Single pill combinations present a proven fast track in practice to reach the target blood pressure

Objective

To assess the efficacy of ambulatory blood pressure (BP) lowering with perindopril/amlodipine (dual SPC arm) and perindopril/amlodipine/indapamide (triple SPC arm) in newly diagnosed and uncontrolled hypertensive patients. Design and method: 450 adults with essential hypertension were assessed in the interventional, open-label, prospective, international, multicentre PRECIOUS trial. Treatment duration was 16 weeks, divided into four treatment periods. ABPM was performed at the baseline and end of the study (prior to the visit 1 and 5), with a validated automated portable BP-measuring device (Mobil-O-Graph PWA) worn on the non-dominant arm for a 24-hour period, measuring BP in 20 minutes interval during the day and 30 minutes interval during the night. At inclusion, naïve or patients uncontrolled on previous mono or dual therapy (other than perindopril/amlodipine (P/A)) were assigned to dual SPC arm with initial dose of 4/5 mg P/A. Those uncontrolled on previous dual or triple therapy were assigned to triple SPC arm with initial dose of 4/5/1.25 mg perindopril/amlodipine/indapamide (P/A/I). If office BP control was not reached, the initial dose was up titrated in 4-week intervals to 8/5 mg, 8/10 mg P/A or 8/10/2.5 mg P/A/I in dual SPC arm and to 8/5/2.5 mg, or 8/10/2.5 mg P/A/I in triple SPC arm.

Results

After 16 weeks of treatment the decrease in average ambulatory BP was −16.1/−10.8 mmHg (from 142.8/92.6 mmHg to 125.1/80.8 mmHg) in dual SPC arm and −21.8/−13.5 mmHg (from 147.3/93.3 mmHg to 124.2/79.0 mmHg) in triple SPC arm. The relative reductions in ambulatory BP were −11.1%/−11.3% in dual and −14.5%/−14.2% in triple SPC arm. The absolute as well as relative ABPM reductions were higher for the awake-time BP. All ambulatory BP reductions were statistically significant in both arms (p<0.001). 71% of patients reached the normal 24h SBP levels and 45.6% the normal 24h DBP levels. At the end of the trial, the mean dose of perindopril was 6.4±2.0 mg and of amlodipine 6.5±2.3 mg in dual SPC arm. In triple SPC arm, the mean dose of perindopril was 6.66±1.89 mg, of amlodipine 6.51±2.30 mg, and of indapamide 2.08±0.59 mg. Treatment tolerability was good. 85% of patients experienced no adverse events; the recorded ones were clinically irrelevant.

Conclusions

Applying dual (perindopril/amlodipine) and triple (perindopril/amlodipine/indapamide) SPC treatment strategy resulted in a significant and fast BP reduction, measured by ABPM, in naïve and in patients uncontrolled on previous therapy. In even 71% of patients normal 24h SBP was reached. It seems that adding long acting diuretic in triple SPC enhanced drug efficacy even though the patients in the triple SPC arm had a more resistant hypertension.

Funding Acknowledgement

Type of funding sources: None.

P6365Contrasting the impact of the European (ESC/ESH 2018) versus American (ACC/AHA 2017) high blood pressure clinical practice guidelines in Poland

Background

The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for the management of arterial hypertension and the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline for the prevention, detection, evaluation, and management of high blood pressure in adults differ in approach to defining stages of hypertension and recommendations for treatment of high blood pressure.

Purpose

To contrast the implications of the ESC/ESH versus ACC/AHA hypertension guidelines among the general population in Poland – a country representing a high CVD risk region in Europe.

Methods

We used data from a representative random sample of 1439 Polish adults aged 40 to 79 from the research program NATPOL 2011. The analysis was weighted in order to reflect the structure of the population in Poland and was stratified by age and gender. We applied the ESC/ESH 10-year SCORE (Systematic COronary Risk Evaluation) and the ACC/AHA ASCVD (atherosclerotic CV disease) risk assessment tools and followed guideline-specific algorithms to detect hypertension and follow recommendations for treatment.

Results

The overall prevalence of hypertension among Polish adults according to the ACC/AHA guideline was 76.9% (95% CI, 74.7–79.0%) versus 51.8% (95% CI, 49.2–54.4%) according to the ESC/ESH guidelines. Application of the ACC/AHA guideline recommendations would result in antihypertensive drug treatment for 63.0% (95% CI, 60.5–65.5%) of Polish adults compared with 46.2% (95% CI, 43.6–48.7%) based on application of the ESC/ESH guidelines (difference 16.8% (95% CI, 14.9–18.8%), table 1).

