Strategies to prevent SARS-CoV-2 transmission in hemodialysis centres across Europe - Lessons for the future

Background

Early reports on the pandemic nature of COVID-19 directed the nephrology community to develop infection prevention and control guidance. We aimed to make an inventory of strategies that dialysis centres followed to prevent infection with COVID-19 in the first pandemic wave.

Methods

We analyzed IPC measures taken by hemodialysis centres treating patients presenting with COVID-19 between March 1, 2020 and July 31, 2020 and that completed the European Renal Association COVID-19 Database centre questionnaire. Additionally, we made an inventory of guidelines published in European countries to prevent spread of SARS-CoV-2 in dialysis centres.

Results

Data from 73 dialysis units located in and bordering Europe were analyzed. All participating centres implemented IPC measures to mitigate the impact of SARS-CoV-2 during the first pandemic wave. Measures mentioned most often included triage with questions before entering the dialysis ward, measuring body temperature, hand disinfection, masking for all patients and staff, and personal protective equipment for staff members. These measures were also recommended in most of the 14 guidelines that were identified in the inventory of national guidelines and were also scored as being among the most important measures by the authors of this paper. Heterogeneity existed between centres and national guidelines regarding the minimal distance between dialysis chairs and recommendations regarding isolation and cohorting.

Conclusions

Although variation existed, measures to prevent transmission of SARS-CoV-2 were relatively similar across centres and national guidelines. Further research is needed to assess causal relationships between measures taken and spread of SARS-CoV-2.

Novel mouse strains to study circulating permeability factor(s) in primary focal segmental glomerulosclerosis

Recurrence of proteinuria after kidney transplantation in primary focal segmental glomerulosclerosis (FSGS) is unpredictable. Several putative circulating permeability factors (CPFs) have been suggested, but none have been validated. A clinically relevant experimental model is required that demonstrates the presence of CPF(s) in patient material, to study CPF(s) and possibly predict recurrence in patients. We aimed to develop a FSGS-prone Thy-1.1 transgenic mouse model with accelerated proteinuria after injection of samples from patients with FSGS. The Thy-1.1 transgene was backcrossed into 5 mouse strains. The age of onset and severity of spontaneous proteinuria varied between the different genetic backgrounds. 129X1/Sv^Thy-1.1 and 129S2/SvPas^Thy-1.1 mice displayed proteinuria at 4 weeks, whereas Balb/c^Thy-1.1 and C57BL/6J^Thy-1.1 mice developed proteinuria from 6 weeks, and were used further. We determined the maximum protein dose that could be injected without causing protein overload in each background. Balb/c^Thy-1.1 and C57BL/6J^Thy-1.1 males and females were injected with presumably CPF-containing plasmapheresis effluent from 6 FSGS patients, which induced albuminuria particularly in Balb/c^Thy-1.1 males. Unfortunately, no response could be detected when using sera instead of plasmapheresis effluent, serum being more clinically relevant in the context of predicting FSGS recurrence. Considering the differences between responses elicited by serum and plasmapheresis effluent, simultaneously collected serum, plasma, and plasmapheresis effluent were tested. Whereas we could detect responses using a validated in vitro model, none of these presumably CPF-containing samples induced proteinuria in Balb/c^Thy-1.1 males. Thus, we have extensively tested the Thy-1.1 mouse model on different genetic backgrounds with proteinuria after injection of FSGS patient material as clinically relevant readout. The Balb/c^Thy-1.1 male mouse strain demonstrated the most promising results, but to detect CPF activity in FSGS serum e.g. prior to kidney transplantation, this strain clearly lacks sensitivity and is therefore not yet clinically applicable. It could, however, still be used as research tool to study CPFs in patient samples that did induce proteinuria.

MO168: Urinary Podocin Cell Count in Relation to Glomerular Damage Markers in Patients with Primary Nephrotic Syndrome

BACKGROUND AND AIMS

Progressive renal failure in patients with glomerular disease is driven by podocyte depletion. Several methods have been proposed to monitor urinary podocyte loss. Here, we investigated the process of podocyte depletion in patients with primary nephrotic syndrome (PNS) by flow cytometric detection of podocin-positive cells in urine.

