Investigating the relationship between the number and activity of natural killer cells with increased cytomegalovirus and CMV disease after kidney transplantation

BACKGROUND

Cytomegalovirus (CMV) infections caused by the cytomegalovirus are one of the most common problems in patients after kidney transplant. We examined the association of the relationship between the number and activity of natural killer cells with increased cytomegalovirus and its related disease after kidney transplantation.

MATERIAL AND METHODS

In this analytical study, 58 new transplant patients in the Labbafinejad Hospital, who did not have any evidence of CMV infection, were evaluated based on the number and percentage of CD56+/16+, CD56+/16-, and CD69+ Natural Killer (NK) cells.

RESULTS

The results of this study showed that CD16+ and CD56+ cells in the group of CMV Ag-positive patients are less than negative patients (p = 0.003) and the difference between the two groups are significant (p = 0.01). However, CD69+ cells did not differ significantly between the two groups (p = 0.1). Moreover, the absolute number of CD16+ and CD56+ cells declined significantly after infection with CMV unlike the CMV Ag - group(p = 0.003).

DISCUSSION

These results indicate that kidney transplant patients suffering from CMV infection after transplantation have a significantly reduced total number of NK cells. On the other hand, a slight decrease in the number of NK subgroups was observed with an increase in the peak serum levels of cyclosporine. As a consequence of these findings, it can be assumed that more dosage and a higher level of the drug will result in more severe immunosuppression and, consequently, increased susceptibility to CMV infections. Thus, taking the right dose of the drug would prevent viral infections and immune system from over-activation.

Impact of Nanographene Oxide on Cisplatin Induced Acute Kidney Injury Managed by Stem Cells Therapy

INTRODUCTION

Graphene-based nanomaterials have shown some degrees of stem cell protection against cell death. Due to their distinctive function, the kidneys are exposed to many toxic substances. On the other hand, minor and trivial effects of stem cells have been reported for the treatment of acute kidney injury (AKI). Here, we explain the use of Graphene oxide (GO) for improving the efficacy of mesenchymal stem cells (MSCs) in the treatment of Cisplatin-induced AKI.

METHODS

In this study, GO particles were synthesized in our lab. Cisplatin-induced AKI was modeled on rats. Thirty adults male Wistar Albino rats were divided into five groups: control group (did not receive any treatment), Cisplatin group (received 5 mg/ kg cisplatin intraperitoneally), sham group (received 500 µL saline intraperitoneally 5th days after Cisplatin injection), [Cisplatin + MSCs] group (received 5×106 /kg MSCs after Cisplatin injection), and [Cisplatin+ MSCs + GO] group (received 1.5 mg/kg GO + MSCs after Cisplatin injection. Biochemical analysis of serum creatinine (Cr) and blood urea nitrogen (BUN) levels, as well as histological study of the kidneys in diverse groups were compared. The oneway analysis of variance (ANOVA) and Dunnett's test were used for comparisons between the study groups.

RESULTS

GO improved the effects of MSCs transplantation on serum Cr and BUN in AKI rat models. It also reduced cell death, hyaline casts, and cell debris in the animal models compared to the MSCs group.

CONCLUSION

It could be concluded that GO can enhance the efficacy of MSCs transplantation in the treatment of damaged kidneys.  DOI: 10.52547/ijkd.7472.

The relationship between CT value and clinical outcomes in renal patients with COVID-19

PURPOSE

Concomitant kidney diseases raise the mortality rate due to the SARS-CoV-2 virus as an independent factor. Although a qualitative PCR test's result is sufficient for diagnosis, Cycle threshold value may present relevant information to the physicians in providing faster treatment in patients with chronic conditions, including kidney diseases, to prevent morbidity and subsequent mortality. Thus, the present study was conducted to determine the relationship between the Cycle threshold value and clinical outcomes in renal patients with the coronavirus 2019.

METHODS

This retrospective study was conducted on renal patients with the coronavirus 2019 infection admitted to Labbafinejad Hospital in Tehran, the capital of Iran, within a period of one year, from late February 2020 to February 2021. Data were collected per the prepared checklist. Cycle threshold values were measured by performing PCR on nasopharynx and oropharynx swab samples of patients.

RESULTS

According to the adjusted analysis, having high viral load increased the odds of in-hospital mortality (aOR = 11.65, 95% CI 3.93-34.54), ICU admission (aOR = 5.49, 95% CI 2.16-13.97), and invasive ventilation (aOR = 7.18, 95% CI 2.61-19.74). Having high viral load also increased the odds of O₂ therapy (aOR = 3.08, 95% CI 0.79-12.01), although the difference was not statistically significant (P = 0.105).

CONCLUSION

Cycle threshold value was a significant predictor of mortality in renal patients. Nevertheless, further studies are required on how to render optimal use of the Cycle threshold value, given that the quality of the test sample and the different groups of patients under study affect the effectiveness of this marker in predicting disease severity.

Measured GFR in Donor Selection, to Do or Not to Do? That is the Question

INTRODUCTION

The accurate assessment of the pre-donation glomerular filtration rate (GFR) is a crucial step in donor selection. We conducted a prospective cross-sectional study to identify the best equation to estimate GFR and the necessity of a radio-nuclear scan in GFR evaluation.

METHODS

In this study, 154 potential donors were enrolled, and GFR equations (the MDRD study, the CKD-EPI study, and the full age spectrum [FAS]), and creatinine clearance were compared with measured GFR (mGFR) by the radio-nuclear method.

RESULTS

The study results indicate that Potential donors had an mGFR of 95.56 ± 15.57 mL/min per 1.73 m2. Though body surface area (BSA) adjusted full age spectrum (FAS) and CKD-EPI equations were most correlated with mGFR, the correlation coefficients were weak (ICC: 0.3 and 0.32, respectively). Misclassification at the cut-off of 80 cc/min/ 1.73 m2 was about 42% for both equations. Besides, 16.8% of donors with eGFR more than 80 cc/min/ 1.73 m2 had a difference in split renal function, and 57.1% of participants had a > 2% probability of having an mGFR < 90 mL/min per 1.73 m2.

CONCLUSION

If the nuclear scan is easily available, we suggest measuring GFR by 99mTc -DTPA scan as the preferred method. Otherwise, our data suggest utilizing mGFR in patients with high body mass index, size asymmetry in CT-scan, eGFR less than 90 mL/min per 1.73 m2 with FAS and/or CKD-EPI equation as these factors deviated the estimated GFR, and also in those with inaccurate creatinine clearance measurements or with posttest probability of having mGFR less than 90 mL/min per 1.73 m2 more than 2%.  DOI: 10.52547/ijkd.7271.

Immunogenicity and Safety of SpikoGen®, an Adjuvanted Recombinant SARS-CoV-2 Spike Protein as a Heterologous Third Booster Dose in Kidney Transplant Patients: A Single-Arm Clinical Trial

Purpose

Studies have shown that immunocompromised patients have suboptimal responses to COVID-19 vaccines leading to approval of a need for booster doses in this population. SpikoGen® is a subunit recombinant spike protein vaccine combined with Advax-CpG55.2™ adjuvant to protect against COVID-19. This vaccine was shown to be safe, immunogenic and efficacious to reduce the risk of COVID-19 including severe disease in previous clinical trials. However, the effects of this vaccine have not been assessed in immunocompromised patients. This study sought to assess the immunogenicity and safety of SpikoGen® vaccine as a third booster dose in kidney transplant patients taking immunosuppressive therapy who have received their primary vaccination based on an inactivated whole virus platform (Sinopharm).

Methods

This was a single-arm trial performed on 43 kidney transplant patients. The participants received a single booster dose of SpikoGen® vaccine 1 to 3 months after primary vaccination with 2 doses of Sinopharm vaccine. Immunogenicity assessments were performed at baseline and 30 days after the booster dose. The primary outcomes were seroconversion rates of anti-S₁ and surrogate virus neutralizing antibodies. Safety outcomes included the incidence of solicited and unsolicited adverse events in the seven days and one month after the booster dose, respectively.

Findings

SpikoGen® vaccine induced positive humoral and cellular responses 30 days after the booster dose in those seropositive or seronegative after two primary doses of Sinopharm vaccine. Thirty days post the SpikoGen® vaccine booster, seroconversion rates were 35.29% (95% CI; 19.75% to 53.51%) to anti-S₁ and 29.41% (95% CI; 13.27% to 46.57%) to surrogate neutralizing antibodies. The most common local and systemic reported solicited adverse events were injection site pain and fatigue, which were largely mild and transient. No serious adverse events were reported.