Table 1 2017 ACC/AHA guideline 2018 ESC/ESH guideline Δ (difference) Hypertension Recommended treatment Hypertension Recommended treatment Hypertension Recommended treatment % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Age   40–49 (n=391) 63.2 (58.4–68.0) 37.3 (32.6–42.1) 32.0 (27.4–36.6) 21.2 (17.2–25.3) 31.2 (26.6–35.8) 16.1 (12.5–19.8)   50–59 (n=452) 77.7 (73.8–81.5) 61.7 (57.2–66.2) 49.1 (44.5–53.7) 40.0 (35.5–44.6) 28.5 (24.4–32.7) 21.7 (17.9–25.5)   60–69 (n=356) 82.3 (78.3–86.3) 75.3 (70.8–79.8) 62.4 (57.3–67.4) 61.5 (56.5–66.6) 19.9 (15.8–24.1) 13.8 (10.2–17.3)   70–79 (n=231) 90.0 (86.2–93.9) 90.0 (86.2–93.9) 74.5 (68.8–80.1) 76.6 (71.2–82.1) 15.6 (10.9–20.3) 13.4 (9.0–17.8) Gender   Male (n=689) 80.4 (77.4–83.4) 67.5 (64.0–71.0) 52.5 (48.8–56.3) 47.2 (43.4–50.9) 27.9 (24.5–31.2) 20.3 (17.3–23.3)   Female (n=741) 73.6 (70.4–76.7) 58.8 (55.3–62.4) 51.2 (47.6–54.8) 45.2 (41.6–48.8) 22.4 (19.4–25.4) 13.6 (11.2–16.1)

Conclusions

Application of the ACC/AHA guideline would result in a considerable increase in the prevalence and antihypertensive drug treatment of hypertension in Polish adults compared with application of the ESC/ESH guidelines.

Prevalence of diabetes and impaired fasting glucose in Poland--the NATPOL 2011 Study

AIMS

The aim of the analysis was to assess the prevalence of diabetes and impaired fasting glucose in Poland.

METHODS

A questionnaire survey on a representative sample of 2411 Polish adults, complemented by blood pressure, anthropometric and fasting plasma glucose measurements. The research was part of the national cross-sectional NATPOL 2011 Study. Diabetes was assessed as self-reported (diagnosed) or screened (fasting plasma glucose level ≥ 7 mmol/l, based on one blood draw).

RESULTS

Total prevalence of diabetes in 2011 was 6.7% (95% CI 5.6-7.9); 6.4% (95% CI 5.0-8.0) in women and 7.0% (95% CI 5.4-8.8) in men and did not change from 2002 (6.8%, 95% CI 95% CI 5.8-7.9). Over one quarter of individuals with diabetes were not aware of having the condition. Obesity, arterial hypertension and male gender were strong predictors of screened diabetes. Total prevalence of impaired fasting glucose in the surveyed population was 15.6% (95% CI 14.0-17.2).

CONCLUSIONS

The prevalence of diabetes in Poland is similar to that observed in other European populations and has not changed over the last decade. The fact that every fourth person with diabetes is unaware of the disease creates important opportunities for screening and detection of the disease.

A novel programme to evaluate and communicate 10-year risk of CHD reduces predicted risk and improves patients' modifiable risk factor profile

AIMS

We assessed whether a novel programme to evaluate/communicate predicted coronary heart disease (CHD) risk could lower patients' predicted Framingham CHD risk vs. usual care.

METHODS

The Risk Evaluation and Communication Health Outcomes and Utilization Trial was a prospective, controlled, cluster-randomised trial in nine European countries, among patients at moderate cardiovascular risk. Following baseline assessments, physicians in the intervention group calculated patients' predicted CHD risk and were instructed to advise patients according to a risk evaluation/communication programme. Usual care physicians did not calculate patients' risk and provided usual care only. The primary end-point was Framingham 10-year CHD risk at 6 months with intervention vs. usual care.