METHOD

We included nine patients with PNS. Urinary cell pellets were spun down, washed and stained for podocin and subsequently counted using FACS. Urinary protein and creatinine levels were determined from the same portion of urine. Normal values of urinary podocin-positive cells were obtained in urine samples of four healthy controls.

RESULTS

Mean urinary podocyte count (podocin-positive cells) was on average 100.0 (3.1–228.1) times higher in patients compared to healthy controls. Podocyte excretion showed significant correlations with urinary protein/creatinine ratios (R2 = 0.86, P < .01).

CONCLUSION

Urinary excretion of podocin-positive podocytes was significantly increased in patients with PNS, and correlated significantly with protein/creatinine ratios in patients with PNS. We conclude that this method can be used to monitor the process of podocyte depletion, and impact of treatment. We are planning prospective studies to evaluate the prognostic value of urinary podocin+ podocyte excretion in patients with PNS.

Massive expansion of human induced pluripotent stem cells resulting in efficient biobanking and functional 3D tissue analysis of genetic cardiomyopathies

Introduction

Over the past decade, various protocols were established to ensure efficient differentiation of hiPSC into cardiomyocytes (CMs). A major limitation, however, remained the batch-to-batch variability of hiPSC-CM efficiency and cell number. Here, we suggest an approach in which concomitant GSK-3β inhibition and removal of cell-cell contact inhibition, resulted in a massive proliferative response of hiPSC-CMs1–3. This efficient method allows expansion and passaging of functional hiPSC-CMs, that routinely can be cryopreserved and subsequently used as a stable cell source for the downstream applications, such 3D in vitro models for the disease modelling of dilated cardiomyopathy (DCM). We focussed on the deletion of arginine 14 in the PLN gene (R14del), which is associated with severe heart failure in DCM patients, associated with arrhythmias, cardiac fibrosis and premature death.

Methods

Subsequent expansion of hiPSC-CM cultures is generally modest (<10 fold). Here, we describe a cost-effective strategy for massive expansion (up to 250-fold) of high-purity hiPSC-CMs relying on two aspects; 1) inhibition of cell-cell contact via low-density seeding and serial passaging in culture flask-format, 2)small molecular glycogen synthase kinase-3β inhibition with CHIR99021 (CHIR). Patient-specific hiPSC-CMs harbouring a PLNR14del mutation were generated and used for EHT formation and functional follow-up.

Results

We observed that proliferating hiPSC-CMs, especially within the first 2 passages, can routinely be cryopreserved and subsequently further expanded or utilized in downstream applications. Moreover, using this strategy, it is possible to produce ultimately >1 billion CMs within 3–5 weeks starting with one differentiation batch of day 11 hiPSC-CMs, without the need for cell sorting or selection. Expanded hiPSC-CMs retain their capacity to mature and allows fibrin-based engineered heart tissues (EHTs) formation. Previously expanded CMs from PLNR14del patient-specific hiPSC were used to generate EHT and displayed a reduced force phenotype (0.137±0.012 mN) vs healthy control (0.229±0.030 mN) and isogenic control (0.224±0.008 mN) in previously expanded CMs.

Conclusion

We provpresent a novel strategy for the massive expansion of functional hiPSC-CMs with concomitant GSK-3β inhibition and low cell density culture that ultimately generates up to a 250-fold increase in hiPSC-CM numbers. Expansion healthy control hiPSC-CMs does not limit the subsequent maturation process, and moreover cells remain fully functional such as required for downstream tissue engineering approaches. Therefore, CM expansion forms a well-controlled platform for upscaling hiPSC-CM production for functional 3-dimensionale PLN cardiac disease models, large drug screenings and multiple translational/regenerative applications.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): PLN Foundation

Rituximab in Membranous Nephropathy

Membranous nephropathy (MN) is the most common cause of primary nephrotic syndrome among adults. The identification of phospholipase A2 receptor (PLA2R) as target antigen in most patients changed the management of MN dramatically, and provided a rationale for B-cell depleting agents such as rituximab. The efficacy of rituximab in inducing remission has been investigated in several studies, including 3 randomized controlled trials, in which complete and partial remission of proteinuria was achieved in approximately two-thirds of treated patients. Due to its favorable safety profile, rituximab is now considered a first-line treatment option for MN, especially in patients at moderate and high risk of deterioration in kidney function. However, questions remain about how to best use rituximab, including the optimal dosing regimen, a potential need for maintenance therapy, and assessment of long-term safety and efficacy outcomes. In this review, we provide an overview of the current literature and discuss both strengths and limitations of "the new standard."

