Reversal of stage 5 chronic kidney disease by aortic valve replacement in kidney transplant recipient: a case report

BACKGROUND

Cardiorenal syndrome (CRS) is a group of pathophysiological disorders affecting heart and kidneys.

CASE PRESENTATION

We present 44-year-old kidney transplant recipient with acute-on-chronic graft failure in the course of CRS due to acutely decompensated heart failure associated with severe aortic regurgitation successfully treated with aortic valve replacement. Because of graft failure progression and difficult to eradicate infections he was treated with dialysis and radical minimization of immunosuppression. After 74 days of renal replacement therapy the patient regained graft function after successful aortic valve replacement. The dialysis could be stopped and immunosuppressive therapy was reintroduced. Heart and renal function are stable and patient is doing well without dialysis for 3 years.

CONCLUSIONS

The return of kidney graft function can occur even after a long period of dialysis therapy due to improved cardiovascular function. Therefore, distinguishing an acute-on-chronic CRS subtype is mandatory to enable specific patient approach.

Comparison of Two Methods of Pancreas Islets Immunoisolation

The efficacy of two methods of Langerhans islets immunoisolation was compared. For this purpose the function of islets encapsulated with alginate/polyethylenimine/protamine/heparin (APPH) or with alginate/poly-L-lisine/alginate (APA) membranes was assessed: in vitro according to their survival and response to glucose challenges, and in vivo according to their capability to provide sufficient insulin delivery to maintain normal fasting blood glucose following xenotransplantation to streptozotocin diabetic mice. In vitro insulin secretion and the response to glucose challenge of APPH and APA encapsulated islets were comparable to free islets. In vivo intraperitoneal concordant xenotransplantation of APA encapsulated rat islets reversed the diabetic state of streptozotocin diabetic mice for a longer period, than APPH islet grafts. This study clearly demonstrated the inadequacy of in vitro methods in the prediction of in vivo results of islets transplantation.

p53 and HER2/neu Expression in Relation to Chemotherapy Response in Patients with Non-Small Cell Lung Cancer

The aim of the study was to investigate a relation between p53 and HER2/neu expression in resected lung tumors and the response of those tumors to neoadjuvant chemotherapy. The study population included 67 consecutive patients with non-small cell lung cancer (NSCLC) in stage II or III who were operated on at the Institute of Tuberculosis, Warsaw, Poland, between 20 April 2001 and 10 March 2003. All patients received two cycles of chemotherapy consisting of cisplatin and vinorelbine prior to the operation. The response to therapy was assessed as complete response (CR), partial response (PR), stable disease (SD) or progressive disease (PD), on the basis of CT scans performed before and after neoadjuvant chemotherapy. p53 and HER2/neu protein expression were evaluated by immunohistochemistry (IHC) using antibodies against p53 (clone PAb 1801, Novocastra) and against HER2/neu (Dako) in paraffin-embedded specimens of tumors. A response to therapy (CR+PR) was observed in 27 patients, while 40 patients (SD+PD) were regarded as resistant to therapy. Resistance was observed significantly more often in tumors above 3 cm in diameter. p53 expression was found in 16 tumors (23.9%) and HER2/neu in 26 tumors (38.8%). We observed a nonsignificant tendency to chemoresistance in tumors with HER-2/neu overexpression and also in tumors with p53 overexpression. If we consider HER-2/neu and p53 together, chemoresistance was observed statistically significantly more often when one or both markers were positive (p<0.05). This significance was independent of tumor size.

Diagnostic accuracy of contrast-enhanced computed tomography and positron emission tomography with 18-FDG in identifying malignant solitary pulmonary nodules