RESULTS

Of 1103 patients across 100 sites, 524 patients receiving intervention, and 461 receiving usual care, were analysed for efficacy. After 6 months, mean predicted risks were 12.5% with intervention, and 13.7% with usual care [odds ratio = 0.896; p = 0.001, adjusted for risk at baseline (17.2% intervention; 16.9% usual care) and other covariates]. The proportion of patients achieving both blood pressure and low-density lipoprotein cholesterol targets was significantly higher with intervention (25.4%) than usual care (14.1%; p < 0.001), and 29.3% of smokers in the intervention group quit smoking vs. 21.4% of those receiving usual care (p = 0.04).

CONCLUSIONS

A physician-implemented CHD risk evaluation/communication programme improved patients' modifiable risk factor profile, and lowered predicted CHD risk compared with usual care. By combining this strategy with more intensive treatment to reduce residual modifiable risk, we believe that substantial improvements in cardiovascular disease prevention could be achieved in clinical practice.

Overexpression of CD39/nucleoside triphosphate diphosphohydrolase-1 decreases smooth muscle cell proliferation and prevents neointima formation after angioplasty

BACKGROUND

Growing evidence implicates the involvement of extracellular nucleotides in the regulation of platelet, leukocyte, endothelial cell (EC) and vascular smooth muscle cell (VSMC) phenotype and function. Within the quiescent vasculature, extracellular nucleotides are rapidly hydrolyzed by CD39, the dominant endothelial nucleoside triphosphate diphosphohydrolase (NTPDase-1). However, vascular CD39/NTPDase-1 activity is lost in EC activated by oxidative stress or proinflammatory mediators, and upon denudation of the endothelium following balloon injury. The consequent increase in extracellular nucleotide concentrations triggers signaling events leading to prothrombotic responses and increased VSMC proliferation.

OBJECTIVES

To investigate the effect of overexpressed CD39/NTPDase-1 in injured aorta.

METHODS

Using adenoviral-mediated gene transfer we expressed CD39/NTPDase-1 in mechanically denudated rat aortas. We measured intima formation by morphometry and VSMC proliferation by the [(3)H]-thymidine incorporation assay.

RESULTS

Targeted expression of CD39 in injured vessels increased NTPDase activity (from 2.91 +/- 0.31 to 22.07 +/- 6.7 nmols Pi mg(-1) protein, 4 days after exposure to the adenovirus) and prevented the formation of neointima. The thickness of the intimal layer in injured aortas exposed to Ad-CD39 was 26.2 +/- 3.9 microm vs. 51.8 +/- 6.1 microm and 64.4 +/- 22.2 microm (P < 0.001) in vessels treated with Ad-beta-gal and saline, respectively. Moreover, targeted expression of CD39/NTPDase-1 caused a 70% (P < 0.01) decrease in proliferation of VSMC isolated from transduced rat aortas as compared with VSMC derived from control vessels.

CONCLUSIONS

The presented data suggest that increasing CD39/NTPDase-1 activity in VSMC could represent a novel therapeutic approach for the prevention of stenosis associated with angioplasty and other occlusive vascular diseases.

Elevated levels of anti-Chlamydia pneumoniae IgA and IgG antibodies in young adults with ischemic stroke

INTRODUCTION

Data on the role of Chlamydia pneumoniae in patients with ischemic stroke are inconsistent. We investigated the presence of anti-C. pneumoniae antibodies in young adults with ischemic stroke.

METHODS

94 patients (<55 years) with ischemic stroke and 103 controls were enrolled. Indices of anti-C. pneumoniae IgA and IgG were assessed with an ELISA. We determined OR and 95% CI for the IgA and IgG seropositivity in stroke cases.

RESULTS

Mean IgA and IgG indices were higher in stroke patients vs controls (IgA: 1.40 vs 0.56; P < 0.001; IgG: 0.85 vs. 0.78; P < 0.003). The IgA seropositivity was associated with stroke risk (11.92; 5.94-23.92; P < 0.001) as well as IgG seropositivity was (2.31; 1.15-4.61; P < 0.016). Seropositivity assessed with combined IgA and IgG indices was associated with increased stroke risk (OR 9.35; 95% CI 4.78-18.29; P < 0.0001). After controlling for age and sex, the IgA seropositivity yielded a significantly adjusted OR for stroke (8.95; 4.44-18.07; P < 0.002), while IgG seropositivity did not (0.85; 0.53-1.63).

