Five-year outcomes in kidney transplant patients converted from cyclosporine to everolimus: the randomized ZEUS study

ZEUS study was an open-label, 12-month, multicenter study in which 300 de novo kidney transplant recipients were randomized to continue receiving cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant. Five-year follow-up data were available for 245/269 patients (91.1%) who completed the core 12-month study (123 everolimus, 109 CsA). At 5 years, adjusted estimated GFR was 66.2 mL/min/1.73 m(2) with everolimus versus 60.9 mL/min/1.73 m(2) with CsA; the mean difference was 5.3 mL/min/1.73 m(2) in favor of everolimus (95% CI 2.4, 8.3; p < 0.001 [intent-to-treat population]). In a post hoc analysis of patients remaining on study drug at 5 years (everolimus 77, CsA 86), mean difference was 8.2 mL/min/1.73 m(2) (95% CI 4.3, 12.1; p < 0.001) in favor of everolimus. The cumulative incidence of biopsy-proven acute rejection postrandomization was 13.6% with everolimus versus 7.5% with CsA (p = 0.095), largely accounted for by grade I rejection (16/21 patients and 7/11 patients, respectively). Postrandomization, graft loss, mortality, serious adverse events and neoplasms were similar in both arms. In conclusion, conversion of kidney transplant patients to everolimus at 4.5 months posttransplant is associated with a significant improvement in renal function that is maintained to at least 5 years. The increase in early mild acute rejection did not affect long-term graft function.

Conversion from cyclosporine to everolimus at 4.5 months posttransplant: 3-year results from the randomized ZEUS study

The long-term effect of conversion from calcineurin inhibitor (CNI) therapy to an mTOR inhibitor requires clarification. Following completion of the 12-month, open-label, multicenter ZEUS study, in which 300 kidney transplant recipients were randomized to continue cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant, outcomes were assessed at month 36 (n = 284; 94.7%). CNI therapy was reintroduced in 28.4% of everolimus patients by month 36. The primary efficacy endpoint, estimated glomerular filtration rate (Nankivell, ANCOVA) was significantly higher with everolimus versus the CsA group at month 24 (7.6 mL/min/1.73 m(2) , 95%CI 4.3, 11.0 mL/min/1.73 m(2) ; p < 0.001) and month 36 (7.5 mL/min/1.73 m(2) , 95%CI 3.6, 11.4 mL/min/1.73 m(2) ; p < 0.001). The incidence of biopsy-proven acute rejection from randomization to month 36 was 13.0% in the everolimus arm and 4.8% in the CsA arm (p = 0.015). Patient and graft survival, as well as incidences of malignancy, severe infections and hospitalization, were similar between groups. Kidney transplant patients who are converted from CsA to everolimus at month 4.5 and who remain on everolimus thereafter may achieve a significant improvement in renal function that is maintained to 3 years. There was a significantly higher rate of rejection in the everolimus arm but this did not exert a deleterious effect by 3 years posttransplant.

Sotrastaurin, a novel small molecule inhibiting protein-kinase C: randomized phase II study in renal transplant recipients

Sotrastaurin, a selective protein-kinase-C inhibitor, blocks early T-cell activation through a calcineurin-independent mechanism. In this study, de novo renal transplant recipients with immediate graft function were randomized 1:2 to tacrolimus (control, n = 44) or sotrastaurin (300 mg b.i.d.; n = 81). All patients received basiliximab, mycophenolic acid (MPA) and steroids. The primary endpoint was the composite of treated biopsy-proven acute rejection (BPAR), graft loss, death or lost to follow-up at month 3. The main safety assessment was estimated glomerular filtration rate (eGFR); modification of diet in renal disease (MDRD) at month 3. Composite efficacy failure at month 3 was higher for the sotrastaurin versus control regimen (25.7% vs. 4.5%, p = 0.001), driven by higher BPAR rates (23.6% vs. 4.5%, p = 0.003), which led to early study termination. Median (± standard deviation [SD]) eGFR was higher for sotrastaurin versus control at all timepoints from day 7 (month 3: 59.0 ± 22.3 vs. 49.5 ± 17.7 mL/min/1.73 m(2) , p = 0.006). The most common adverse events were gastrointestinal disorders (control: 63.6%; sotrastaurin: 88.9%) which led to study-medication discontinuation in two sotrastaurin patients. This study demonstrated a lower degree of efficacy but better renal function with the calcineurin-inhibitor-free regimen of sotrastaurin+MPA versus the tacrolimus-based control. Ongoing studies are evaluating alternative sotrastaurin regimens.