Rituximab in adult minimal change disease and focal segmental glomerulosclerosis - What is known and what is still unknown?

Primary forms of minimal change disease and focal segmental glomerulosclerosis are rare podocytopathies and clinically characterized by nephrotic syndrome. Glucocorticoids are the cornerstone of the initial immunosuppressive treatment in these two entities. Especially among adults with minimal change disease or focal segmental glomerulosclerosis, relapses, steroid dependence or resistance are common and necessitate re-initiation of steroids and other immunosuppressants. Effective steroid-sparing therapies and introduction of less toxic immunosuppressive agents are urgently needed to reduce undesirable side effects, in particular for patients whose disease course is complex. Rituximab, a B cell depleting monoclonal antibody, is increasingly used off-label in these circumstances, despite a low level of evidence for adult patients. Hence, critical questions concerning drug-safety, long-term efficacy and the optimal regimen for rituximab-treatment remain unanswered. Evidence in the form of large, multicenter studies and randomized controlled trials are urgently needed to overcome these limitations.

Dysfunktionelle respiratorische Symptome bei Kindern und Jugendlichen

Dysfunktionelle respiratorische Symptome sind durch rekurrierend oder chronisch auftretende respiratorische Krankheitszeichen charakterisiert, die sich nicht durch strukturelle Besonderheiten der Atemwege erklären lassen und Symptome somatischer Erkrankungen imitieren können (somatoforme Atemstörungen). Die Systematisierung von dysfunktionellen respiratorischen Symptomen sowie die Entwicklung diagnostischer und therapeutischer Algorithmen sind relativ junge Arbeitsfelder der Pädiatrischen Pneumologie. Inzwischen sind diagnostische Mindestkriterien vorgeschlagen worden, die zur besseren Erkennung und Abgrenzung von somatischen Erkrankungen beitragen sollen. Eine frühzeitige Diagnosestellung ist erforderlich, um der Entwicklung von Fehlanpassungen entgegenzuwirken.

Isolated Fracture of the posterolateral tibial lip (Volkmann's triangle)

Purpose: to retrospectively evaluate the underlying pathomechanism of isolated fracture of the posterolateral tibial lip (Volkmann's triangle), and to demonstrate associated radiographic methods.

Material and Methods: Retrospective analysis of 2500 ankle lesions showed an isolated fracture of the dorsal tibial lip in 25 cases. Distal tibial lesions of growing individuals were not considered. All patients were examined by radiography in internal oblique and lateral views.

Results: Sixteen of 25 patients had had their accident during winter; 11 had slipped on ice or snow. All 25 patients showed a closed ankle lesion in the correct joint position with no clinical signs of instability. Evaluation of the standard images showed isolated fracture of the posterolateral tibial lip in 24 patients. the fracture was best recognized in the standard lateral view in 22 patients. in 2 patients the lateral stress projection demonstrated the fracture (20° internal rotation). in one case the fracture was only seen on axial CT images. Twenty-two patients with small wedge fragments were treated conservatively; 3 with a displaced and large fragment had surgical revision and stabilization. Sixteen cases were examined by conventional radiography at follow-up examination and 5 of these showed radiological signs of arthrosis.

Conclusion: Plain conventional radiography is still necessary in the primary diagnosis of ankle joint lesions. the isolated fracture of the dorsal tibial margin is best seen in the standard lateral view. Indication for CT in routine diagnostics is limited to cases showing clinical evidence of ankle injury without roentgenological signs of a fracture in the standard images. Differential diagnoses include the pilon lesion and the Maison-neuve-type fracture.