Implications

A single booster dose of SpikoGen® vaccine given 1-3 months after primary vaccination with 2 doses of Sinopharm vaccine induced positive humoral and cellular immune responses in immunosuppressed renal transplant patients thereby achieving spike antibody levels predictive of protection. It should be noted that this study was performed as just a single center study, and it will be important for future large multi-center studies to extend these results to other immunocompromised patient groups.

Frequency of CD39+, LAG3+, and CTLA4+ Regulatory T Cells in Two Different Immunosuppressive Protocols in Renal Allograft Recipients (Sirolimus vs Mycophenolate mofetil): A Cohort Report

BACKGROUND

Impaired renal function is considered as a significant risk factor for cardiovascular events in chronic kidney disease patients. Several immunosuppressive drugs are used in these patients, which necessitates to minimize the drug-related side effects by employing alternative strategies.

OBJECTIVE

This study aimed to evaluate prospectively the influence of low dose ATG induction therapy with two different protocols (Sirolimus versus Mycophenolate mofetil) on the expression of functional markers (LAG-3, CD39, and intracellular CTLA-4) on conventional Tregs in renal recipients.

METHODS

Thirty-eight renal transplant recipients were enrolled in this study. The patients were randomly assigned into two groups, including TMP: Tacrolimus (Tac), Mycophenolate mofetil (MMF), and Prednisolone (n=23); and TSP: Tac, Sirolimus (SRL), and Prednisolone (n=15). The frequency of LAG-3, CD39, and intracellular CTLA-4 on circulating Tregs was analyzed by flow cytometry before and after transplantation.

RESULTS

Analysis of the flow cytometry data showed that the frequency of CD4+CD25+FOXP3+ Tregs increased 4 months post-transplantation compared to pre-transplantation in both groups, although this increase was only significant in TMP group. In TMP treated patients, the frequency of LAG-3+ Tregs and CD39+ Tregs increased, whereas the frequency of intracellular CTLA-4+ Tregs decreased 4 months post-transplantation. In TSP group, while the frequency of CD39+ Tregs increased, the frequency of CTLA-4+ Tregs decreased in post-transplantation compared to pre-transplantation.

CONCLUSIONS

it seems that both treatment regimen protocols with a low dose ATG induction therapy may be clinically applicable in kidney transplant recipients.

Influence of cytotoxic T lymphocyte antigen 4 genetic variants on acute rejection in kidney transplant patients: precision medicine perspective

Background

The most effective and common treatment for end-stage renal disease is kidney transplantation.The personalized approach to kidney transplantation, which utilizes precision medicine principles, determines distinctive genomics characteristics of candidates/recipients that must be taken into account. Cytotoxic T lymphocyte associated protein 4 (CTLA4) may be a suitable candidate gene for studying allograft rejection. The aim of this study was to understand whether we can consider two common variants of the CTLA4 gene as a risk factor of transplant rejection in a group of Iranian population.

Methods

Totally, 169 kidney transplant recipients, including acute rejections (N=39) and non-rejection (N=130) groups who underwent transplantation were included in this study. The genotyping of rs5742909 (-318C/T) and rs231775 (+49A/G) variants of the CTLA4 gene were performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique.

Results

The AG genotype frequency of rs231775 variant was the same in both patients with and without a history of rejection while, none of those groups had homozygote genotype. In rs5742909, both CT and TT frequencies of patients with rejected transplant were lower than patients with a normal outcome.

Conclusions

The results of the presented study suggest that rs231775 and rs5742909 of CTLA4 genetic variants are not linked to acute rejection who underwent kidney transplantation. So, these variants cannot be considered as risk factors of acute allograft rejection in a group of Iranian renal transplantation recipients. However, the transplantation precision medicine may be an important area for the improvement of patients outcome as the precision medicine has already entered clinical practice in kidney transplantation.

Humoral Immunity of BBIBP-CorV (Sinopharm) in kidney transplant recipients: Is it time to revise vaccination strategies

BACKGROUND

The mortality of COVID-19 is high in transplant patients, and effective vaccination is aimed to reduce severe disease and mortality.

METHODS

We conducted a cross-sectional study to evaluate humoral and cellular response to two 4μg-doses of BBIBP-CorV vaccine in 100 kidney transplant recipients, using Anti-Spike IgG, Total Anti-RBD, Neutralizing Ab level (ELISA), and interferon-gamma release assay (IGRA).

RESULTS

Seroconversion was evaluated 85.84 ± 30.72 days after second dose. 58% of all and 43.05% infection-naïve participants have developed at least one of the tested antibodies. IGRA was positive in 30.7% of tested transplant recipients. 60% of the participants had either humoral or cellular response to COIVD-19. Only age was independently linked to seropositivity of any degree after vaccination (p<0.05). COVID-naïve patients older than 60 years developed significantly less neutralizing antibody. (p value: 0.011). Six patients developed mild COVID infection more than a month after 2^nd dose of vaccine (54.5 ± 20.8 days). No vaccine-related adverse effects were reported, except self-limited mild to moderate fever and injection site pain.

CONCLUSION

BBIBP-CorV vaccine can be used safely in kidney transplant recipient, although impaired cellular and humoral immunity necessitates adjustments in vaccination strategies, like higher (8μg-doses), forth booster dose, or boost with different platform vaccine. This article is protected by copyright. All rights reserved.

Association of IL-15 and IP-10 Serum Levels with Cytomegalovirus Infection, CMV Viral Load and Cyclosporine Level after Kidney Transplantation

BACKGROUND

Cytomegalovirus (CMV) infection is the most common complications following kidney transplantation. Natural killer (NK) cells demonstrated critical anti-viral role in controlling and elimination of CMV after transplantation. Interleukin-15 (IL-15) is a pleiotropic cytokine that promotes the activity of NK cells and strengthens the acquired immune system. Also, IP10 (CXCL10) is a chemotactic factor which regulates NK cell recruitment and antiviral immune response. We aimed to determine the correlation between the serum levels of IL-15 and IP-10 cytokines with CMV infection, CMV viral load, and cyclosporine as a major immunosuppressive treatment after transplantation.

METHODS

Fifty-eight kidney transplant recipient patients without evidence of CMV virus disease before transplantation surgery were included in the study. From the day of transplant surgery, the patients were evaluated based on the presence of CMV Ag pp65, CMV viral load, serum levels of IL-15 & IP-10, Cyclosporine levels (C0 & C2), Glomerular Filtration Rate (GFR), and hematological & biochemical Index, up to 75 days.

RESULTS

Comparison analysis of serum levels of IL-15 and IP-10 showed no significant association with CMV infection in kidney transplant recipients. In addition, CMV viral load and cyclosporine levels at C0 and C2 did not affect patients' IL-15 and IP-10 levels.

CONCLUSION

The levels of IP-10 and IL-15 cytokines are not affected with CMV infection, even if a viral infection occurs in the early days after transplantation or long afterwards. In addition, taking the different levels of cyclosporine did not affect the cytokines levels. Other mechanisms may play a role in maintaining the levels of these cytokines.

A Noninvasive Urine Metabolome Panel as Potential Biomarkers for Diagnosis of T Cell-Mediated Renal Transplant Rejection

Acute T cell-mediated rejection (TCMR) is a major complication after renal transplantation. TCMR diagnosis is very challenging and currently depends on invasive renal biopsy and nonspecific markers such as serum creatinine. A noninvasive metabolomics panel could allow early diagnosis and improved accuracy and specificity. We report, in this study, on urine metabolome changes in renal transplant recipients diagnosed with TCMR, with a view to future metabolomics-based diagnostics in transplant medicine. We performed urine metabolomic analyses in three study groups: (1) 7 kidney transplant recipients with acute TCMR, (2) 15 kidney transplant recipients without rejection but with impaired kidney function, and (3) 6 kidney transplant recipients with stable renal function, using ¹H-nuclear magnetic resonance. Multivariate modeling of metabolites suggested a diagnostic panel where the diagnostic accuracy of each metabolite was calculated by receiver operating characteristic curve analysis. The impaired metabolic pathways associated with TCMR were identified by pathway analysis. In all, a panel of nine differential metabolites encompassing nicotinamide adenine dinucleotide, 1-methylnicotinamide, cholesterol sulfate, gamma-aminobutyric acid (GABA), nicotinic acid, nicotinamide adenine dinucleotide phosphate, proline, spermidine, and alpha-hydroxyhippuric acid were identified as novel potential metabolite biomarkers of TCMR. Proline, spermidine, and GABA had the highest area under the curve (>0.7) and were overrepresented in the TCMR group. Nicotinate and nicotinamide metabolism was the most important pathway in TCMR. These findings call for clinical validation in larger study samples and suggest that urinary metabolomics warrants future consideration as a noninvasive research tool for TCMR diagnostic innovation.