Similar lipid profile but improved long-term outcomes with sirolimus after cyclosporine withdrawal compared to sirolimus with continuous cyclosporine

Renal transplant recipients show an increased risk of cardiovascular disease compared with a nontransplant population. Herein we have shown an analysis of a randomized controlled trial wherein 525 patients receiving a first or second (9.7%) renal allograft from a deceased (89.1%), a living-related (7.8%), or a living-unrelated donor (3.1%) received sirolimus (SRL), cyclosporine (CsA), and steroids (ST) at the time of transplantation with randomization at 3 months after transplantation of 430 eligible patients to continue on SRL-CsA-ST or to have CsA withdrawn with increased SRL trough targets (SRL-ST group). Graft survival, patient survival, and renal function at 5 years were analyzed by average fasting total cholesterol (<or=200 or >200 mg/dL) and triglyceride (<or=240 or >240 mg/dL) subgroups. At 5 years, total, high-density lipoprotein (HDL), and low-density lipoprotein [LDL] cholesterol and triglyceride values were similar between the groups. Statins ( approximately 80% of patients of both groups) were most effective to lower cholesterol ( approximately 50 mg/dL; P < .001; both groups), and fibrates ( approximately 25% of patients of both groups) were most effective to decrease triglycerides ( approximately 100 mg/dL; P < .001; both groups). Renal function and blood pressure were significantly better with SRL-ST. Hypercholesterolemia and hypertriglyceridemia were associated with reduced graft survival, patient survival, and calculated GFR, but the only significant difference was lower graft survival among SRL-CsA-ST patients with hypertriglyceridemia. Cardiovascular-related deaths were reported in 3.7% and 2.8% of patients in the SRL-CsA-ST and SRL-ST groups, respectively. In conclusion, when compared with continuous SRL-CsA-ST, CsA withdrawal at 3 months followed by SRL-ST significantly improved glomerular filtration rate (GFR) and blood pressure without a further increase in lipid parameters or an incidence of untoward effects from hyperlipidemia, despite a 2-fold higher SRL exposure.

Laparoscopic live donor nephrectomy: Are ten cases per year enough to reach the quality standards? A report from a single small-volume transplant center

BACKGROUND

Laparoscopic live donor nephrectomy is the preferred method of kidney donation in high-volume US transplant centers, but for small transplant programs the question of the minimal case load per year necessary to reach the quality standards is open.

PATIENTS AND METHODS

From 1996 to 2007 we performed 130 live kidney donations including 93 laparoscopic donor nephrectomies followed by transplantation in a community hospital with an average case load of 10 laparoscopic cases per year. We compared the results after 37 open and 93 laparoscopic live donor operations with respect to operating time, conversion rate, complications, and recipients' outcome.

RESULTS

There were no significant differences in terms of safe outcome of donor patients after open or laparoscopic donor nephrectomy. The mean operating time was significantly shorter (p < 0.001) in the open group (125 min, OG) than in the laparoscopic group (150 min, LG). Mean hospital stay was significantly shorter (p < 0.001) in LG (6.8 days) versus OG (9.7 days). The conversion rate was 3.2% in the LG. Postoperative complication of donors consisted of temporary nerve irritation (two patients) and retroperitoneal hematoma (one patient) in the LG, and wound infection followed by hernia formation (one patient) and ileus 1 year after organ donation (one patient) in the OG. Safe outcome of the recipients after open (RaOD) or laparoscopic donation (RaLD) was similar. Uneventful transplantation occurred in 94.6% of the RaOD and in 92.5% of the RaLD. One kidney was lost due to renal vein thrombosis (RaLD). Mean postoperative creatinine after 4 weeks showed no difference between RaOD (1.6 mg/dl) and RaLD (1.7 mg/dl).

CONCLUSION

Approximately ten cases per year may be enough to ensure safety and quality of laparoscopic live donor nephrectomy.