Experimental realization of a polarization-independent ultraviolet/visible coaxial plasmonic metamaterial

We report the experimental realization of an optical metamaterial composed of a hexagonal array of coaxial plasmonic metal/insulator/metal waveguides that shows strong polarization-independent optical mode index dispersion in the ultraviolet/blue. The metamaterial is composed of silicon coaxes with a well-defined diameter in the range of 150-168 nm with extremely thin sidewalls (13-15 nm), embedded in a silver film, fabricated using a combination of electron beam lithography, physical vapor deposition, reactive ion etching, and focused ion beam polishing. Using a Mach-Zehnder interferometer the phase advance is measured on several metamaterial samples with different dimensions in the UV/visible part of the spectrum. For all geometries the spectral features as well as the geometry dependence of the data correspond well with numerical finite-difference time domain simulations and the calculated waveguide dispersion diagram, showing a negative mode index between 440 and 500 nm.

Crustal evolution, intra-cratonic architecture and the metallogeny of an Archaean craton

The generation of the Earth's continental crust modified the composition of the mantle and provided a stable, buoyant reservoir capable of capturing mantle material and ultimately preserving ore deposits. Within the continental crust, lithospheric architecture and associated cratonic margins are a first-order control on camp-scale mineralization. Here we show that the evolving crustal architecture of the Archaean Yilgarn Craton, Western Australia, played a key role in controlling the localization of camp-scale gold, iron and nickel mineralized systems. The age and source characteristics of Archaean lithosphere are heterogeneous in both space and time and are recorded by the varying Nd isotopic signature of crustal rocks. Spatial and temporal variations in isotopic character document the evolution of an intra-cratonic architecture through time, and in doing so map transient lithospheric discontinuities where gold, nickel and iron mineral systems were concentrated. Komatiite-hosted nickel deposits cluster into camps localized within young, juvenile crust at the isotopic margin with older lithosphere; orogenic gold systems are typically localized along major structures within juvenile crust; and banded iron formation (BIF)-hosted iron deposits are localized at the edge of, and within, older lithospheric blocks. Furthermore, this work shows that crustal evolution plays an important role in the development and localization of favourable sources of nickel, gold and iron by controlling the occurrence of thick BIFs, ultramafic lavas and fertile (juvenile) crust, respectively. Fundamentally, this study demonstrates that the lithospheric architecture of a craton can be effectively imaged by isotopic techniques and used to identify regions prospective for camp-scale mineralization.

An overview of immunosuppressive therapy in idiopathic membranous nephropathy

Idiopathic membranous nephropathy is the most common cause of nephrotic syndrome. In patients who present with nephrotic range proteinuria the clinical course is variable, with 50% of patients developing end stage renal disease after extended follow-up without therapy. We review the various immunosuppressive treatment modalities. The efficacy of alkylating agents is demonstrated in randomized trials, although side effects are a major drawback. Calcineurin inhibitors, rituximab and possibly adrenocorticotropic hormone (ACTH) are able to induce remission of proteinuria, which portends a good prognosis. However, the efficacy of these agents must be confirmed in randomized trials with adequate renal end points. Immunosuppressive treatment should be restricted to high risk patients. The use of immunosuppressive therapy has improved outcome of patients with iMN, with nowadays less than 10% of patients progressing to end stage renal disease (ESRD).

[MR imaging of the Achilles tendon: evaluation of criteria for the differentiation of asymptomatic and symptomatic tendons]

PURPOSE

The purpose of this study was to develop quantitative and qualitative MRI criteria to differentiate between healthy and pathological Achilles tendons.

MATERIALS AND METHODS

364 Achilles tendons were examined on a 1.5 T MRI scanner. 264 patients had Achilles tendon complaints, 100 asymptomatic Achilles tendons served as a control. T 1-weighted, T 2-weighted and a STIR sequence were performed in sagittal and axial orientation. Images were evaluated in consensus by two radiologists. Quantitative and qualitative criteria were assessed. A Mann-Whitney-U-Test and a regression analysis were used for statistical analysis.

RESULTS

There were statistically significant differences between the patients with disorders and the control group concerning the depth (12.0 mm and 6.3 mm, p < 0.001) and length (83.2 mm and 45.9 mm, p < 0.001) of the tendon, the area of the tendon cross section (1.60 mm (2) and 061 mm (2), p < 0.001), as well as the length of the bursa retrocalcanea (8.3 mm and 5.3 mm, p < 0.001). There was a sensitivity of 97 % and a specificity of 91 % using a formula including the 3 criteria: tendon depth (A4), length of bursa (A5) and area of tendon (F).