The relationship between T-cell infiltration in biopsy proven acute T-cell mediated rejection with allograft function and response to therapy: A retrospective study

AIM

To evaluate the degree of CD3, CD20, Th17, and Tregs infiltration in kidney biopsy of the patients with acute cellular rejection and the possible relation with graft outcome.

MATERIALS AND METHODS

In this retrospective study, fifty patients with Acute T Cell-Mediated Rejection (ATCMR) were enrolled. Previous and one year clinical follow-up data were collected. The kidney specimens were evaluated for infiltration of CD3, CD20, FOXP3, and Th17 with IHC. According to the serum creatinine level in one-year follow-up of the patients after rejection therapy and function of the transplanted organ from the day admitted into the hospital, they were respectively categorized in Stable graft function versus impaired graft function; appropriate response to treatment versus failure to response.

RESULTS

Treg (P = 0.96) and Th17 (P = 0.24) cells were more in the unstable group than the stable group, but the difference wasn't significant. On the other hand, the FOXP3/Th17 ratio was higher in the stable group (P = 0.22). Moreover Treg (P = 0.1) and Th17 (P = 0.15) were higher in failure to response group, but FOXP3/Th17 was higher in proper response group (P = 0.8).

CONCLUSION

From the results, it can be concluded that TH17 infiltration has a more significant effect on graft outcome and response to rejection therapy.

Urinary epidermal growth factor is a novel biomarker for early diagnosis of antibody mediated kidney allograft rejection: A urinary proteomics analysis

Although antibody mediated rejection (AMR) accounts for 20-30% of all acute renal allograft rejections, introducing biomarkers for a timely detection of allograft rejection has been remained challenging. This study investigated novel diagnostic biomarkers of AMR by examining of urine proteome in renal transplant patients. Thirty-six patients with kidney transplantation including 22 AMR patients and 14 patients with stable renal function (control group) were enrolled in this study. Urinary samples were collected and Label free quantification (LFQ) proteomics technique was applied on urine samples and data was subjected to Random Forest (RF) algorithm to predict main candidate proteins contributing in AMR. Finally, applicability of candidate diagnostic biomarkers was evaluated in new sets of AMR subjects, stable patients and healthy volunteers. A total of 1020 proteins were detected in urine proteome. RF algorithm predicted 20 differentially expressed proteins with the highest sensitivity and specificity and combination of EGF, COL6A, and NID-1 was identified as possible panel for early diagnosis of AMR. Applicability of EGF as diagnostic biomarker was validated in urine samples of independent set of AMR subjects. This is the first urinary proteomics study in AMR patients demonstrating that urinary EGF might be used as early diagnostic biomarker for AMR. SIGNIFICANCE: Renal antibody mediated rejection (AMR) accounts for 20-30% of all acute rejections of allografted kidneys. Although several possible biomarkers have been proposed to predict AMR, ineffectiveness of current urinary biomarkers in early diagnosing of AMR patients and in distinguishing AMR subjects from patients with stable kidney function casts doubts on their applicability in clinic. Here for the first time and based on the analysis of urinary proteome we showed that uEGF and uEGF/Cr might be candidate biomarkers to predict AMR with high diagnostic power.

Predictive Biomarker Panel in Proliferative Lupus Nephritis- Two-Dimensional Shotgun Proteomics

INTRODUCTION

Lupus nephritis (LN) is one of the most serious complications of systemic lupus erythematous (SLE). With no specific clinical or laboratory manifestation to predict response to treatment, this study was aimed to provide a panel of predictive biomarkers of response before initiation of treatment.

METHODS

Liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis was performed on plasma and urine samples of 11 patients with biopsy proven proliferative LN at the time of biopsy. Unsupervised principal component analysis (PCA), orthogonal projection to latent structures discriminant analysis (OPLS-DA), gene ontology annotation and protein mapping were performed on 326 proteins in plasma and 1381 proteins in urine samples.

RESULTS

Samples of eight patients achieved complete remission and three reached partial remission were analyzed. The mean 24-hour protein excretion was 3259 mg/day and the mean eGFR was 87.73 cc/min. OPLS-DA analysis of plasma samples showed a clear discrimination for complete and partial remission patients. Twenty plasma proteins and ten urine proteins with the highest fold changes and AUCs were selected as candidate biomarkers (IGHV1-18, PI16, IGHD, C3, FCER2, EPS8L2, CTTN, BLVRB). This plasma and urine biomarker panel is involved in oxidative stress, acute inflammation, reduction in regulatory T cells, complement pathway consumption, and proximal tubule bicarbonate reclamation.

CONCLUSION

Our suggested panel of plasma and urine biomarkers can precisely discriminate patients with possibility of complete response to treatment. It seems that the higher indices of inflammation will associate with better chance of achieving complete remission.

Agreement between the results of tuberculin skin test and Interferon-Gamma Release Assays in renal transplant candidates

Introduction:

Identification of latent tuberculosis (TB) infection is important in kidney transplant candidates. Due to the absence of a gold standard, both tuberculin skin test (TST) and interferon-gamma release assays (IGRA) are used to screen patients. The aim of this study was to evaluate the agreement of these two tests in patients undergoing renal transplantation.

Materials and Methods:

Two hundred kidney transplant candidates at a referral center in 2014–2017 were included in this study. TST and Quantiferon-Gold (QFT-G) tests were performed for all patients before transplantation. In case of a positive result in any of the tests, patients were administered a 9-month prophylaxis treatment using isoniazid. Cohen's kappa coefficient (k) test was used to determine the agreement between the two tests.

Results:

The mean age of patients was 40.72 ± 18.33. Nine (4.5%) patients had positive TST and 16 (8%) had positive IGRA. Concordance of the two tests was evaluated as medium (κ = 0.44 and P < 0.001). No association was found between the underlying causes of renal failure and skin test positive or IGRA. The tests showed a poor agreement among diabetics, candidates of re-transplantation, and those who were on dialysis for longer than a year (κ < 0.20).

Conclusion:

TST or IGRA can be used to screen TB in kidney transplant candidates with a moderate agreement. However, we suggest using both TST and QFT-G in diabetics, re-transplant candidates, and those on dialysis for >1 year.

Methylation of the PKD1 Promoter Inversely Correlates with its Expression in Autosomal Dominant Polycystic Kidney Disease

Background

Autosomal dominant polycystic kidney disease (ADPKD), a multisystem disorder, is the most prevalent type of hereditary kidney disease. Here, we aimed to evaluate methylation of the PKD1 gene (PKD1) promoter and its correlation with PKD1 expression in peripheral blood.

Methods

In this case-control study methylation of the PKD1 promoter was evaluated using methylation-sensitive high-resolution melt (MS-HRM) analysis. PKD1 expression was assessed by quantitative real-time PCR. The correlation was evaluated using the Pearson correlation test.

Results

Twenty subjects from both the patient and control groups (n= 40 for each) were methylated at the PKD1 promoter to various levels (18.9% in patients and 62.5% in controls). This difference was statistically significant (p< 0.0001). PKD1 expression in blood samples was significantly greater in ADPKD patients than in controls (p= 0.0081). Significant correlation was seen between PKD1 expression and its promoter methylation status in peripheral blood (r case= -0.5300, p= 0.0162, and r control = -0.6265, p= 0.0031).

Conclusion

Methylation of the PKD1 promoter in ADPKD patients was inversely correlated with PKD1 expression.

Low rate of COVID-19 pneumonia in kidney transplant recipients-A battle between infection and immune response?