[The way to establish laparoscopic donor nephrectomy as the method of choice in live kidney donation--a single centre experience]

INTRODUCTION

In contrast to the USA, laparoscopic donor nephrectomy is rarely practised in German transplant centres. Safety concerns and difficulties with the learning curve of this advanced laparoscopic procedure are the main obstacles to the establishment of this operation.

PATIENTS AND METHODS

From 1998-2005, we performed laparoscopic kidney procurement in 50 live kidney donors on an intention to treat basis harvesting a total of 29 left and 21 right kidneys for transplantation.

RESULTS

Negative adverse effects on the donor side were temporary nerve irritation (2 patients) and postoperative retroperitoneal hematoma. Reasons to convert to open nephrectomy were bleeding (2 patients) and adhesions (1 patient). On the recipient side, one kidney was lost due to renal vein thrombosis. Three patients required short-time dialysis after transplantation. All other kidney transplants worked without any problems.

CONCLUSION

Laparoscopic donor nephrectomy is a safe procedure and has been established as the method of choice for live kidney donation in our hospital.

Laparoscopic live donor nephrectomy for right kidneys: Experience in a German community hospital

BACKGROUND

Laparoscopic live donor nephrectomy has become the new gold standard for kidney procurement in many high-volume transplant centres worldwide, but it is often limited to left-sided donor kidneys. Concerns about adequate anatomical renal vessel length and sufficient surgical exposure are the main obstacles to the use of the laparoscopic approach for right kidney live donors as well.

MATERIAL AND METHODS

From 1998 to 2006 we performed laparoscopic kidney procurement in 73 live kidney donors on an intention-to-treat basis, harvesting a total of 48 left (LKG) and 25 right kidneys (RKG) for transplantation. We compared these two groups with respect to operating time, conversion rate, complications, hospital stay, and recipient outcome.

RESULTS

There were no differences in outcome of donor patients after left (D-LKG) or right laparoscopic donor nephrectomy (D-RKG). Operating time was 160 min in D-RKG versus 164 min in D-LKG. Warm ischemia was below 150 s in both groups. Hospital stay was 7.0 (D-RKG) versus 6.7 days (D-LKG). Negative events on the donor site were one temporary nerve irritation in each group and one postoperative retroperitoneal hematoma in the left kidney group. Reasons to convert to open nephrectomy were bleeding in two patients in the left kidney group and adhesions in one patient in the right kidney group. The outcome of the recipients after left (R-LKG) or right kidney (R-RKG) transplantation was similar. One kidney was lost due to renal vein thrombosis (R-LKG). Postoperative ureter complications occurred in one patient of each group. One patient of the R-RKG and two patients of the R-LKG required lymphocele fenestration. All other kidney transplants worked without problems.

CONCLUSION

Laparoscopic donor nephrectomy is a safe procedure and has been established as the method of choice for live kidney donation in our clinic. Laparoscopic procurement of right and left kidneys can be performed with comparable quality and outcome for donors and recipients.

Plasma concentrations of mycophenolic acid acyl glucuronide are not associated with diarrhea in renal transplant recipients

The aim of this study was to determine whether plasma concentrations of the acyl (AcMPAG) and phenolic (MPAG) glucuronide metabolites of mycophenolic acid (MPA) were related to diarrhoea in renal transplant patients on mycophenolate mofetil (MMF) with cyclosporine (CsA) or tacrolimus (TCL). Blood samples (0, 30, 120 min) were taken at days 3, 10, week 4, months 3, 6 and 12 for determination of MPA, MPAG and AcMPAG. MPA-AUC was estimated using validated algorithms. Two hour AUCs were calculated for MPAG and AcMPAG. Immunosuppressive therapy consisted of CsA/MMF (n= 110) and of TCL/MMF (n= 180). In 70/290 (24%) patients 86 episodes of diarrhoea were recorded during 12 months. Significantly more patients on TCL (31.1%) suffered from diarrhea compared to CsA (12.7%). MMF dose, MPA-AUC and the 2 h AUCs of MPAG and AcMPAG did not differ between patients with and without diarrhoea. Plasma AcMPAG and MPAG concentrations were substantially higher in patients on CsA compared with TCL, while MPA-AUC was lower in the former group. These data support the concept that CsA inhibits the biliary excretion of MPAG and AcMPAG, thereby potentially reducing the risk of intestinal injury through enterohepatic recycling of MPA and its metabolites.