CONCLUSION

The measurement of the Achilles tendon and the binary-logistic regression analysis allow differentiation between normal and pathological Achilles tendons.

Asymmetric dimethylarginine as an independent risk marker for mortality in ambulatory patients with peripheral arterial disease

BACKGROUND

Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide (NO) synthesis causing endothelial dysfunction, an early sign of atherogenesis. Symmetric dimethylarginine (SDMA) does not inhibit NO synthases. Peripheral arterial disease (PAD) is a systemic indication of atherosclerosis.

METHODS

We assessed the associations between both ADMA and SDMA blood levels and major cardiovascular and cerebrovascular events or death from any cause within a 5-year follow-up in the multicentre getABI trial. From a cohort of 6821 primary care patients, aged ≥65 years, all 1260 patients with prevalent PAD were compared with a random sample of 1187 non-PAD controls. A total of 11,544 patient-years were documented. Multivariate risks were calculated by Cox proportional hazard models, adjusting for PAD, renal dysfunction and other important cardiovascular risk factors.

RESULTS

We documented 390 deaths, 296 cardiovascular events and 98 cerebrovascular events. Increased ADMA levels in the 4th quartile were significantly associated with total mortality [hazard ratio (HR) 1.41; 95% CI 1.14-1.74] and with cardiovascular events (HR 1.32; 95% CI 1.03-1.69), but there was a nonsignificant association with cerebrovascular events (HR 1.50; 95% CI 0.98-2.29). Increased SDMA was only just significantly associated with mortality (HR 1.27; 95% CI 1.01-1.59). In PAD patients compared with non-PAD controls, only mean SDMA concentration was considerably increased (0.52 μmol L(-1) vs. 0.48 μmol L(-1); P < 0.001) mainly because of a highly significant association with impaired renal function.

CONCLUSION

These data suggest that ADMA but not SDMA is an independent risk marker for death from any cause or from cardiovascular events. The association between SDMA and mortality is in part explained by a close link between SDMA and renal function.

Vaccination with a soluble recombinant hemagglutinin trimer protects pigs against a challenge with pandemic (H1N1) 2009 influenza virus

In 2009 a new influenza A/H1N1 virus strain ("pandemic (H1N1) 2009", H1N1v) emerged that rapidly spread around the world. The virus is suspected to have originated in swine through reassortment and to have subsequently crossed the species-barrier towards humans. Several cases of reintroduction into pigs have since been reported, which could possibly create a reservoir for human exposure or ultimately become endemic in the pig population with similar clinical disease problems as current swine influenza strains. A soluble trimer of hemagglutinin (HA), derived from the H1N1v, was used as a vaccine in pigs to investigate the extent to which this vaccine would be able to protect pigs against infection with the H1N1v influenza strain, especially with respect to reducing virus replication and excretion. In a group of unvaccinated control pigs, no clinical symptoms were observed, but (histo)pathological changes consistent with an influenza infection were found on days 1 and 3 after inoculation. Live virus was isolated from the upper and lower respiratory tract, with titres up to 10(6) TCID(50) per gram of tissue. Furthermore, live virus was detected in brain samples. Control pigs were shedding live virus for up to 6 days after infection, with titres of up to 10(5) TCID(50) per nasal or oropharyngeal swab. The soluble H1N1v HA trimer diminished virus replication and excretion after a double vaccination and subsequent challenge. Live virus could not be detected in any of the samples taken from the vaccinated pigs. Vaccines based on soluble HA trimers provide an attractive alternative to the current inactivated vaccines.

Redox-generated isoprostanes are associated with residual platelet activity in aspirin-treated patients with stable coronary heart disease

AIM

Insufficient platelet inhibition by low-dose aspirin is associated with poor prognosis in patients with coronary heart disease (CHD). We sought to investigate the prevalence of this phenomenon in patients with stable CHD and to study whether oxidative stress plays a role in its pathogenesis.