CONCLUSIONS

We find an increased risk of stroke in young patients seropositive to C. pneumoniae in the IgA antibody class. Further studies to explore this finding are warranted.

Why study sympathetic nervous system?

Cardiovascular diseases are the most frequent causes of morbidity and mortality around the world. However, during last decades, an improvement was made in diagnosis and therapy of cardiovascular diseases, there was still a need for better understanding of their pathophysiology. Among neurohormonal systems, SNS plays a central role in cardiovascular regulation in both health and disease. Involvement of SNS in pathogenesis of hypertension, coronary artery disease or heart failure is well known and proved. Methods such as microneurography, direct catecholamine measurements, heart rate variability or baroreflex sensitivity assessment allowed studying sympathetic activity and its influence on cardiovascular disorders. Although introduced into scientific practice methods of SNS evaluation are not commonly used in the clinic. However, two of the methods: analysis of heart rate variability (HRV) and baroreflex sensitivity (BRS) were recommended as the diagnostic tools and can be found in clinical guidelines as basic assessment methods.

Efficacy and safety of sibutramine in 2225 subjects with cardiovascular risk factors: short-term, open-label, observational study

This study aims to determine the efficacy and tolerability of sibutramine hydrochloride in overweight and obese patients with cardiovascular risk factors. This was a 12-week, open-label, observational trial carried out in primary care settings. Patients' data were obtained from questionnaires received from 153 physicians. A total of 2225 overweight and obese (BMI> or =27 kg/m2) patients received sibutramine in single daily doses of 10 and/or 15 mg. The study population included patients in general good health and with controlled hypertension (41.2%), type II diabetes mellitus (15.6%), hyperlipidaemia (45.5%), and who were chronic tobacco users (smokers) (37.0%). The main outcome measures were changes in body weight, blood pressure and heart rate, and evaluation of reported adverse events. Reduction of body weight of at least >5% from baseline to week 12 was achieved in 2030 (91%) patients and >10% was achieved in 987 (44%) patients. Baseline differences in the percentages of male and female patients, presence or absence of hyperlipidaemia or smoking status did not appear to affect the rate of weight change. Weight loss was less in patients with type II diabetes mellitus and/or controlled systolic hypertension at baseline compared to those patients without these conditions. Mean systolic and diastolic blood pressure and heart rate decreased from baseline to week 12. Overall, sibutramine was well tolerated. In conclusions, treatment with sibutramine resulted in clinically significant weight loss during short-term therapy in obese adults with a range of cardiovascular risk factors..

Do high levels of serum triglycerides in pancreas graft recipients before transplantation promote graft pancreatitis?

OBJECTIVE

Graft pancreatitis is a serious complication following pancreas transplantation. The aim of this study was to evaluate the influence of pretransplant serum lipid levels on the development of graft pancreatitis among patients undergoing simultaneous pancreas and kidney transplantation (spkTx).

METHODS

We reviewed data from spkTx patients engrafted between 1999 and 2002. Group 1 consisted of 10 recipients with well-established pancreas and kidney graft function without postoperative pancreatitis; group 2 5 spkTx recipients who developed fatal graft pancreatitis in the first posttransplant month. The lipid parameters evaluated within 1 hour before transplantation and after hemodialysis included total cholesterol, HDL, LDL, VLDL, triglicerides and apoproteins A and B.

RESULTS

Triglycerides, apoprotein B and VLDL were significantly increased just before transplantation among patients who developed fatal pancreatitis compared to those patients with good graft function.

CONCLUSION

Recipient hypertriglyceridemia promotes graft pancreatitis in previously injured pancreatic graft.