Noninfectious gastrointestinal (GI) complications of mycophenolic acid therapy: a consequence of local GI toxicity?

Mycophenolic acid (MPA), a reversible inhibitor of inosine 5''-monophosphate dehydrogenase (IMPDH), selectively inhibits T- and B-cell proliferation. MPA exposure correlates inversely with the risk of acute rejection. Mycophenolate mofetil (CellCept; MMF) is an immediate-release formulation of MPA that is absorbed in the stomach and small intestine. Enteric-coated mycophenolate sodium (myfortic; EC-MPS) delays MPA release until the small intestine. There are some indications that EC-MPS may be associated with improved gastrointestinal (GI) toxicity. It is widely believed that systemic MPA exposure determines the extent of GI toxicity. However, intestinal cells absorb purines locally from the gut lumen via passive diffusion and a specific transport mechanism. It seems likely that local, rather than systemic, MPA exposure is responsible for GI events. Acyl-MPAG, a toxic metabolite of MPA, may be produced by GI cells contributing to MPA-related gut toxicity, suggesting that measures to alter the rate or location of MPA absorption could be beneficial. Lastly, the release of N-(2-hydroxyethyl)morpholine following deestification of MMF may have local irritative effects on gastric mucosal cells. Research which more closely focuses on the local gut pathobiology of MPA-containing drugs may provide a much clearer understanding of the dose-limiting toxicity of this drug class.

Conversion to Enteric-Coated Mycophenolate Sodium From Various Doses of Mycophenolate Mofetil: Results of a Prospective International Multicenter Trial in Maintenance Renal Transplant Patients Receiving Cyclosporine

Conversion from mycophenolate mofetil (MMF, CellCept) to enteric-coated mycophenolate sodium (EC-MPS, myfortic) is safe and effective in renal transplant patients treated with the standard dose of 2 g MMF. In this 6-month, international, multicenter, open-label, single-arm trial, a large cohort of maintenance renal transplant patients receiving different doses of MMF were converted under normal clinical conditions to equimolar doses of EC-MPS. Mean calculated creatinine clearance remained stable from the time of study entry (59.6 +/- 19.7 mL/min) to the end of the study (58.3 +/- 19.8 mL/min). Adverse events were reported by 152 patients (67%), with gastrointestinal complications being observed in 45 patients (20%). Thirty-three patients (15%) experienced adverse events or infections with a suspected relation to EC-MPS, including one case of anemia and two cases of leukopenia. Eleven patients (4.9%) required a reduction in EC-MPS dose and seven patients (3.1%) permanently discontinued EC-MPS owing to adverse events. At month 6 after conversion, five patients (2.2%) experienced biopsy-proven acute rejection. There were no graft losses or deaths. These data support earlier findings that stable maintenance renal transplant patients receiving MMF with cyclosporine with or without corticosteroids can be converted to EC-MPS with no compromise in efficacy and tolerability, and no adverse effect on renal function.

Absorption characteristics of EC-MPS – an enteric-coated formulation of mycophenolic sodium

Enteric-coated mycophenolate sodium is an advanced formulation delivering mycophenolic acid (MPA), designed to improve MPA-related upper gastrointestinal adverse events by delaying MPA release until the small intestine.

OBJECTIVE

Two studies were undertaken to identify the absolute bioavailability and dose-proportionality of enteric-coated mycophenolate sodium in stable renal transplant patients receiving cyclosporine.

METHODS

Study 1: The mean MPA AUC(0-t) was shown to be greater after MPA infusion than after oral enteric-coated mycophenolate sodium (42.1 vs. 28.9 microg x h/ml). Mean absolute bioavailability was 0.71 +/- 0.21 (SD). Study 2: The AUC(0-t) and C(max) for MPA were proportional to the dose of enteric-coated mycophenolate sodium, similarly mean AUC(0-infinity) and C(max) for MPA glucuronide were proportional to dose administered.

