprehensively analyze the impact of this translocation on the expression of the ERG gene in hormone-naïve (untreated) and castration-resistant prostate cancers and to define the influence of AR protein expression and genomic amplification in this context.

Methods: We constructed a tissue microarray (TMA) containing 915 tissue cores from 107 hormone-naïve PC and from 101 castration-resistant (CR) PC. In addition, we included 56 specimens from distant metastases. We analyzed the TMPRSS2-ERG translocation status by fluorescence in-situ hybridization and the expression profiles of ERG, AR and the proliferation marker Ki67 by immunohistochemistry.

Results: Nearly half of the analyzed PC tissue specimens (untreated: 38%, castration-resistant: 46%) harbored a TMPRSS2-ERG gene fusion. Untreated PC with positive translocation status showed increased tumor cell proliferation (p &lt; 0.05). As expected, TMPRSS2-ERG gene fusion was strongly associated with increased ERG protein expression in untreated, as well as in castration-resistant PC (both p &lt; 0.0001). However, we detected a subgroup (26%) of CR PCs with the gene fusion, but without detectable ERG protein expression. This subgroup showed significantly lower levels of AR protein expression and of the androgen regulated serum PSA (both p&gt;0.05).

Conclusions: This comprehensive study comparing the TMPRSS2-ERG gene and ERG protein expression status in a large cohort of hormone-naïve and CR PC, identifies a subgroup of translocated CR PCs without ERG protein expression. Our results suggest that this subgroup may represent CR PCs with a dispensed AR pathway. Further analyses may help to explain if these tumors represent a distinct subgroup of AR independent CR PCs.

Citation Format: Shyh-Han Tan, I. Sesterhenn, S. Srivastava, L. Bubendorf, C. Ruiz, M. Braun, V.J. Scheble, T. Zellweger, C.A. Rentsch, A. Bachmann, Albert Dobi, S. Perner. Comprehensive analysis of the TMPRSS2-ERG translocation during prostate cancer progression [abstract]. In: Proceedings of the AACR Special Conference on Advances in Prostate Cancer Research; 2012 Feb 6-9; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2012;72(4 Suppl):Abstract nr A27.

Comprehensive analysis of electrically-pumped GaSb-based VCSELs

This paper discusses several performance-related aspects of electrically-pumped GaSb-based buried tunnel junction VCSELs with an emission wavelength of 2.6 μm based on theoretical and experimental results. These results allow a deeper insight into the internal device physics, such as radial diffusion of carriers, maximum continuous-wave operating temperature, diffraction loss, internal temperature, gain and loss parameters, internal quantum efficiency of the active region etc. These parameters can be taken into account while designing mid-infrared lasers which leads to an improved device performance. A simple thermal model of the devices based on the two-dimensional (2-D) finite element method using the material data from the literature is also presented. In addition, an application-based result utilizing these lasers for the measurement of absolute water vapor concentration by wavelength modulation spectroscopy (WMS) method are also described, hinting that devices are well-suited for the targeted sensing applications.

Retroperitoneal LESS donor nephrectomy

Donor nephrectomy with laparo-endoscopic single site (LESS) surgery has been reported via the transperitoneal approach. We describe a novel technique of retroperitoneal donor nephrectomy using a single surgical incision in the groin, below the abdominal skin crease or "bikini line". The LESS groin incision offers superior cosmesis, while the retroperitoneal approach has distinct advantages, such as the ability to identify the renal vessels early. The new procedure has been performed in two obese patients (body mass index 32 and 33 kg/m2, respectively). The operative times were 4 and 5 hours, warm ischemic times 135 and 315 seconds, blood loss 100 and 250 mL, and hospitalization 3 and 2 days, respectively. Retroperitoneal LESS donor nephrectomy through a single, inconspicuous groin incision is feasible and safe. Further evaluation of the technique in a larger patient cohort is indicated.