The effect of chronic allograft rejection on plasma regulators of fibrinolysis

Chronic renal allograft rejection is often associated with the presence of fibrin thrombi in the microcirculation. Our purpose was to evaluate the influence of chronic rejection on fibrinolytic regulators in plasma of renal allograft recipients. We evaluated the concentration and activities of tPA, uPA and PAI-I in plasma from kidney allograft recipients. We studied 64 patients who underwent kidney transplantation from cadaveric allograft donors. At the time of the study 38 patients had stable graft function for at least 6 months proceeding the study, and 26 recipients had biopsy-proven chronic rejection of the kidney transplant. Control group included 30 healthy blood donors. In kidney transplant recipients we found significantly higher plasma tPA activity (median: 0.99 IU/ml; range: 0-3.8 IU/ml) in comparison to healthy controls (median: 0.15 IU/ml; range: 0-2.8 IU/ml) (p = 0.002) as well as significantly lower plasma PAI-I activity (median: 7.06 U/ml; range: 0-33.2 U/ml) in comparison to healthy controls (median: 21.8 U/ml; range: 0-36.7 U/ml), (p = 0.0001). Among transplant recipients, PAI-I plasma activity in recipients with chronic graft rejection (median: 10.16 U/ml; range: 0-33.2 U/ml) was significantly higher than in patients with stable graft function (median: 4.83 U/ml; range: 0-22.9 U/ml), (p = 0.01). In transplant recipients with stable graft function and poorly controlled hypertension we found significantly higher PAI-I plasma activity in comparison to recipients with normal blood pressure (p = 0.006). In kidney transplant recipients there was a positive correlation between the dose of prednisone and PAI-I activity in plasma (p = 0.01) and an association between BMI value and plasma PAI-I activity (p = 0.008), as well as an association between BMI value and plasma tPA-Ant concentration (p = 0.006). Among transplant recipients, patients treated with ACE inhibitors had significantly lower uPA plasma activity than the rest of the group (p = 0.003). In recipients with stable graft function we found a correlation between CsA concentration and tPA activity (p = 0.04), as well as an association between the dose of CsA and uPA-Ant concentration in plasma (p = 0.049). In patients with chronic graft rejection we found a negative correlation between the dose of prednisone and uPA-Ant plasma level (p = 0.004). Renal allograft recipients have higher tPA and lower PAI-I activities in plasma in comparison to healthy individuals. Chronic allograft rejection, is as well as poorly controlled hypertension, seem to be associated with an increase PAI-I plasma activity. In kidney graft recipients there is a relation between the value of BMI and the activity and concentration of tPA-Ant as well as the value of BMI and the PAI-I activity in plasma. Poorly controlled hypertension is associated with an increase in PAI-I plasma activity. The results of our study suggest a stimulatory effect of CsA on tPA and PAI-I plasma activities as well as on uPA-Ant concentration, while prednisone in turn seems to enhance PAI-I activity in plasma and decrease uPA expression. In renal allograft recipients ACE inhibitors seem to reduce uPA plasma activity.

Protease administration decreases enhanced transforming growth factor-beta 1 content in isolated glomeruli of diabetic rats

Overproduction of transforming growth factor (TGF)-beta 1 messenger RNA is of fundamental importance in the pathogenesis of diabetic nephropathy. In vitro studies have recently shown that the serine protease trypsin diminishes the enhanced TGF-beta 1-expression induced by advanced glycation end products. Moreover, proteolytic enzymes may accelerate the removal of TGF-beta 1 from renal tissue via a protease-induced activation of alpha 2-macroglobulin (alpha 2M). This activation results in the binding of numerous cytokines, including TGF-beta 1 and is followed by enhanced plasma clearance of the protease alpha 2M-cytokine complex. In the present study in streptozotocin-diabetic rats we investigated whether the administration of Phlogenzym, a fixed combination of the proteases trypsin and bromelain combined with the antioxidant rutosid, modulates renal hypertrophy and the formation of TGF-beta 1 in isolated glomeruli. Three weeks after induction of diabetes, renal hypertrophy developed with an enhanced kidney/body weight ratio. When compared with normal rats, an elevated content of intraglomerular TGF-beta 1 (44.25 +/- 21.9 vs. 71.1 +/- 23.4 ng/microgram DNA, p < 0.05) as well as fibronectin (2.62 +/- 0.49 vs. 3.42 +/- 0.62 ng/microgram DNA, p < 0.05) was observed. In the diabetic rats, treatment with intraperitoneal proteases prevented the rise of intraglomerular TGF-beta 1 content (34.9 +/- 22.2 ng/microgram DNA, p < 0.01) and attenuated the rise of fibronectin (3.03 +/- 1.12 ng/microgram DNA NS). Furthermore, a decrease in the kidney/body weight ratio (p < 0.01) was achieved. Protease administration did not affect blood glucose concentration and was without visible adverse effects.