BACKGROUND

With COVID-19 pandemic, concerns about kidney transplant recipients are rising. However, the incidence, clinical course, outcome, and predictive factors of disease severity are obscured.

METHODS

We describe clinical and laboratory manifestations, radiologic findings, clinical course, and finally outcome of kidney transplant recipients with COVID-19 pneumonia.

RESULTS

Of 2493 kidney transplant recipients under follow-up in our clinic, 19 cases (4 cases diagnosed based on radiologic findings) were admitted. The mean age of patients was 47.6 ± 12.4 years, and the mean time from transplantation was 115.6 ± 70.3 months. Lymphopenia and eosinopenia were 84.2% and 78.9%, respectively. Nine patients did not survive the hospital course. History of acute rejection during the past 12 months, diabetes, higher N/L ratio, lower platelet count, elevated N/L x CRP, higher levels of LDH, positive D-dimer, higher troponin, and prolonged PT were associated with mortality. Among patients with positive COVID-19 test, history of acute rejection, low platelet count, and positive D-dimer were associated with poor outcome. Treatment with cyclosporine was associated with better clinical outcome.

CONCLUSIONS

Low rate of admission in transplant recipients specially in the very first years of transplantation might be due to protective effects of immunosuppressive agents against cytokine storm or modification of immunity function. We suggest evaluation of T-cell number, function, and cytokine profile as a guide to manage COVID-19 mainly in patients with higher risk of mortality.

Early Graft Function in Deceased Donor Renal Recipients: Role of N-Acetylcysteine

Reduced graft function (RGF) in donor renal transplant recipients is caused by oxidative damage due to extensive ischemia-reperfusion (I/R) injury during transplantation. Neutrophil gelatinase-associated lipocalin (NGAL) is a promising biomarker to detect tubular injury early after renal transplantation. N-acetylcysteine (NAC) is a potent antioxidant that can reduce I/R injury by improving oxidative damage. The aim of the present study is to assess the efficacy of NAC in improving graft function and reducing renal tubular injury in deceased donor renal transplant recipients. A double-blind, randomized clinical trial was conducted on 50 deceased donor renal transplant recipients. The patients were randomized into two groups, receiving either 600 mg NAC twice daily, or placebo (days 0 to 5). Results were assessed based on the rate of RGF, levels of plasma NGAL (p-NGAL) and the estimated glomerular filtration rate (eGFR). The rate of RGF was significantly lower in the patients receiving NAC vs. placebo (21.4% vs. 50%). The measurement of p-NGAL levels showed that the patients in the NAC group had significantly greater reduction of p-NGAL by both days 1 and 5 post-transplantation than those in the placebo group. A near steady-state eGFR level was reached by week 1 in the NAC group, however, the improvement of eGFR was significantly slower in the placebo group and a near steady-state was only achieved by week 4. NAC has promising potential in reducing tubular injury and improving graft function, evidenced by significant reduction in the rate of RGF and levels of p-NGAL.

Biomarkers in Primary Membranous Nephropathy, A Guide to Precision Medicine

Membranous nephropathy (MN) as one of the most common glomerulonephritis still relies on an invasive procedure of kidney biopsy for precise recognition. Over the recent past years noninvasive methods using wide range of biomarkers have been developed in order to diagnose and estimating the final prognosis of MN. Plasma, urine and tissue are readily accessible specimens for identification of these biomarkers. In order to utilize a single biomarker or a panel of them for detection of a specific entity, many factors should taking into consideration like the accuracy, precision, and validity, accompanying with being available and cost effective. This review is focused on recently developed biomarkers and their application on the diagnosis besides determining the prognosis of MN. The clinical utilities and limitations of each biomarker are discussed in details.

Time-Varying Covariates and Risk Factors for Graft Loss in Kidney Transplantation

OBJECTIVES

The present study was designed to evaluate the factors involved in long-term graft survival in recipients of kidney transplantation.

MATERIALS AND METHODS

We reviewed 755 Iranian adult recipients who underwent kidney transplantation at Shahid Labbafinejad Medical Center in Tehran, Iran. Patients were followed for 5 years after transplantation. The primary outcome was the time between transplantation and graft loss. Using Cox regression, we studied the effect of time-independent variables (recipients' age and sex, donors' age, and type of donor), time-dependent covariates (body mass index [BMI], systolic blood pressure, diastolic blood pressure, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol levels, proteinuria and serum creatinine level), and immunosuppressive drugs on graft loss 60 months after transplantation. The results are presented as the hazard ratio (HR) with 95% confidence intervals.

RESULTS

Result from Cox proportional hazards model showed that the HR of graft loss was 1.62 (95% CI: 1.03-2.54) in cadaveric donor compared with living donor kidney recipients. The HR of graft loss for recipient age was 1.02 (95% CI: 1.002-1.030). Moreover, according to obtained results, the risk of losing functional transplant increased for each mg/dL rise in serum creatinine at least 9% and at most 40%. Our results also showed that 1 unit increase of BMI has at least a 2% and at most a 15% decremented effect on the hazard ratio of graft loss.

CONCLUSIONS

Having lower levels of creatinine and receiving a kidney from a younger living donor were associated with a decreased risk of graft loss. Graft loss is more likely to occur in patients with lower BMI.

Clinical and Radiologic Characteristics of COVID-19 in Patients With CKD

INTRODUCTION

In this study, we aimed to evaluate the presentation and outcome of COVID-19 in patients with chronic kidney disease (CKD).

METHODS

We included 43 patients with a past history of CKD and confirmed diagnosis of COVID-19. Patients were evaluated for demographic characteristics, clinical and laboratory data and findings of initial chest computed tomography (CT) and were followed until either death or discharge occurred. Then, study variables were compared based on final outcome and stage of CKD.

RESULTS

Mean age ± SD of patients was 60.65 ± 14.36 years; 65.1% were male. Five of 43 patients (11.6%) died on follow-up and the rest were discharged. Disease outcome did not differ across CKD stages (P > .05). More than half of the patients (58.1%) presented with severe disease on admission. Clinical symptoms were similar to those of non-CKD individuals. Mean duration of hospitalization was higher in those who died, although not significant (16.6 ± 8.38 vs. 11 ± 6.26, P > .05). The only hematologic parameter that significantly differed between survivors and non-survivors was lactase dehydrogenase level (P < .05). Ground-glass opacification and reticular pattern were the most frequent patterns on CT and pleural effusion existed in about one-fifth of all patients. A greater lower zone score was noted in deceased patients (P < .05).

CONCLUSION

Patients with CKD are vulnerable to a more severe form of COVID-19 and experience a higher mortality rate than the general population; however, higher CKD stage is not related to worse prognosis or different imaging manifestation compared with lower stage.

Adding Colchicine to the Antiretroviral Medication - Lopinavir/Ritonavir (Kaletra) in Hospitalized Patients with Non-Severe Covid-19 Pneumonia: A Structured Summary of a Study Protocol for a Randomized Controlled Trial

Objectives

Colchicine is a well-known drug, which has been used for years to treat a wide range of rheumatic and inflammatory disorders. It helps break the cycle of inflammation through diverse mechanisms including reducing Intereukin-6, Interleukin-8, Tumour Necrosis Factor-alpha besides controlling oxidative stress pathways which all are important and pathologic components in the clinical course and outcome of patients infected with COVID-19. This study aims to assess the anti-inflammatory effects of colchicine in non-severe hospitalized COVID-19 patients.

Trial design

Prospective, randomized (1:1 ratio), double blind study with parallel group design.

Participants

Hospitalized patients with positive nasopharyngeal swab for COVID-19 infection (RT -PCR) and lung Computed tomography scan involvement compatible with COVID-19 pneumonia. The patients are not severely hypoxic, do not need intubation or invasive oxygenation.

Exclusion criteria: known hypersensitivity to colchicine; known hepatic failure; estimated glomerular filtration rate (eGFR)<30 ml/min/1.73m² (by the CKD-EPI Creatinine Equation for Glomerular Filtration Rate (GFR) which estimates GFR based on serum creatinine. ; kidney transplant recipients, using Digoxin, QTc >450 msec.

Participants will be recruited from inpatients at Labbafinejad Meidcal Center , Tehran, Iran.