Contrast-enhanced computed tomography (CECT) and positron emission tomography with 18-FDG (FDG-PET/CT) are used to identify malignant solitary pulmonary nodules. The aim of the study was to evaluate the accuracy of CECT and FDG-PET/CT in diagnosing the etiology of solitary pulmonary nodule (SPN). Eighty patients with newly diagnosed SPN >8 mm were enrolled. The patients were scheduled for either or both, CECT and FDG-PET/CT. The nature of SPN (malignant or benign) was determined either by its pathological examination or radiological criteria. In 71 patients, the etiology of SPN was established and these patients were included in the final analysis. The median SPN diameter in these patients was 13 mm (range 8-30 mm). Twenty-two nodules (31%) were malignant, whereas 49 nodules were benign. FDG-PET/CT was performed in 40 patients, and CECT in 39 subjects. Diagnostic accuracy of CECT was 0.58 (95% confidence interval [CI] 0.41-0.74). The optimal cutoff level discriminating between malignant and benign SPN was an enhancement value of 19 Hounsfield units, for which the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CECT were 100%, 37%, 32%, and 100%, respectively. Diagnostic accuracy of FDG-PET/CT reached 0.9 (95% CI 0.76-0.9). The optimal cutoff level for FDG-PET/CT was maximal standardized uptake value (SUV max) 2.1. At this point, the sensitivity, specificity, PPV, and NPV were 77%, 92%, 83%, and 89%, respectively. The diagnostic accuracy of FDG-PET/CT is higher than that of CECT. The advantage of CECT is its high sensitivity and negative predictive value.

Assessment of some porcine strains as donors of islets of langerhans

Mass isolation of viable porcine islets is a difficult task because of their fragility, and because of donor variability with respect to strain, age, sex, feeding, and methods of slaughtering. Not all strains are equally suitable for islet separation. The aim of this study was to evaluate porcine pancreata as an alternative source of islets for clinical transplantation. Pancreata were digested from pig strains available in Poland: 248 market weight slaughterhouse pigs and 42 pigs, belonging to the Polish Large White (WBP, 14 sows and 3 males), Polish White Pendant-Ears (PBZ; 16 sows), Pietrain (8 sows), and Yorkshire (1 sow) races. Prepurification data of recoverable islets/g and islet equivalents/g were considered as representative for the number of recoverable islets. Acceptable results namely, islet and/or islet-equivalent (IE) number of at least 1000/g, were obtained from only 56 of 248 slaughterhouse pigs, namely 2073 +/- 137.4 SE (median 1767/g) islets with values of IE of 2994 +/- 303 SE (median 1874/g). Our data support Krickhahn et al suggesting that only pancreata with an average islet size exceeding 199 microm should be digested and that only from 1 of 3 to 5 porcine pancreata is an adequate amount of islets generated.

[Primary lung hemangiopericytoma--a rare neoplasm with a long course of recurrence over many years]

Hemangiopericytoma (HPC) is a rare neoplasm arising from pericytes that occur mostly around smaller vessels. Up to now only about 100 cases have been reported to arise primarily in the lung. The behavior of pulmonary hemangiopericytomas is difficult to predict and all tumors should be considered potentially malignant, even though the criteria for malignancy are not well developed. The diagnosis of HPC is known to confound even experienced pathologist. Pericytes lack readily identifiable morphologic features, therefore hemangiopericytomas are often confused with other soft tissue tumors that may have hemangiopericytoma--like pattern. We report a rare case of primary HPC of the lung with an asymptomatic, long course of the disease. The diagnosis of hamartoma was established after the first operation. Subsequently, seven years later, a chest radiograph revealed new lesions. Histological examination, including immunohistochemistry lead to the final diagnosis of hemangiopericytoma. The small number of cases of primary pulmonary hemangiopericytoma makes it difficult to define the correct histopathological diagnosis especially without modern methods.

[Aspergilloma of the lung imitating lung cancer]

75-year old woman admitted to Institute of TB due to the opacity in middle lobe of the right lung is described. The chest X-ray might suggest possibility of the lung cancer. The examination of the patient did not revealed any abnormalities. At the admission the nature of the lesion was not recognised by the accessible methods. Therefore, the thoracotomy was performed, and the aspergilloma was confirmed by intraoperative histopathologic methods. The middle lobe with the lesion was totally resected. The postoperative period was uneventful. The six months follow-up revealed that patient was cured.

Reversal of hyperglycemia in streptozotocin diabetic mice by xenotransplantation of microencapsulated rat islets

Rat pancreatic islets were immunoisolated within alginate capsules with additional polyethyleneimine-protamine-heparin highly biocompatible membrane. Perifusion study in vitro demonstrated satisfactory similarities between the insulin release profiles of encapsulated and free islets. Concordant xenotransplantation of microencapsulated rat islets significantly prolonged mean time of restored normoglycemia (46 +/- 15 days) in streptozotocin-diabetic BALB/c mice recipients comparing to uncoated grafts (7 +/- 2 days).