RESULTS AND CONCLUSIONS

In patients receiving cyclosporine the absolute bioavailability of MPA provided by enteric-coated mycophenolate sodium is equivalent to that provided by mycophenolate mofetil when administered in combination with cyclosporine, and exhibits dose-proportionality. Enteric-coated mycophenolate sodium was well tolerated from 180 - 2,160 mg with no serious adverse events reported.

Cyclosporine C2 levels in de novo renal allograft recipients: a German multicenter prospective observational study

This ongoing multicenter prospective observational study was undertaken in de novo renal allograft recipients managed with cyclosporine (CsA) trough (C0) and 2-hour postdose (C2) level monitoring at defined times so as to assess the risk for an acute rejection episode or allograft dysfunction. The renal transplant recipients (n = 159) were enrolled at 11 German centers. The 6-month posttransplant data from 138 patients were evaluable for this interim analysis. Mean C2 levels (ng/mL), which were measured by liquid chromatography-tandem mass spectrometry at a central laboratory, were: days 3 to 5: 873.1 +/- 391.9; days 7 to 10: 939.1 +/- 422.8; days 14 to 28: 1116.3 +/- 497.6; 3 months: 905.0 +/- 316.8; and after 6 months: 787.0 +/- 276.5. To identify patients at higher risk for acute rejection or allograft dysfunction, we calculated the relative CsA absorption capacity (C2 [ng/mL]/morning dose [mg/kg]; CsA-Abs), yielding mean values on days 3 to 5: 284.4 +/- 115.1; days 7 to 10: 306.7 +/- 134.8; days 14 to 28: 382.5 +/- 164.7; month 3: 501.5 +/- 168.8; month 6: 512.7 +/- 176.5. Three groups were distinguished by CsA-Abs at days 7 to 10: low absorbers (CsA-Abs < 200), normal absorbers (CsA-Abs 200 to 350), and high absorbers (CsA-Abs > 350). A between-group comparison of absorption level at 6 months posttransplant revealed the incidences of biopsy-proven acute rejection and Cockcroft-Gault formula-based mean glomerular filtration rates of 23.8% and 54.7 +/- 19.0 mL/min, 22.6% and 59.5 +/- 20.7 mL/min, and 17.6% and 67.7 +/- 23.5, respectively. In conclusion, mean C2 levels >1000 ng/mL are attained within 2 to 4 weeks, with CsA-Abs increasing continuously over the first 6 posttransplant months. High CsA absorbers show a propensity toward good allograft function and lower acute rejection rates at 6 months after renal transplantation.

Conversion from mycophenolate mofetil to enteric-coated mycophenolate sodium in maintenance renal transplant patients: preliminary results from the Myfortic Prospective Multicenter Study

Mycophenolate mofetil (MMF), in combination with cyclosporine and corticosteroids, improves long-term graft survival in renal transplant recipients. However, optimal MMF therapy may be limited by gastrointestinal (GI) intolerance, which may result in the need for MMF dose reduction, interruption, or discontinuation, leading to increased risk of acute rejection. Enteric-coated mycophenolate sodium (EC-MPS) is a new formulation delivering mycophenolic acid developed with the aim of improving upper GI tolerability. A large prospective, open-label, multicenter program (myPROMS: myfortic PROspective Multicenter Study) is underway to determine the efficacy and safety of EC-MPS, in combination with cyclosporine microemulsion (CsA; Neoral) in a large population of de novo and maintenance renal transplant recipients. myPROMS consists of one global protocol with 14 subprotocols. Each subprotocol is designed to address further specific objectives, such as specific patient populations, steroid regimens, and various CsA C2 targets. The preliminary data summarized here are from two subprotocols, which investigated the benefits of converting maintenance renal transplant patients receiving MMF to EC-MPS. The 3-month interim analyses suggest that the conversion from MMF to EC-MPS is well tolerated in maintenance renal transplant recipients.

[Renal oxalosis with renal failure after infusion of xylitol]

HISTORY AND FINDINGS

Ten days after a complication-free operation for early gastric cancer a 61-year old man had a seizure and acute renal failure.

INVESTIGATIONS

A percutaneous renal biopsy was performed to find the cause of the renal failure, which at times required several sessions of haemodialysis.

TREATMENT AND COURSE

The seizure was thought to have been due to cerebrovascular deposits of oxalate crystals (renocerebral oxalosis). Parenteral xylitol had been given postoperatively, as a glucose substitute (total dose 1560g), together with other routine drugs. Primary oxalosis and other causes of secondary oxalosis had been excluded.