Intervention and comparator

Eligible enrolled patients will be randomized into two groups. Group A will receive the antiretroviral Lopinavir/Ritonavir (Kaletra) while group B will receive Lopinavir/Ritonavir (Kaletra) + Colchicine 1.5 mg loading then 0.5 mg twice daily orally. All patients in both groups will receive the same amounts of essential minerals, vitamins as antioxidants, and antibiotics.

Patients of both groups will be treated under optimal treatment based on the CDC and WHO guidelines and national consensus proposed in Iran including the same dosages of Lopinavir/Ritonavir, antibiotics, trace elements and antioxidants while only in group-B patients Colchicine will be added on top of this protocol.

Main outcomes

Primary: Time for clinical improvement and lung CT score changes 14 days after treatment.

Secondary: 14 days after treatment

– C-Reactive Protein test x Neutrophil to Lymphocyte Ratio , Interleukin-6, malondialdehyde (MDA) levels reduction

– Percentage of patients who require supplemental Oxygen

– Mean hospital stay length

Randomisation

Patients will be allocated to each group (ratio 1:1) by using an online randomization tool: http://www.graphpad.com/quickcalcs/index.cfm

Blinding (masking)

This will be a double-blind study in which participants and those assessing the final outcomes will be blinded to group assignment.

Numbers to be randomised (sample size)

Regarding the pandemic crisis and our center capacity to hospitalize confirmed COVID-19 patients, a total of 80 patients was found to be logical to be randomized into two groups of 40- patients.

Trial Status

Recruitment is ongoing. Recruitment began on 20/03/2020 and the date by which the recruitment is anticipated to be completed is 30/05/2020.

Trial registration

ClinicalTrials.gov Identifier: NCT04360980, registered 24/04/2020.

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

SO015URINE NMR-BASED METABOLOMICS FOR EARLY DETECTION OF POST-PROCEDURAL CONTRAST NEPHROPATHY

Background and Aims

Contrast induced nephropathy (CIN) has been reported to be the third foremost cause of acute renal failure. Metabolomics is a robust technique that has been used to identify potential biomarkers for early detection of renal damage after procedures with using contrast media. We aim to analyze the serum and urine metabolites changes, after using contrast for coronary angiography, to determine if metabolomics can use as a tool for early detection of CIN.

Method

Sixty-six patients with positive primary non-invasive diagnostic tests for coronary artery disease (CAD) who were candidate of elective coronary angiography recruited. Spot urine samples collected in the morning before angiography and 4 hours after angiography. Patients with &gt; 0.5 mg/dL creatinine rise compared to baseline were considered as case (CIN group). Urine samples were centrifuged at 3000 rcf for 20 minutes at 4°C to remove the cell debris and after addition of sodium azide to prevent bacterial growth, were stored at -80 degree Celsius in aliquots until required. The mixtures were then transferred to a standard 5 mm NMR tube for analysis. 1H-NMR spectra were acquired at 300 K on a Bruker DRX 500 MHz spectrometer by using Carr–Pucell–Meiboom–Gill (CPMG) technique. For each spectrum, 154 scans were collected into 32K data points using a spectral width of 8389.26 Hz during the relaxation time of 2.5 s.

Results

Structure and outliers of the dataset composed of patient with CIN (n = 10) before angiography and after angiography were evaluated by PCA. A model with two principal components (PC1 and PC2) with R2X = 0.775 and Q2(cum) = 0.487 was obtained .A supervised OPLS-DA model was built to identify discriminative variables between metabolite profiles before and after angiography in patients with CIN. The high level of AUC 0.95 that was obtained from 10-fold cross validation besides decreased R2 (0.0, 0.415) and Q2 (0.0, -0.454) intercepts of 999 random permutations reflects the good validity of this diagnostic model. According to this valid OPLS-DA model, 15 chemical shifts were significant based on VIP &gt; 1 and FC &gt; 1.2. To check these suggested chemical shifts if their changes are due to kidney injury and not caused by contrast agent, a decoy OPLS-DA model was built for non-CIN patients before and after angiography .Two common significant chemical shifts (2.42 and 2.78 ppm) were found in comparison of these two models (i.e. before vs. after angiography in CIN group in compared with before vs. after angiography in non-CIN group) and were excluded from the results. Metabolites corresponding with the remaining list of 12 significant chemical shifts were identified and suggested as early detection biomarker candidates for CIN (Fig 1). The AUC value of a panel of four biomarker candidates were higher than single biomarkers that reflects the value of simultaneous measurement of these four metabolite candidates than single candidates. Figure 2 shows the list of diagnostic metabolite candidates with p &lt; 0.05 . Pathway characterization was used to better understanding of pathophysiology of CIN. As the input data was small list of metabolites, only “Histidine_ lysine_ phenylalanine, tyrosine, proline and tryptophan catabolism” pathway (p &lt; 0.05) was significant and suggested as the most important disturbed pathway in CIN.

Conclusion

Early detection of CIN as early as only 4 hours after using contrast can help better management of these patients. In this study, only after 4 hours passed from using contrast a panel of metabolites could be found in urine of patients who develop CIN, which facilitates early detection of CIN. This is the first study to investigate urine metabolic profile using NMR-based metabolomics for early detection of CIN after coronary angiography. The use of this suggested panel might significantly improve clinical consequences of this harmful complication.

P1738COULD ADDING BORTEZOMIB HAVE BENEFIT FOR ANTIBODY MEDIATED REJECTION AFTER KIDNEY TRANSPLANTATION?

Background and Aims

Antibody Mediated Rejection (ABMR) is a severe complication that frequently occurs after kidney transplantation. The present RCT designed to evaluate the role of adding Bortezomib to standard regimen with plasma exchange, intravenous immunoglobulin and Rituximab in treatment of AMR after kidney transplantation.

Method

26 kidney transplant recipients (KTRs) with a biopsy proven diagnosis of AMR and positive DSA in a randomized clinical trial were compared: Thirteen KTRs treated with plasmapheresis, intravenous immunoglobulin and rituximab (PE-IVIG- RTX ) plus bortezomib versus 13 patients treated with standard of care regimen without bortezomib. We evaluated graft survival and DSA titer with MFI during a year after biopsy proven diagnosis.

Results

Statistical difference in graft survival between the two groups was noted: three out of 13 patients in the PE-IVIG-RTX group (23%) and 1/13 in the bortezomib group (7.5%) experienced loss of allograft function at a median time after diagnosis of 6 month and 12 month, respectively. DSA MFI titers 12 month after AMR diagnosis showed significant reducing slope in Bortezomib group. Regarding pathological changes micro vascular inflammation (glomerulitis + peritubular capillaritis score) reduced after PE-IVIG- RTX plus bortezomib in 7 out of 13 patients whom underwent protocol biopsies after treatment (53%) (Median score 3 in pre- treatment biopsy vs. 1 in post-treatment biopsy; P = 0.036).

Conclusion

Although DSA titer may not differ at 6 months after treatment of AMR between those who received standard regimen and those treated with adding Bortezomib, but at the end of one year patients treated with standard regimen plus Bortezomib reached lower MFI DSA titer. Adding Bortezomib to PE-IVIG- RTX for the treatment of AMR after kidney transplantation may enable clinicians to fight the DSA better and change the future of next generation of highly sensitized kidney transplant candidates.

Living or deceased-donor kidney transplant: the role of psycho-socioeconomic factors and outcomes associated with each type of transplant

BACKGROUND

Kidney transplant improves patients' survival and quality of life. Worldwide, concern about the equality of access to the renal transplant wait-list is increasing. In Iran, patients have the choice to be placed on either the living or deceased-donor transplant wait-list.

METHODS

This was a prospective study performed on 416 kidney transplant recipients (n = 217 (52.2%) from living donors and n = 199 (47.8%) from deceased donors). Subjects were recruited from four referral kidney transplant centers across Tehran, Iran, during 2016-2017. The primary outcome was to identify the psycho-socioeconomic factors influencing the selection of type of donor (living versus deceased). Secondary objective was to compare the outcomes associated with each type of transplant. The impact of psycho-socioeconomic variables on selecting type of donor was evaluated by using multiple logistic regression and the effect of surgical and non-surgical variables on the early post-transplant creatinine trend was assessed by univariate repeated measure ANOVA.