METHODS AND RESULTS

We studied the platelet response to long-term (≥ 6 months) low-dose (100 mg per day) aspirin in 130 consecutive patients with stable CHD (age 66 ± 8 years, 83% male). Among a wide distribution of platelet responses to collagen, ADP, and arachidonic acid, the vast majority of patients in the highest tertile of residual platelet activity (defined as 'aspirin low-responders') were characterized by lack of platelet inhibition by aspirin in vitro, significantly although not completely suppressed platelet TXB₂ production and COX-1 activity, and significantly higher urinary 8-iso-prostaglandin F(2α) excretion [186 (147-230) vs. 230 (188-318) pg per mg creatinine; median (IQR), P < 0.001; measured by GC-MS].

CONCLUSION

A relevant proportion of patients with CHD show insufficient platelet inhibition by low-dose aspirin. Oxidative stress and lipid peroxidation causing isoprostane formation may underlie inadequate platelet inhibition in an aspirin-insensitive manner in patients with cardiovascular disease.

Rapid development of severe end-organ damage in C57BL/6 mice by combining DOCA salt and angiotensin II

The C57BL/6 mouse strain serves as the genetic background of many transgenic and gene knockout models; however, this strain appears to be resistant to hypertension-induced renal injury. We developed a new model of hypertensive end-organ damage in C57BL/6 mice by combining deoxycorticosterone acetate (DOCA) and salt with angiotensin II infusion. The systolic blood pressure (SBP) was significantly elevated in DOCA salt-angiotensin II mice compared to control mice or mice treated individually with DOCA salt or angiotensin II. Hypertensive glomerular damage, increased expression of profibrotic and inflammatory genes, albuminuria, tubular casts, increased plasma cholesterol, cardiac hypertrophy, and fibrosis were found in mice treated with DOCA salt-angiotensin II. The SBP in the angiotensin II-infused group was further increased by increasing the infusion rate; only mild injury was observed in these mice, suggesting that blood pressure was not a causal factor. Removal of DOCA and the angiotensin pump lowered blood pressure to normal; however, albuminuria along with the glomerular and cardiac damage did not completely resolve. Our study describes a new model of hypertensive end-organ damage and repair in C57BL/6 mice.

[Palliation in patients with metastatic breast cancer often better with antitumour treatment than with only symptomatic treatment]

Two women, aged 57 and 55 years, with metastatic breast cancer were admitted for uncontrolled pain due to bone metastases. Despite the fact that progressive disease was evident, a change in antitumour therapy had not been recommended. The pain control was optimised in both patients. In one patient, palliative chemotherapy was installed, combined with trastuzumab because of HER2/neu overexpression. She was still alive after one and a half year of treatment. The other patient could not adjust mentally to the fact that her palliative therapy was changed to antitumour therapy; she died one month later. It is important to be aware of the various kinds of therapy in metastatic breast cancer because palliative treatment is more than just symptomatic treatment. Systemic antitumour therapy includes hormone therapy, chemotherapy and targeted therapy. Furthermore, in patients with bone metastases, radiotherapy combined with bisphosphonates results in pain relief and can reduce skeletal complications. Because of the ensuing complexity of the treatment of metastatic breast cancer, these patients should be regularly managed by a breast-cancer care team in order to improve the quality of care.

Computational modeling of arterial wall growth. Attempts towards patient-specific simulations based on computer tomography

The present manuscript documents our first experiences with a computational model for stress-induced arterial wall growth and in-stent restenosis related to atherosclerosis. The underlying theoretical framework is provided by the kinematics of finite growth combined with open system thermodynamics. The computational simulation is embedded in a finite element approach in which growth is essentially captured by a single scalar-valued growth factor introduced as internal variable on the integration point level. The conceptual simplicity of the model enables its straightforward implementation into standard commercial finite element codes. Qualitative studies of stress-induced changes of the arterial wall thickness in response to balloon angioplasty or stenting are presented to illustrate the features of the suggested growth model. First attempts towards a patient-specific simulation based on realistic artery morphologies generated from computer tomography data are discussed.

Determination of a reference value for N(G), N(G)-dimethyl-L-arginine in 500 subjects

BACKGROUND

Asymmetric dimethylarginine (ADMA) acts as an endogenous inhibitor of NO-synthase. In the last years ADMA has emerged as a cardiovascular risk factor. The aim of this study was to determine a reference value for ADMA.