Experience with pancreas islets separation, immunoisolation and cryopreservation

Experience of Warsaw Pancreas Laboratory is presented. Some improvement in the methods of rat, human and pig pancreases digestion, and in identification of Langerhans islets by means of intravenous injection of I-DTZ was achieved. For immunoisolation of islets, 2 methods were elaborated: capsules containing alginate/polyethyleneimine/protamine/heparin membrane prepared by modified Sun method, and microcapsules based on Zekorn method. Biocompability of hollow fibers, prepared with polypropylene (PP), surface modified PP (PPS) and polysulphone (PS) was assessed in vitro. Only PS fibers were fully compatible. It was shown, that the mixture of exocrine tissue did not influence in vitro insulin secretion, providing that alginate in which islets are embedded remain gelled. The efficacy of 3 methods of islets cryopreservation was compared: freezing in "semicontrolable" conditions, in programmable Kriomedpol machine, and vitrification. The highest percentage of frozen/thawed living cells, and the most reliable results were obtained with Kriomedpol method.

[Primary biliary cirrhosis with sarcoid-like infiltrations in the lung]

A women, 50 years old, has been observed for 4 years because of recurrent infiltrations in both lungs. Biopsy of those lesions revealed sarcoid-like granulomas. Tubercle baccilli were not present in those lesions nor in the sputum or bronchial washings. Anti-tuberculosis therapy was without effect. On admission to our hospital she was in good performance state. There was an infiltration in the base of the left lung. Hepatosplenomegaly was observed on USG examination. Aspartate aminotransferase was 49 UI/l, alanine aminotransferase 70 UI/l. Alkaline phosphatase was 167 UI/l and the titer of antimitochondrial antibodies was 1:2000. Primary biliary cirrhosis was suspected, but the patient refused liver biopsy. Prednisone in the dose of 60 mg per day was given to suppress the granuloma formation in the lungs. During this treatment there was a decrease in size of liver and spleen, lung lesion disappeared and the titer of antimitochondrial antibodies decreased to 1:40. After 3 months of treatment the dose of prednisone was reduced gradually. When she was receiving 15 mg of prednisone every other day the titer of antimitochondrial antibodies rose to 1:8000 and the activity of alkaline phosphatase to 448 UI/l. At this time she accepted liver biopsy. Primary biliary cirrhosis was diagnosed. The possible connection between sarcoid-like granulomas in the lungs and the primary biliary cirrhosis is discussed.

[Atypical case of bronchial carcinoid]

This article illustrates problems in diagnosis and treatment of an atypical form of bronchial carcinoid. We described the case of a 49-year old man, exposed to granite dust and noise for 25 years who had suffered from frequent bronchitis inflammations and pneumonias for 5 years prior to the diagnosis. He was admitted to our clinic because of supposed occupational nature of hearing deficiency. Although a pneumoconiosis was excluded before the admission, we found clinical and X-ray features of the right lung emphysema with medium restrictive ventilation disturbances. Bronchoscopy was performed because of "bright" right lung and ventilation disturbances and it showed presence of the carcinoid. Unusual in this case were tiny anamnestical findings (mild dyspnea attacks after physical effort or nervousness) plus increasing frequency of reported from the childhood bronchitis and pneumonias and uncharacteristic "bright" right lung in X-ray. Therapeutical difficulties resulted from atypical histological form of the tumor, its diameter, polypous-infiltrative character, and inconvenient localization. In spite of late diagnosis of carcinoid and significant acceleration of respiratory decompensation symptoms after the diagnosis the attempt of surgical therapy was appropriate but unsuccessful. After the operation the patient was suffering long lasting lowering of arterial pressure (what was corrected with catecholamine infusions) probably as a result of serotonin secretion. However it was not established because of technical reasons.