RESULTS

Based on standardized coefficients, the main predictors for selecting living donor were academic educational level (adjusted OR = 3.25, 95% CI: 1.176-9.005, p = 0.023), psychological status based on general health questionnaire (GHQ) (adjusted OR = 2.46, 95% CI: 1.105-5.489, p = 0.028), and lower monthly income (adjusted OR = 2.20, 95% CI: 1.242-3.916, p = 0.007). The waiting time was substantially shorter in patients who received kidneys from living donors (p < 0.001). The early post-transplant creatinine trend was more desirable in recipients of living donors (β = 0.80, 95% CI: 0.16-1.44, p-value = 0.014), patients with an ICU stay of fewer than five days (β = - 0.583, 95% CI: - 0.643- -0.522, p-value = < 0.001), and those with less dialysis duration time (β = 0.016, 95% CI: 0.004-0.028, p-value = 0.012). Post-operative surgical outcomes were not different across the two groups of recipients (p = 0.08), however, medical complications occurred considerably less in the living-donor group (p = 0.04).

CONCLUSION

Kidney transplant from living donors was associated with shorter transplant wait-list period and better early outcome, however, inequality of access to living donors was observed. Patients with higher socioeconomic status and higher level of education and those suffering from anxiety and sleep disorders were significantly more likely to select living donors.

COVID-19 Rapid Guideline in Kidney Transplant Recipients

in the reports presented about COVID-19, patients receiving kidney transplantation have not been specifically studied and based on national flowchart, this population is classified as highrisk group, thus it is necessary to be aware of the step-by-step treatment approach of these patients. Suspicious cases included patients with a history of dry cough, chills or sore throat accompanying by shortness of breath with or without fever, patients with upper/lower respiratory symptoms with radiological manifestations as single or double-sided multilobular infiltrations on CT scan or plain chest radiography, any one that has a history of close contact with a definite COVID-19 case within the last 14 days, any one with a history of presence in COVID-19 epidemic regions within the last 14 days and patient with pneumonia that despite of proper treatment has an inappropriate clinical response and clinical condition becomes more severe in an unusual way or unexpectedly.

Perspective of 20 Years Hemodialysis Registry in Iran, on the Road to Progress

End-stage renal disease (ESRD) is a foremost health issue with major consequences in various parts of the world. In Iran, the prevalence/incidence of ESRD has increased during the past decades. The economic burden of ESRD treatment on patients, their families, and the whole healthcare system is huge as well. Hence ESRD is considered emerging public health problem in developing countries, including Iran, requiring short- and longterm changes in healthcare policies. Developing a national registry system for dialysis patients in Iran now enables us to summarize certain clinical characteristics of these patients and compares the present situation with the late 1990s when dialysis services just began to expand in the country. In this paper, the authors provide information regarding the process of establishing dialysis registry in Iran along with the report of the output of such a registry. Focusing on such an important measure in the whole country of around along with the data that it has produced is a gateway to further progress.

Intraperitoneal Injection of Graphene Oxide Nanoparticle Accelerates Stem Cell Therapy Effects on Acute Kidney Injury

PURPOSE

Graphene-based nanostructures have shown some degree of stem cell protection against cell death. Acute kidney injury (AKI) is a major cause of mortality in hospitalized patients. Here, graphene oxide (GO) was used to improve the efficacy of bone marrow-derived mesenchymal stem cells (MSCs) in the treatment of AKI induced by cisplatin, a chemotherapy medication used to treat a number of cancers.

MATERIALS AND METHODS

Cisplatin-induced AKI was modeled in male rats. Intraperitoneal injection of MSCs mixed with GO, synthesized by graphite powder, H2SO4, and KMnO4 was administered in modeled animals. Biochemical analysis of serum and histological and immunohistochemical (IHC) staining of kidney tissue samples were determined.

RESULTS

Administration of GO nanoparticles suspended in MSCs reduced serum levels of creatinine (Cr) and blood urea nitrogen (BUN) in cisplatin-induced AKI in the experimental group compared to the control group. Histopathological evaluation also showed an improvement of morphological alterations of kidney, such as cellular proliferation, apoptosis and necrosis, cyst formation and intratubular debris in the experimental group compared to the control group. Our data revealed that GO injection alone without MSCs accelerated the improvement of the kidney injury induced by cisplatin.

CONCLUSION

This study demonstrated that suspended GO could enhance the efficacy of stem cells in the treatment of AKI. GO alone without stem cell accelerates the improvement of cisplatin-induced AKI.

The Frequency and Risk Factors of Delayed Graft Function in living Donor Kidney Transplantation and Its Clinical Impact on Graft and Patient Survival in Part of Middle East

Delayed graft function (DGF) is a form of acute renal failure which results in increased post-transplantation allograft immunogenicity and risk of acute rejection episodes in addition to decreased long-term survival. Its incidence and risk factors have been extensively studied, especially after deceased donation. Until now, only few data has been  published on DGF in living donor kidney transplant recipients. The present study was performed to investigate the frequency and risk factors of DGF among living- kidney transplant recipients. In this retrospective study, data had been collected from existing local hospital registries in three countries (Iran, Kingdom of Saudi Arabia (KSA) , and Kuwait ).

Urine and serum NMR-based metabolomics in pre-procedural prediction of contrast-induced nephropathy

Contrast induced nephropathy (CIN) has been reported to be the third foremost cause of acute renal failure. Metabolomics is a robust technique that has been used to identify potential biomarkers for the prediction of renal damage. We aim to analyze the serum and urine metabolites changes, before and after using contrast for coronary angiography, to determine if metabolomics can predict early development of CIN. 66 patients undergoing elective coronary angiography were eligible for enrollment. Urine and serum samples were collected prior to administration of CM and 72 h post procedure and analyzed by nuclear magnetic resonance. The significant differential metabolites between patients who develop CIN and patients who have stable renal function after angiography were identified using U test and receiver operating characteristic analysis was performed for each metabolite candidate. Potential susceptible pathways to cytotoxic effect of CM were investigated by pathway analysis. A predictive panel composed of six urinary metabolites had the best area under the curve. Glutamic acid, uridine diphosphate, glutamine and tyrosine were the most important serum predictive biomarkers. Several pathways related to amino acid and nicotinamide metabolism were suggested as impaired pathways in CIN prone patients. Changes exist in urine and serum metabolomics patterns in patients who do and do not develop CIN after coronary angiography hence metabolites may be potential predictive identifiers of CIN.

Expression Levels of lncRNAs in the Patients with the Renal Transplant Rejection

PURPOSE

Long non-coding RNAs (lncRNAs) include a vast portion of human transcripts. They exert regulatory roles in immune responses and participate in diverse biological functions. Recent studies indicated dysregulation of lncRNAs in the process of transplant rejection. In the current study, we aimed at identification of the expression of five lncRNAs (OIP5-AS1, FAS-AS1, TUG1, NEAT1 and PANDAR) in association with the process of transplant rejection.

MATERIAL AND METHODS

We assessed expression of these lncRNAs in the peripheral blood of 61 kidney transplant receivers including 29 transplant rejected patients and 32 transplant non-rejected patients using real time PCR technique.

RESULTS

Expression of FAS-AS1 was significantly higher in rejected group compared to non-rejected group in males, however, differences between case and control groups were insignificant among females. For other lncRNAs no significant differences were detected between two study groups. Quantile regression model showed that patients' gender was an important parameter in determination of FAS-AS1 expression (Beta=-9.46, t=-2.82, P=0.007) but not for other lncRNAs expressions. Significant pairwise correlations were detected between expression levels of lncRNAs in a disease related manner.

CONCLUSION

Based on the higher expression of FAS-AS1 in patients with transplant rejection, this lncRNA might be associated with the pathogenesis of renal transplant rejection.

Downregulation of Protein Inhibitor of Activated STAT (PIAS) 1 Is Possibly Involved in the Process of Allograft Rejection

BACKGROUND

Protein inhibitors of activated STAT (PIAS) proteins are regarded as negative regulators of cytokine-signaling and potent immunosuppressive proteins. However, their role in the process of organ transplant rejection has not been elucidated.

METHODS

In the current study, we compared transcript levels of PIAS1 to 4 in the peripheral blood of renal transplant recipients who experienced transplant rejection with those having normal transplant functions. Expression of PIAS1 was significantly higher in nonrejected group compared with the rejected group among male recipients; however, differences were insignificant among female recipients. Expressions of other PIAS genes were not different between study groups. Significant pairwise correlations were found between expression levels of PIAS genes in all study subgroups. The current investigation highlights the role of PIAS1 downregulation in the evolution of graft rejection and potentiates this gene as a predictive marker for transplant fate.