METHODS

Plasma samples of 500 healthy subjects in the 19-75 year age group were analyzed. Exclusion criteria from this study were smoking, any known significant disease, body-mass-index (BMI) above 30 kg m(-2), elevated plasma lipid levels, impaired renal function, hypertension, and intake of any medication. The ADMA levels were determined by ELISA, (DLD Diagnostics, Hamburg, Germany).

RESULTS

Mean ADMA plasma concentration of the total population was 0.69 micromol L(-1) (SD 0.20) and 95% of the measured values were in the range from 0.36 micromol L(-1) to 1.17 micromol L(-1). Women below 50 years of age had lower ADMA levels than men below 50 years of age [0.62 (0.17) micromol L(-1) vs. 0.69 (0.19) micromol L(-1); P = 0.001] and woman above 50 years of age had higher ADMA levels than men above 50 years of age [0.80 (0.22) micromol L(-1) vs. 0.73 (0.20) micromol L(-1); P = 0.036]. A regression analysis of ADMA levels and age was performed for each sex. The regression factor was r = 0.444 for women in a squared regression model (P < 0.001) and r = 0.212 for men in a linear regression model (P < 0.001).

CONCLUSION

The study was able to define a reference value for ADMA plasma levels with 0.36-1.17 micromol L(-1) and found sex dependent correlations between ADMA and age. Women showed a significant increase in ADMA plasma levels with onset of menopause.

[Biomarkers as prognostic factors in pulmonary arterial hypertension. Rationale and study design]

CURRENT SITUATION

Pulmonary arterial hypertension (PAH) is a serious disease. Its prognostic is based on the functional status quantified by the NYHA class and the 6-min walking test, and the hemodynamic data. The algorithms of treatment are solely based on the hemodynamic data and the functional status. The main objective is to test whether basal concentrations of isoprostanes, Big endotheline 1, ADMA, high sensitivity CRP, NT-Pro-BNP and cardiac troponin T are a 3-year prognostic factor in PAH using a combined criterion: death from any cause and pulmonary or cardiopulmonary transplantation.

MATERIALS AND METHODS

This is a multicenter, prospective, prognostic, single blinded study (plasma and urinary samples being blinded). The study started in november 2003, running for 2 years, with a 3 year follow-up for each patient. The main inclusion criterion is PAH. The data analysis will use a multivariable Cox model, taking into account the functional and hemodynamic parameters.

EXPECTED RESULTS

This study will determine whether any of the biomarkers tested provides additional prognostic information in PAH in addition to the functional and hemodynamic parameters.

Validation study to evaluate the reproducibility of a candidate in vitro potency assay of newcastle disease vaccines and to establish the suitability of a candidate biological reference preparation

A quantification assay for the Haemagglutinin-Neuraminidase (HN) protein of Newcastle Disease Virus (NDV) has been developed at CIDC-Lelystad as a candidate in vitro potency test for inactivated Newcastle disease (ND) vaccines. In studies performed at CIDC-Lelystad, a high correlation was demonstrated between the results of this candidate in vitro potency assay and the results of the serological potency assay (European Pharmacopoeia monograph 0870; test A). Furthermore, a high correlation between the serological data (Haemagglutination Inhibition-antibody titres) and clinical protection after challenge was demonstrated. Correlation between in vivo and in vitro potency assays was confirmed in a collaborative pre-validation study. In the pre-validation study three Official Medicines Control Laboratories (OMCLs) determined both the NDV-HN antigen content and the in vivo potency (vaccination-serology and vaccination-challenge) of 6 vaccine batches. The conclusion of the pre-validation study was that a large-scale collaborative study should be organised to validate the in vitro method and the suitability of the reference preparation. This report describes the outcome of this study. In brief, 14 laboratories (8 OMCLs and 6 vaccine manufacturers) determined the NDV-HN antigen content of 9 different vaccines in 3 independent tests. The vaccine batches were produced by 5 different manufacturers and represent a quantitative range of ND antigen content. One vaccine batch with insufficient potency and one poultry vaccine not containing NDV were included. Statistical evaluation of the results indicated that the antigen content could be determined with high precision. A good repeatability as well as reproducibility was found. Furthermore all laboratories found a similar ranking of the vaccines, based on the antigen content. Comparison of the antigen content and the in vivo potency of a series of vaccines with relatively low potencies indicated that a threshold relative antigen level of 7.0 antigen units per dose would discriminate between vaccine batches with sufficient and insufficient potency. An in vitro assay with this threshold level for antigen content did not result in any false positive results and only a limited number of false negative results in the BSP055 study. We conclude that the in vitro measurement of the antigen content of inactivated ND-vaccines with the proposed method is a reliable alternative potency assay that could be included as a new method in monograph 0870 on ND-vaccines.