Serum levels of the adipokine fasting-induced adipose factor/angiopoietin-like protein 4 depend on renal function

Fasting-induced adipose factor/angiopoietin-like protein 4 (FIAF/Angptl4) was recently introduced as a novel adipokine influencing glucose and lipid homeostasis. In the current study, we quantified circulating FIAF/Angtl4 levels in patients on chronic hemodialysis (CD) as compared to controls with a glomerular filtration rate above 50 ml/min. FIAF/Angptl4 was determined by ELISA in control (n=60) and CD (n=60) patients and correlated to clinical and biochemical measures of renal function, glucose and lipid metabolism, as well as inflammation, in both groups. Median serum FIAF/Angptl4 levels were more than 5-fold higher in CD patients (48.3 μg/l) as compared to control subjects (8.4 μg/l) (p<0.001). Furthermore, serum creatinine independently predicted FIAF/Angptl4 concentrations in multiple regression analyses in control subjects (p<0.01). In CD patients, C-reactive protein was independently and positively associated with circulating FIAF/Angptl4 (p<0.01). Taken together, we show that serum FIAF/Angptl4 levels are significantly increased in end-stage renal disease and independently associated with markers of renal function in control subjects.

Kidney transplant from the same donor without maintenance immunosuppression after previous hematopoietic stem cell transplant

In January 2005, an 18-year-old male patient with acute myeloid leukemia (AML) received a haploidentical hematopoietic stem cell transplantation (HSCT) from his father. He developed hemolytic uremic syndrome and end-stage renal disease (ESRD) requiring hemodialysis on day 357 after HSCT. On day 1020 after HSCT, a living kidney donation from the stem cell donor was carried out. The creatinine before kidney transplantation (KT) was ≈450 μmol/L, 268 μmol/L on day 2 after KT, 88 μM on day 38 and 89 μmol/L on day 960 (day 1980 after HSCT). Immunosuppression was gradually discontinued: cortisone on day 28, tacrolimus on day 32 and MMF on day 100 after KT (day 1120 after HSCT). As of June 2010, 66 months after HSCT and 32 months after KT, the patient has had neither rejection episodes nor clinical manifestations of transplantation-related complications. The patient reached 100% hematopoietic donor chimerism prekidney transplant and retained this state postkidney transplant. This unique case is the first report of a successful kidney transplant without immunosuppression after HSCT from the same haploidentical donor.

Comparison of guideline recommendations with daily practice in patients with renal cell carcinoma

Objectives and Aims

To compare guideline recommendations with daily practice patterns in a German patient cohort with renal cell carcinoma.

Patients and methods

81 patients with T1 oder T2 renal cell carcinoma (RCC) were included in this prospective single-center study. All patients were operated in a single institution either by open radical nephrectomy (ORN) or nephron sparing surgery (NSS). Patients and doctors were evaluated using a written questionnaire with a follow-up of 12 months. Follow-up intervals, follow-up modalities (e. g. imaging modalities, laboratory controls of blood and urine) and the call on psycho-oncological support were evaluated.

Results

The majority of patients (72%) were followed up by their urologists. Follow-up examinations included abdominal ultrasound, urine and blood diagnostics, conventional chest x-rays, computed tomography (CT) of abdomen, chest or head or abdominal Magnetic Resonance Imaging (MRI). There were no significant differences between patients operated by ORN or NSS. In total, 12.5% of patients were asking for psycho-oncological support.

Conclusions

In general, patients were followed up according to existing guideline recommendations. Only a small proportion of patients asked for psycho-oncological treatment.

Fibroblast growth factor 19 serum levels: relation to renal function and metabolic parameters

Fibroblast growth factor 19 (FGF19) was recently introduced as a novel metabolic regulator reversing diabetes mellitus, hepatic steatosis, hyperlipidemia, and adiposity. In the current study, we determined circulating FGF19 levels in patients on chronic hemodialysis (CD) as compared to controls with a glomerular filtration rate (GFR) above 50 ml/min. FGF19 was measured by ELISA in control (n=60) and CD (n=60) patients and correlated to clinical and biochemical measures of renal function, glucose, and lipid metabolism, as well as inflammation, in both groups. Median serum FGF19 levels were 1.5-fold higher in CD patients (266.7 microg/l) as compared to subjects with a GFR above 50 ml/min (178.1 microg/l) (p=0.001). Furthermore, fasting glucose negatively and independently predicted circulating FGF19 in controls (p<0.05). Moreover, adiponectin was a positive and C-reactive protein was a negative independent predictor of FGF19 serum concentrations in CD patients. Taken together, we have demonstrated that circulating FGF19 levels are significantly increased in end-stage renal disease. Furthermore, FGF19 is associated with a beneficial metabolic profile in both control and CD patients.