Frequency of dendritic cell subsets and ILT3, ILT4 gene expression in two different immunosuppressive protocols in kidney transplant recipients. A cohort report

Dendritic cells (DCs) have a major role in the initiation of an immune response and Immunoglobulin-like transcript 3&4 (ILT3&ILT4) are inhibitory receptors that induce tolerance in DCs. Recent studies show that immunosuppressive agents affect frequency of DCs. Herein, we compared the effect of mycophenolate mofetil (MMF) and sirolimus (SRL) in tacrolimus (TAC)-based immunosuppression on DC subsets frequency and ILT3/ILT4 gene expression in kidney transplant recipients. We enrolled 24 adult transplant recipients who received MMF/TAC (n = 14) or SRL/TAC (n = 10). Peripheral blood samples were obtained from recipients, 24-48 h before transplantation and 4 months after transplantation. The frequency of DC subsets was analyzed by flow cytometry and gene expression of ILT3/ILT4 were estimated by real-time PCR. Our results showed that MMF vs. SRL treated recipient showed an increase in pDC % with increased in the expression of ILT3/ILT4 which is in favor of better allograft survival; However, for confirming the results of this preliminary study, a cohort study with larger sample size is necessary.

High Expression of FOXP3 mRNA in Blood and Urine as a Predictive Marker in Kidney Transplantation

BACKGROUND

Diagnosis of allograft dysfunction by noninvasive biomarker tests is preferable to invasive allograft biopsies and has been extensively considered in recent years. This study aims to evaluate blood and urinary forkhead box P3 (FOXP3) messenger RNA (mRNA) expression in renal transplant recipients in an attempt to determine whether differential diagnosis of graft dysfunction is feasible using mRNA profiles.

METHODS

We analyzed FOXP3 mRNA expression in paired urinary and peripheral blood mononuclear cell (PBMC) samples. A total of 91 kidney transplant recipients enrolled in this study that were classified into 3 groups: biopsy-proven acute rejection (AR; n = 27), chronic allograft nephropathy (n = 19), and well-functioning graft (n = 45). The FOXP3 mRNA expression was quantified by TaqMan probe real-time polymerase chain reaction.

RESULTS

Acute rejection patients had a higher expression level of transcription factor FOXP3 compared to the chronic nephropathy and control groups. Analysis of receiver operating characteristic curves showed that rejection could be diagnosed with 100% sensitivity and 96% specificity in urine, and 92% sensitivity and 86% specificity in PBMC samples using the optimal FOXP3 mRNA cutoff value. We subdivided the AR group into progressive and nonprogressive patients, which showed a significant difference in FOXP3 mRNA expression. This result confirmed the role of FOXP3 as a diagnostic marker in predicting transplantation outcomes.

CONCLUSION

Our results suggested that elevated expression of FOXP3 in blood and urine samples from kidney transplant recipients could be a useful noninvasive biomarker to diagnose graft dysfunction.

Suppressor of cytokine signaling genes in renal transplant receivers: Association with transplant fate

Suppressor of cytokine signaling (SOCS) proteins have acknowledged roles in regulation of immune responses. Moreover, their role in the evolution of allograft rejection is being elucidated. In the current investigation, we measured transcript levels of SOCS1-4 in the peripheral blood of a group of renal transplant recipients including both rejected and non-rejected allografts. Expression analyses showed that relative expression of SOCS2 was significantly higher in transplant-rejected male patients compared to non-rejected group. However, such significant difference was not detected between female subjects. Expression of SOCS2 was significantly higher in T-cell-mediated rejection group compared with non-rejected individuals with creatinine rise (Relative expression difference [95% CrI] =6.74 [0.94, 12.65], P = 0.043). Conversely, SOCS4 expression was significantly lower in T-cell-mediated rejection group compared with non-rejected individuals with creatinine rise (Relative expression difference [95% CrI] = -0.35 [-0.63, -0.1], P = 0.008). Patterns of correlations between expression levels of SOCS genes were different in non-rejected group. The obtained results indicate the role SOCS genes in development of allograft rejection.

Chondroitin sulfate degradation and eicosanoid metabolism pathways are impaired in focal segmental glomerulosclerosis: Experimental confirmation of an in silico prediction

Introduction: Focal segmental glomerulosclerosis (FSGS), the most common primary glomerular disease, is a diverse clinical entity that occurs after podocyte injury. Although numerous studies have suggested molecular pathways responsible for the development of FSGS, many still remain unknown about its pathogenic mechanisms. Two important pathways were predicted as candidates for the pathogenesis of FSGS in our previous in silico analysis, whom we aim to confirm experimentally in the present study. Methods: The expression levels of 4 enzyme genes that are representative of "chondroitin sulfate degradation" and "eicosanoid metabolism" pathways were investigated in the urinary sediments of biopsy-proven FSGS patients and healthy subjects using real-time polymerase chain reaction (RT-PCR). These target genes were arylsulfatase, hexosaminidase, cyclooxygenase-2 (COX-2), and prostaglandin I2 synthase. The patients were sub-divided into 2 groups based on the range of proteinuria and glomerular filtration rate and were compared for variation in the expression of target genes. Correlation of target genes with clinical and pathological characteristics of the disease was calculated and receiver operating characteristic (ROC) analysis was performed. Results: A combined panel of arylsulfatase, hexosaminidase, and COX-2 improved the diagnosis of FSGS by 76%. Hexosaminidase was correlated with the level of proteinuria, while COX-2 was correlated with interstitial inflammation and serum creatinine level in the disease group. Conclusion: Our data supported the implication of these target genes and pathways in the pathogenesis of FSGS. In addition, these genes can be considered as non-invasive biomarkers for FSGS.

THE METABOLOMICS SIGNATURE ASSOCIATED WITH RESPONSIVENESS TO STEROID THERAPY IN FOCAL SEGMENTAL GLOMERULOSCLEROSIS: A PILOT STUDY

Background

Focal segmental glomerulosclerosis (FSGS) is considered one of the most severe glomerular diseases and around 80% of cases are resistant to steroid treatment. Since a large proportion of steroid-resistant (SR) FSGS patients progress to end-stage renal disease, other therapeutic strategies may benefit this population. However, identification of non-invasive biomarkers to predict this high-risk population is needed.

Objective

We aimed to identify the biomarker candidates to distinguish SR from steroid-sensitive (SS) patients using metabolomics approach and to identify the possible molecular mechanism of resistance.

Methods

Urine was collected from biopsy-proven FSGS patients eligible for monotherapy with prednisolone. Patients were followed for 6-8 weeks and categorized as SS or SR. Metabolite profile of urine samples was analyzed by one-dimensional ¹H-nuclear magnetic resonance (¹H-NMR). Predictive biomarker candidates and their diagnostic importance impaired molecular pathways in SR patients, and the common target molecules between biomarker candidates and drug were predicted.

Results

Homovanillic acid, 4-methylcatechol, and tyrosine were suggested as the significant predictive biomarker candidates, while L-3,4-dihydroxyphenylalanine, norepinephrine, and gentisic acid had high accuracy as well. Tyrosine metabolism was the most important pathway that is perturbed in SR patients. Common targets of the action of biomarker candidates and prednisolone were molecules that contributed in apoptosis.

Conclusion

Urine metabolites including homovanillic acid, 4-methylcatechol, and tyrosine may serve as potential non-invasive predictive biomarkers for evaluating the responsiveness of FSGS patients.

An update of urine and blood metabolomics in chronic kidney disease

Chronic kidney disease is considered as a serious obstacle in global health, with increasing incidence and prevalence. In spite of numerous attempts by using recent omics technologies, specially metabolomics, for understanding pathophysiology, molecular mechanism and identification reliable consensus biomarkers for diagnosis and prognosis of this complex disease, the current biomarkers are still insensitive and many questions about its pathomechanism are still to be unanswered. This review is focused on recent findings about urine and serum/plasma metabolite biomarkers and changes in the pathways that occurs in the disease conditions. The urine and blood metabolome content in the normal and disease state is investigated based on the current metabolomics studies and well known metabolite candidate biomarkers for chronic kidney disease are discussed.