An inhibitor of mTOR reduces neoplasia and normalizes p70/S6 kinase activity in Pten+/- mice

PTEN phosphatase acts as a tumor suppressor by negatively regulating the phosphoinositide 3-kinase (PI3K) signaling pathway. It is unclear which downstream components of this pathway are necessary for oncogenic transformation. In this report we show that transformed cells of PTEN(+/-) mice have elevated levels of phosphorylated Akt and activated p70/S6 kinase associated with an increase in proliferation. Pharmacological inactivation of mTOR/RAFT/FRAP reduced neoplastic proliferation, tumor size, and p70/S6 kinase activity, but did not affect the status of Akt. These data suggest that p70/S6K and possibly other targets of mTOR contribute significantly to tumor development and that inhibition of these proteins may be therapeutic for cancer patients with deranged PI3K signaling.

Donor DNA can be detected in recipient tissues during rejection of allograft

The main source of donor DNA in recipients of allograft are "passenger" cells. It is claimed that they are responsible for the posttransplantation microchimerism and prolongation of allograft survival. We have observed that besides cellular microchimerism, donor DNA can be found in the recipient tissues at the time of rejection of the allograft. In this study, we provide evidence for the presence in the recipient of both DNA in "passenger cells" and free DNA in tissues at the terminal stage of rejection. Male BN (RT1 n) rat heart or skin was transplanted to female LEW (RT1 l) rats followed by a vascularized bone marrow in a hindlimb transplant. In another group, heart and skin were transplanted followed by immediate i.v. infusion of donor-type bone marrow cells. CsA was given in a dose of 17 mg/kg body weight for 30 days, then the rats were followed up until day 100 unless rejection occurred earlier. LEW blood, spleen, mesenteric node and bone marrow cells were stained with moAb OX27 specific for BN but not LEW. Genomic male DNA was isolated and amplified with SRY oligonucleotide. At day 30 and day 100 cellular microchimerism was detected in blood, spleen, nodes and bone marrow cells. Donor DNA was detected in recipient skin, liver and heart extracts, as well as lymphoid organs, at the time of rejection of allograft, but not when the rats were maintained on CsA. Taken together, donor DNAwas detected in recipient tissues at the time of heart or skin rejection. It appeared to be released from cells of rejecting grafts and not from "passenger" cells, representing only a minor cellular mass compared with the graft.

[Morphologic and functional assessment of renal artery stenosis: use of combined MR angiography and MR renography--preliminary report]

PURPOSE

To assess the possibility of use of multiphase magnetic resonance angiography for simultaneous acquiring of angiographic images and curves of contrast enhancement of renal cortex, medulla and pyelocalyceal system and evaluation of quality of obtained images.

MATERIAL AND METHODS

Twenty-four patients suspected of having renal artery stenosis underwent power-injection of 30 ml of Gd-DTPA (3 ml/sec). From 10 to 360 seconds after the beginning of the injection, 3D MRA sequence was performed multiple times. Acquisition time of single phase of MR examination was 7.5-8 sec (TR = 5 ms, TE = 1:6 ms, single 7 cm thick slab with 35 partitions, 164 x 512 matrix). First three phases were used to obtain angiographic images. All phases were used to obtain curves of renal cortical, medullary and pyelocaliceal enhancement. Two readers evaluated quality of MRA images, as well as, quality of enhancement curves.

RESULTS

21 of 24 MRA examinations were of good, 2 of fair and none of poor quality. Quality of enhancement curves was good in 22 cases. It was suboptimal in 2 cases because of irregular breath-holding. Maximum number of acquisitions per minute was 4-5. Eight accessory, 2 obstructed and 9 stenosed renal arteries were visualized. Renographic curves were abnormal in 8 patients.

CONCLUSIONS

MRA sequence with short acquisition time enables simultaneous acquisition of angiographic images and renographic curves of good quality. With further reduction in acquisition time it may be possible to obtain more points on MR renographic curves.