CONCLUSION

Xylitol should not be used parenterally as a glucose substitute (banned in the USA).

Concentration-guided strategies in drug development: experience with a cyclosporine analog in transplantation

A concentration-guided study was designed to maintain adequate immunosuppression and avoid excessive drug exposure while determining steady-state relative bioavailability of two cyclosporine G (CyG) oral formulations in stable renal transplant patients. In period I (week 1), 26 patients taking cyclosporine A (CyA)-based immunosuppressive regimens entered the study. Doses were titrated to maintain trough concentrations within a predefined range, as measured by fluorescence polarization immunoassay (FPIA). Patients were given an oral solution of CyG in period II (weeks 2-3), and a microemulsion capsule formulation of CyG in period III (weeks 4-5), with dose titration as necessary to achieve trough concentrations in a predefined range, as measured by FPIA. Full pharmacokinetic profiles were obtained on the last day of each study period. Treatment with CyA was reinitiated in period IV (week 6) at the same doses as at study entry. All blood samples were analyzed at the conclusion of the study using CyG- and CyA-specific high-performance liquid chromatography (HPLC). When changing from oral solution to capsule for CyG, an average 19% dose reduction was necessary to compensate for the elevated trough concentrations resulting from the increased bioavailability of the capsule formulation. The concentration-guided strategy was successful in avoiding over-exposure, and resulted in comparable values for area under the concentration-time curve (AUC) for both formulations of CyG. Dose normalization of the pharmacokinetic parameters subsequently allowed calculation of the relative bioavailability. Specifically, a faster rate and greater extent of CyG absorption from the capsule than the oral solution were manifested as a slightly earlier time to peak concentration (tmax), an average 44% increase in the maximum concentration (Cmax), and an average 29% increase in AUC. This experience demonstrated that a concentration-guided trial design allowed a drug development question for a compound with a narrow therapeutic index to be addressed safely and directly in the target patient population.

Acute effect of cyclosporin on renal function following the initial changeover to a microemulsion formulation in stable kidney transplant patients

Potential differences in the acute effect of cyclosporin on renal function when dosed orally as the current market formulation or following a milligram-to-milligram conversion to a new microemulsion formulation were investigated in 14 stable kidney transplant patients. The study consisted of three sequential periods of 2 weeks duration each. Patients entered (period I) and completed (period III) the investigation with the market formulation and received the microemulsion formulation in period II; individualized cyclosporin doses remained unchanged throughout the study. Over one steady-state dosing interval at the end of each study period, whole blood cyclosporin pharmacokinetic profiles were assessed in parallel with endogenous creatinine clearances over sequential 1- to 2-h intervals. The rate and extent of cyclosporin absorption were significantly greater (P < 0.01) from the microemulsion formulation with average increases of 73% in peak concentration and 44% in area under the curve compared to the market formulation. Sequential creatinine clearances exhibited a transient decrease with the nadir occurring on average between 4 and 6 h post dose followed by a rapid return to baseline. Specifically in period I on the market formulation, clearances decreased from a baseline of 71.7 +/- 20.6 to a minimum of 51.1 +/- 17.9 ml/min per 1.73 m2 (similar values in period III) and from 76.8 +/- 24.8 to 53.5 +/- 17.5 ml/min 1.73 m2 in period II on the microemulsion. Neither the baseline nor minimum clearances were significantly different among the study periods.(ABSTRACT TRUNCATED AT 250 WORDS)

Within-day consistency in cyclosporine pharmacokinetics from a microemulsion formulation in renal transplant patients