Validation of a candidate in vitro potency assay for inactivated Newcastle disease vaccines

An NDV-HN antigen quantification assay has been developed as a candidate in vitro batch potency assay for inactivated vaccines. The assay consists of extraction of the viral antigens from the oil emulsion vaccines and quantification of the NDV-HN in a DAS-EUSA. After optimisation and preliminary validation, large stocks of lyophilised test reagents were prepared. Stability studies showed that there was no decrease in reactivity of the reagents in one year at -20 degrees after lyophilisation. Also in accelerated stability studies no decrease in reactivity was found after storage at higher temperatures. Antigen recovery, accuracy of the assay and specificity of the assay were found to be satisfactory in an in-house validation study. The intermediate precision was good to very good with coefficient of variation (CV) values that were always below 15%. The transferability of the test protocols has been studied in a pre-validation study in which three laboratories from two different countries participated. The protocols and the assay could be transferred to other laboratories without difficulty. Furthermore, vaccines with low and high potency as well as negative controls were identified by all participants. Finally between-assay as well as between-laboratory variation was satisfactory with CV-values of 0 to 30.

Antigen content of inactivated Newcastle disease oil emulsion vaccines as an in vitro indicator of potency

The potency of each batch of inactivated Newcastle disease virus (NDV) vaccine is measured in either a vaccination-serology or a vaccination-challenge experiment. We have developed an antigen quantification assay as an in vitro alternative for these currently prescribed in vivo potency assays. The in vitro assay consists of extraction of the viral antigens from the oil emulsion vaccines by isopropylmyristate, followed by quantification of the NDV HN-antigen in an ELISA. The analysis of 20 inactivated vaccines, representing the most common NDV-vaccines in Western Europe, indicated that large differences in antigen content exist between these vaccines. A comparison of the antigen content with the serological response after vaccination with 1/50 vaccine dose demonstrated that a reliable estimate of the potency can be made, based on the HN-antigen content of the vaccine. We therefore present our antigen quantification assay for NDV as a candidate in vitro potency assay. An international feasibility and validation study will be needed to prove the suitability and reliability of this candidate in vitro potency assay for inactivated NDV vaccines.

Feasibility study to evaluate the correlation between results of a candidate in vitro assay and established in vivo assays for potency determination of Newcastle disease vaccines

A Newcastle disease virus antigen quantification assay has been developed at CIDC-Lelystad as a candidate in vitro potency test for inactivated Newcastle disease vaccines. In studies performed at CIDC-Lelystad, a high correlation was demonstrated between the results of this candidate in vitro potency assay and the results of the serological potency assay (European Pharmacopoeia monograph 0870; test A). Furthermore, a high correlation between the serological data (Haemagglutination Inhibition-antibody titres) and clinical protection after challenge was demonstrated. The aim of the feasibility study was to confirm the correlation between the results obtained using the candidate in vitro potency assay and the results from both the in vivo potency assays currently prescribed in Ph Eur monograph 0870, in different laboratories and to determine whether a large-scale validation study of the in vitro method should ensue. In the feasibility study three Official Medicines Control Laboratories tested the potency of 5 different inactivated Newcastle disease vaccines and one experimental vaccine, using both of the in vivo methods described in the European Pharmacopoeia and the candidate in vitro method. The 6 vaccine batches represented a quantitative range of Newcastle disease virus antigen content and were produced by different manufacturers. Statistical evaluation of all results indicated that a satisfactory correlation was found in all laboratories between the two types of in vivo tests currently in place, and the candidate in vitro test. An excellent reproducibility of the proposed in vitro method was observed with respect to the ranking of the vaccines included in this study. It is concluded that the results of this feasibility study indicate that a large-scale collaborative study can be organised to validate the in vitro method and the suitability of the reference preparation.