Treatment of chronic hepatitis B and C with interferon-alpha in renal allograft recipients: preliminary results

We evaluated the effects of treatment with interferon (IFN) on liver disease and renal allograft function in ten immunosuppressed cadaver kidney recipients. Two females and eight males (mean age 39 years) with biopsy-proven chronic active hepatitis (n = 8) or persistent hepatitis (n = 2) and serum positive for hepatitis B surface antigen (HBsAg) and HBe antigen (n = 5) or serum positive for anti-HCV antibodies (n = 3) or serum positive for HBsAg, anti-HCV and anti-HDV antibodies (n = 2) received 3 million units IFN thrice weekly of 6 months. All patients responded with a reduction in serum aminotransferase activity and in five of them liver function completely normalized. Three patients among five infected with HBV cleared HBeAg. During the follow-up period liver function remained stable in 9 patients after discontinuation of IFN therapy. Three patients lost their grafts due to rejection 1, 2, and 4 months after IFN therapy, respectively. In six patients renal function remained stable during and after IFN therapy. We conclude that in selected groups of renal allograft recipients IFN can be used safely and effectively for the treatment of chronic viral hepatitis.

Fucoidan improves the renal blood flow in the early stage of renal ischemia/reperfusion injury in the rat

It has been shown that monoclonal anti-P-selectin antibody administration protects renal function in an ischemic model of acute renal failure. This study was designed to evaluate the effect of administration of fucoidan, P-selectin inhibitor, on reduction in renal blood flow induced by ischemia/reperfusion injury in the rat. Experiments were performed on male Wistar rats weighting 35-400 g. The systemic blood pressure (mm Hg) (BP) and renal blood flow (RBF) were monitored continuously and renal vascular resistance (RVR) was calculated. After 20 min period of stabilization animals (6 rats in each group) received one of the following agents administered by continuous i.v. infusion during 165 min: 1 mg/kg of body weight of fucoidan (F1), 10 mg/kg of fucoidan (F10), 100 mg/kg of fucoidan (F100), 10 mg/kg of heparin (H), or 0.9% NaCl solution (control). After 15 min of drug administration the renal vessels of the both kidney were occluded with vascular clamps for 60 min. There were no significant changes in the initial values of RBF, RVR and BP between groups. None procedure affected significantly BP during all experiments. In F10 RBF returned to the initial values in 70th min of reperfusion and did not change up to 90th min. This value was significantly higher than respective value in the control group. In F1 group RBF in 90th min was also higher than in the control group, but it was not statistically significant. The dose of heparine and fucoidan used in the H and F100 groups failed to preserve RBF during reperfusion. In the present study we found that administration of fucoidan--P-selectin inhibitor, increases significantly postischemic renal blood flow and may have renoprotective activity.

Fucoidan inhibits smooth muscle cell proliferation and reduces mitogen-activated protein kinase activity

OBJECTIVES AND DESIGN

fucoidan has previously been shown to inhibit the proliferation of arterial smooth muscle cells both in animal models and in vitro. However, the mechanisms behind the anti-proliferative effects of this polysulfated polysaccharide are not known in detail. Here, the inhibitory effect of fucoidan on rat aortic smooth muscle cell proliferation was examined and compared with the effects of heparin after stimulation with fetal calf serum, platelet-derived growth factor BB, basic fibroblast growth factor, heparin-binding epidermal growth factor, and angiotensin II.

MATERIALS AND METHODS

the cultures were analysed with respect to cell proliferation and DNA synthesis by cell counting and measurement of(3)H-thymidine incorporation. Phosphorylation of mitogen-activated protein kinase and nuclear translocation of phosphorylated mitogen-activated protein kinase were studied by immunoblotting and immunocytochemistry.

RESULTS

fucoidan was shown to be a more potent inhibitor of smooth muscle cell proliferation than heparin. Fucoidan also reduced growth factor-induced activation of mitogen-activated protein kinase and prevented nuclear translocation of phosphorylated mitogen-activated protein kinase.

CONCLUSION

fucoidan is a more potent anti-proliferative polysulphated polysaccharide than heparin and may mediate its effects through inhibition of the mitogen-activated protein kinase pathway in a similar manner as heparin.