Association Between Delayed Graft Function (DGF) Biomarkers and Long-term Outcomes After Living Donor Kidney Transplantation

BACKGROUND AND OBJECTIVES

The association between preoperative Urine Neutrophil Gelatinase-associated Lipocalin (uNGAL) and interleukin-18 (uIL-18) with poor 1-year allograft function has been shown in deceased-donor kidney transplant recipients previously, and also these markers could predict 3-month allograft function. However, it is unknown whether there is an association between these postoperative biomarkers with important recipient outcomes beyond this time in livedonor transplants.

METHODS

NGAL and IL-18 four and 24 hours were measured in live-donor kidney transplant recipients after transplantation. The relationships between changes in these markers with clinical outcomes as well as kidney function were examined at 1 month and 2 years. Moreover, the association between delayed graft function with clinical outcome and Serum Creatinine (SrCr) was evaluated during this period.

RESULTS

The Mean age for kidney recipients was 23.9 years. Significant interaction was observed between uNGAL 24 hr (pvalue=0.01) and uIL-18 four and 24 hr after transplantation (pvalue=0.04, 0.03; respectively) with patients' outcome after 1 month and changes in uNGAL with outcomes after 2 years (pvalue= 0.04).

CONCLUSION

Changes in urine NGAL postoperative are associated with worst outcomes, 2 years after kidney transplantation, suggesting its potential role in identifying patients that are at high risk for diminished allograft function, outcome and survival.

Th1, Th2, Th17 cell subsets in two different immunosuppressive protocols in renal allograft recipients (Sirolimus vs mycophenolate mofetil): A cohort study

Long-term use of calcineurin inhibitors (CNI) is associated with nephrotoxicity, which is an important cause of renal dysfunction. Therefore, CNI-minimization strategies which decrease the CNI nephrotoxicity under the protection of additional immunosuppressant drugs have been developed. The aim of current cohort study was to compare the effect of two immunosuppressive protocols [tacrolimus (TAC) in combination with mycophenolate mofetil (MMF) and prednisolone (PRED) versus TAC in combination with sirolimus (SRL) and prednisolone] on the frequency of T helper cell subsets (Th1, Th2 and Th17 cells) and their associated cytokine (IFN-γ, IL-4 and IL-17A) levels in renal allograft recipients. In this study, renal transplant recipients who received induction therapy (Antithymocyte globulin) and were also on triple immunosuppressive therapy were included and divided in to two groups: Group A was comprised 14 patients who received TAC, MMF and PERD whereas group B was composed of 10 patients who received TAC, SRL and PERD. The frequency of Th1, Th2 and Th17 cells in the peripheral blood mononuclear cells (PBMCs) of the patients was analyzed by flow cytometry before and 4 months after transplantation. In addition, IFN-γ, IL-4 and IL-17A concentrations in PBMC culture supernatants of patients before and 4 months after transplantation were quantified by ELISA. The results of our study showed that TAC, MMF and PRED protocol did not diminish the frequency of Th17 cells at 4 months post-transplantation (5% ± 2.5) compared with pre-transplantation (2.3% ± 1; P < 0.05). However, Th17 (3.6% ± 1.5 pre-transplantation vs 2.2% ± 0.9 at 4 months post-transplantation; P < 0.05), Th2 (1.4% ± 0.3 pre-transplantation vs 0.8% ± 0.4 at 4 months post-transplantation; P < 0.05) cell subsets and IL-4 concentration (71.5 pg/ml ± 12 pre-transplantation vs 62.5 pg/ml ±4.4 at 4 months post-transplantation; P < 0.05) were significantly decreased after transplantation in patients who had received SRL, TAC and PRED. In conclusion, the data of the current study suggest that using reduced dose of TAC in SRL, TAC and PRED protocol is in favor of allograft survival; however a cohort study with larger sample size is needed for confirming our results.

Downregulation of Profibrotic Gene Expression by Angiotensin Receptor Blockers

INTRODUCTION

Chronic allograft nephropathy is characterized by interstitial fibrosis and tubular atrophy. The main players in the process of fibrosis are transforming growth factor-β (TGF-β) and miR-21 expression with a bidirectional interplay. This study aimed to evaluate the effects of angiotensin receptor type 1 antagonist, losartan, on peripheral blood and tissue expression of TGF-β and miR-21 and histologic findings in allograft biopsy in kidney transplant recipients.

MATERIALS AND METHODS

In a randomized controlled trial, 54 patients were enrolled and divided randomly into 2 groups. Group 1 was treated with a daily dose of 25 mg of losartan and group 2 was considered as control. Blood sampling was done at 48 hours posttransplantation and the 3rd and 6th months after transplantation for measurement of TGF-β RNA and miR-21. Protocol biopsy was performed at the 6th month posttransplantation for RNA extraction and histologic evaluation of interstitial fibrosis and tubular atrophy.

RESULTS

Although patients were not different initially, those who underwent treatment with losartan had lower miR-21 and TGF-β levels in circulating PBMCs, and there was a decreasing trend in peripheral blood TGF-β levels during the 6-month follow-up period. Tissue expression of miR-21 and TGF-β was also considerably lower among the losartan-treated patients at the time of tissue biopsy.

CONCLUSIONS

Losartan treatment decreased the tissue expression of miR-21 and TGF-β and tissue fibrosis in kidney transplant patient, and it had a protective effect on allograft function and may delay chronic allograft dysfunction by reducing mediators of fibrosis.

Network analysis of membranous glomerulonephritis based on metabolomics data

Membranous glomerulonephritis (MGN) is one of the most frequent causes of nephrotic syndrome in adults. It is characterized by the thickening of the glomerular basement membrane in the renal tissue. The current diagnosis of MGN is based on renal biopsy and the detection of antibodies to the few podocyte antigens. Due to the limitations of the current diagnostic methods, including invasiveness and the lack of sensitivity of the current biomarkers, there is a requirement to identify more applicable biomarkers. The present study aimed to identify diagnostic metabolites that are involved in the development of the disease using topological features in the component‑reaction‑enzyme‑gene (CREG) network for MGN. Significant differential metabolites in MGN compared with healthy controls were identified using proton nuclear magnetic resonance and gas chromatography‑mass spectrometry techniques, and multivariate analysis. The CREG network for MGN was constructed, and metabolites with a high centrality and a striking fold‑change in patients, compared with healthy controls, were introduced as putative diagnostic biomarkers. In addition, a protein‑protein interaction (PPI) network, which was based on proteins associated with MGN, was built and analyzed using PPI analysis methods, including molecular complex detection and ClueGene Ontology. A total of 26 metabolites were identified as hub nodes in the CREG network, 13 of which had salient centrality and fold‑changes: Dopamine, carnosine, fumarate, nicotinamide D‑ribonucleotide, adenosine monophosphate, pyridoxal, deoxyguanosine triphosphate, L‑citrulline, nicotinamide, phenylalanine, deoxyuridine, tryptamine and succinate. A total of 13 subnetworks were identified using PPI analysis. In total, two of the clusters contained seed proteins (phenylalanine‑4‑hydroxlylase and cystathionine γ‑lyase) that were associated with MGN based on the CREG network. The following biological processes associated with MGN were identified using gene ontology analysis: 'Pyrimidine‑containing compound biosynthetic process', 'purine ribonucleoside metabolic process', 'nucleoside catabolic process', 'ribonucleoside metabolic process' and 'aromatic amino acid family metabolic process'. The results of the present study may be helpful in the diagnostic and therapeutic procedures of MGN. However, validation is required in the future.

Cutaneous Infection With Mycobacterium haemophilum in an Immunocompromised Patient

Mycobacterium haemophilum is a fastidious nontuberculosis Mycobacterium that must be considered in the differential diagnosis of infections in immunocompromised patients. Mycobacterium haemophilum typically is a pathogen of the cutaneous or subcutaneous tissue and also presents as septic arthritis, osteomyelitis, pulmonary disease, and lymphadenitis. We report a 32-year-old man with past medical history of kidney transplantation, endocarditis, gastrointestinal bleeding, and hypertension, complaining of multiple painful nodular lesions since 3 months earlier. A tissue biopsy and polymerase chain reaction detected Mycobacterium haemophilum. Atypical mycobacterial species like Mycobacterium haemophilum should be assessed in immunocompromised patients positive for acid fast staining and negative for Mycobacterium tuberculosis.