A new microemulsion formulation of cyclosporine (Sandimmune Neoral) was compared to the commercially available formulation (Sandimmune) in 11 stable renal transplant patients with regard to the consistency in cyclosporine pharmacokinetics between a daytime fasting, and a nighttime nonfasting administration. Daily cyclosporine doses were individualized and administered in equal, divided doses every 12 h as soft gelatin capsules; doses were kept constant throughout the study. Serial blood samples were obtained over a 24-h period (two consecutive dosing intervals) at steady-state for each formulation, and cyclosporine concentrations were determined in whole blood by a specific radioimmunoassay method. Within-formulation consistency in pharmacokinetic parameters between the daytime and nighttime administrations was assessed in terms of bioequivalence criteria. Following the mg-to-mg conversion from the commercial to the microemulsion formulation, area under the curve (AUC) was increased on average by 30% due to absorption-related pharmacokinetic differences, while trough concentrations remained in the therapeutic range. Within each formulation, AUC was bioequivalent when comparing the daytime fasting to the nighttime nonfasting administration. For the commercial formulation, however, there was considerable variation in absorption rate, dampening of peak-trough fluctuation, and elevation of trough concentration following the nighttime nonfasting dose. By contrast, the microemulsion exhibited a more stable concentration-time profile over the two dosing intervals, with bioequivalence in peak-trough fluctuation and trough concentrations. Hence, the steady-state pharmacokinetics of cyclosporine from the microemulsion formulation exhibit greater within-day consistency compared to the commercial formulation in stable renal allograft recipients.

Graft survival and long-term renal function after sequential conventional cyclosporin A therapy in cadaver kidney transplantation--a prospective randomized trial

In a prospective randomized trial 50 renal transplant patients (group A) received a sequential course of 14 days conventional immunosuppression (Lymphocytoglobulin (ALG), azathioprine, steroids) and cyclosporin and steroids thereafter, while 50 patients (group B) received the conventional immunosuppression for 7 days followed by cyclosporin and steroids. In the latter group ALG was tolerated for the whole period while in the first group conversion from conventional to cyclosporin A therapy had to be performed after a mean of 11 days, due to ALG intolerance. Actual patient survival rates 1 year posttransplant were 100% in both groups and graft survival rates 96% in group A and 86% in group B (P less than 0.05). There was a mean dialysis frequency per patient of 0.7 +/- 2.0 in group A and 1.8 +/- 3.4 in group B (P = 0.064). Serum creatinine 1 year posttransplant was 1.8 +/- 0.8 mg/dl in group A and 2.2 +/- 1.4 in group B. A total of 58 patients had a serum creatinine of less than 2 mg/dl at the time of conversion to cyclosporin. These patients had a significantly better graft survival rate (98.3%) and serum creatinine 1 year posttransplant (1.6 +/- 0.5 mg/dl) than the 40 patients with a serum creatinine of more than 2 mg/dl at the time of conversion (85%; 2.4 +/- 1.4 mg/dl), indicating that a delayed onset of cyclosporin therapy might benefit the kidney in the immediate posttransplant period when it is susceptible to nephrotoxicity due to the damage from hypothermic storage.

[Cytomegalovirus hyperimmunoglobulin prophylaxis following kidney transplantation. Results of a prospective randomized study]

The effectiveness of preventing cytomegalovirus (CMV) infections by administering CMV hyperimmunoglobulin was evaluated in a prospective randomized trial. The patients in the treatment group (n = 50) had intravenous infusions of 2 ml/kg bodyweight of CMV-Polyglobin at three-week intervals, up to day 105 after kidney transplantation. The 50 patients in the control group received no infusions. There was no significant difference between the treatment and control groups in transplant survival or patients survival rates. But the number of symptomatic CMV infections was higher in the control (n = 11) than the treatment group (n = 5). There were also significantly fewer symptomatic herpes-simplex infections in the treatment (n = 6) than in the control group (n = 25). It is concluded from these results that prophylaxis with CMV hyperimmunoglobulin should be undertaken either selectively or for shorter periods than those chosen for the reported trial.

[Occlusion of sinus sagittalis superior by infiltration of a tumor metastasis (author's transl)]

As a casuistic contribution to differential diagnosis of thrombosis of cerebral veins and sinuses a case of occlusion of sinus sagittalis superior by infiltration of an intracerebral metastasis from a teratoma of testis is reported. The leading symptoms - epileptic seizures, progressive hemiplegia, choked papilla and clouding of consciousness - gave rise to the tentative diagnosis of a cerebral tumor; in carotis angiography however, the metastasis was not detected, merely the occlusion of the sinus was demonstrated. Therefore the progress of the syndrome was misinterpreted as caused by an advancement of a venous thrombosis. Only autopsy showed the symptomless primary tumor and its formation of metastases.