Comparison of two methods of pancreas islets immunoisolation

The efficacy of two methods of Langerhans islets immunoisolation was compared. For this purpose the function of islets encapsulated with alginate/polyethylenimine/protamine/heparin (APPH) or with alginate/poly-L-lisine/alginate (APA) membranes was assessed: in vitro according to their survival and response to glucose challenges, and in vivo according to their capability to provide sufficient insulin delivery to maintain normal fasting blood glucose following xenotransplantation to streptozotocin diabetic mice. In vitro insulin secretion and the response to glucose challenge of APPH and APA encapsulated islets were comparable to free islets. In vivo intraperitoneal concordant xenotransplantation of APA encapsulated rat islets reversed the diabetic state of streptozotocin diabetic mice for a longer period, than APPH islet grafts. This study clearly demonstrated the inadequacy of in vitro methods in the prediction of in vivo results of islets transplantation.

[Experiments with pancreas islet xenotransplantation]

Different methods of human, porcine and rat pancreata digestion Langerhans islets purification, immuno-isolation and cryopreservation were compared. The results obtained were assessed in vitro and in vivo. The longest concordial xenograft survival was observed after transplantation of rats islets immunoisolated by Sun's method to streptozotocin diabetic mice. Due to its simplicity and lesser time consumption using Kriomedpol machine was recommended.

In vitro and in vivo evaluation of protamine-heparin membrane for microencapsulation of rat Langerhans islets

Rat pancreatic islets were microencapsulated with multilayer protamine-heparin (PH) membrane. Basal and stimulatory insulin secretion of microencapsulated islets was similar to the controlled free islets in vitro. During the long-term culture (up to 2 weeks) mean insulin release of encapsulated islets did not significantly differ from the mean of free ones (the ratio of mentioned means was 54-167%). Empty PH microcapsules transplanted into Wistar rats intraperitoneally and under the kidney capsule were generally harmless up to 4 months. In only a few cases traces of fibrotic tissue around capsules entrapped in the omentum were found. No damage of microcapsules structure was observed. The worst results were obtained in the instance of retroperitoneal transplantation. We conclude, therefore, that PH membrane was proved to be highly biocompatible, nontoxic for islets, and did not impair viability and glucose-dependent insulin secretion of Langerhans islets in in vitro culture.

The influence of the H-2 receptor antagonist ranitidine on cadaver kidney allograft function

To assess the influence of ranitidine on kidney allograft function a double-blind, placebo-controlled clinical study in 42 cadaver kidney recipients has been performed. Patients received ranitidine or placebo for 1 month. Four years after transplantation 81% of the patients in the control group were alive; 67% in the control and 71% in the ranitidine group with functioning grafts. These differences were statistically not significant. However, a slightly more intensive steroid therapy was given to keep the ranitidine patients adequately immunosuppressed. Ranitidine thus can be safely used in kidney graft recipients. Because of a lack of gastrointestinal complications in both groups, no conclusions can be drawn regarding the prophylactic value of ranitidine.

Diagnostic and prognostic value of antibody-dependent cellular cytotoxicity and lectin-induced cellular cytotoxicity tests for renal graft rejection

Peripheral blood lymphocytes from both normal subjects and kidney allograft recipients, before and on the 4th to 5th days after transplantation, were examined for antibody-dependent cellular cytotoxicity (ADCC) and lectin-induced cellular cytotoxicity (LICC). The graft recipients were treated with standard immunosuppression, which included azathioprine and prednisolone. 51Cr-labeled L1210 cells were used as targets for these two tests. ADCC and LICC activity were evaluated in the presence of rabbit anti-L1210 anti-serum and phytohemagglutinin (PHA), respectively. Comparison of the results obtained from healthy subjects with those of patients before grafting showed a significantly higher LICC activity in the latter group. The ADCC activity did not differ between the groups of healthy females and those awaiting transplantation but it was significantly decreased in the group of males awaiting transplantation as compared to healthy males. Four to 5 days after transplantation, the activity of ADCC and LICC remained unchanged in spite of the immunosuppressive treatment in 37 and 61% of the patients studied, respectively. In most of the patients, high ADCC and/or LIcC activity was followed by an accelerated acute rejection episode. A correlation between the ADCC and LICC activities, measured 4 to 5 days after transplantation, and the time of the first rejection episode was found. We conclude that double screening with ADCC and LICC tests in the 1st week after transplantation is valuable.