DNA from rejecting allografts can be detected in recipient nonlymphoid tissues

The main source of donor DNA in recipients of allograft are "passenger" cells. They are claimed to be responsible for the posttransplantation microchimerism and prolongation of allograft survival. We have noticed that beside of the cellular microchimerism, donor DNA can be found in the recipient tissues at the time of rejection of allograft. In this study we provide evidence for presence in the recipient of both, DNA in "passenger cells" and free DNA in tissues at terminal stage of rejection. Male BN (RTIn) rat heart or skin were transplanted to female LEW (RTII) rats followed by a vascularized bone marrow in hind-limb transplant. CsA was given in a dose of 17mg/kg b.w. for 30 days, then rats were followed until day 100 unless rejection occurred earlier. LEW blood, spleen, mesenteric node and bone marrow cells were stained with moAb OX27 specific for BN but not LEW. Genomic male DNA was isolated and amplified with SRY oligonucleotide. At day 30 and 100 cellular microchimerism was detected in blood, spleen, nodes and bone marrow cells. Donor DNA was detected in recipient skin, liver and heart extracts, beside of lymphoid organs, at the time of rejection of allograft but not when rats were maintained on CsA. Taken together, donor DNA can be detected in recipient tissues at the time of heart or skin rejection. It seems to be released from cells of rejecting grafts and not from "passenger" cells representing only a minor cellular mass compared with the graft.

Factors affecting reactivation of Epstein-Barr virus infection after kidney allograft transplantation

OBJECTIVES

Reactivation of Epstein-Barr virus (EBV) infection in renal transplant recipients may cause significant morbidity and mortality. To evaluate factors associated with activation of EBV replication we followed prospectively a group of 65 recipients of cadaveric kidney for 12 months.

METHODS

Sera were collected periodically from these patients and analyzed for the presence of specific anti-EBV antibodies. Control group consisted of renal (n=35) and healthy blood donors (n=35). Enzyme-linked immunoassays based on recombinant EBV proteins were used to detect the following antibody specificities: early antigen (EA) IgA, IgM, and IgG, nuclear antigen (EBNA) IgG.

RESULTS

During first year after transplantation, primary infection developed in 4 (6.15%) recipients and reactivation occurred in 18 (27.7%) recipients. Analysis did not show the association of reactivation with type of basic immunosuppressive therapy, prophylactic or therapeutic use of anti-lymphocyte antibodies, as well as acute rejection episodes. There was a borderline association (p=0.068) between the incidence of CMV infection and EBV reactivation.

CONCLUSIONS

Our data suggest casual relationship between CMV infection and EBV reactivation.

Arteriosclerosis in rat aortic allografts: early changes in endothelial integrity and smooth muscle phenotype

BACKGROUND

Transplant arteriosclerosis remains a limiting factor for the long-term survival of transplanted organs and effective treatment is lacking. A rat model of aortic allografts was used to analyze this process by electron microscopy and further characterize the phenotypic properties of the cells involved.

METHODS

A segment of abdominal aorta was transplanted orthotopically from Fischer to Lewis rats. The animals were killed 1-12 weeks after the operation (four to six rats/group), and the grafts were removed and processed for microscopy.

RESULTS

The first changes (1 week) included detachment of endothelial cells, adhesion of degranulating platelets to the subendothelial matrix, and modification of smooth muscle cells in the media. The latter process was distinguished by loss of myofilaments and formation of a prominent endoplasmic reticulum and Golgi complex (shift from contractile to synthetic phenotype). Subsequently, modified smooth muscle cells invaded the intima. In parallel, lymphocytes and monocytes/macrophages infiltrated the intima and adventitia. The neointima grew in size by cell proliferation and production of extracellular matrix (4-8 weeks). Smooth muscle cells and monocytes/macrophages in the neointima and media were also noted to accumulate cytoplasmic lipid droplets and eventually turn into foam cells and die. Within the lipid-rich cell remnants, calcification occurred. Finally (12 weeks), the growth in mass of the intimal lesions ceased and in some places reformation of an endothelial lining was detected. Few viable smooth muscle cells remained in the media and the inflammatory infiltrate in the adventitia was reduced.

CONCLUSIONS

These observations highlight the importance of early changes in endothelial integrity and smooth muscle phenotype in the development of allograft vascular disease and form the basis for a partly modified model of the cellular mechanisms in this process.

The effect of cyclosporine on regulators of fibrinolysis in plasma from renal allograft recipients

Fibrinolytic disturbances are thought to play an important role in processes leading to deterioration of renal allograft function. We investigated the effect of CsA therapy on the regulation of fibrinolysis in kidney graft recipients by measuring plasma concentration and activity of plasminogen activators (tPA, uPA) and their inhibitors (PAI-1, 2). We found an increase in tPA activity and in PAI-1 concentration as well as a decrease in PAI-1 activity in renal allograft recipients as compared to healthy controls, but did not confirm a correlation between these observations and CsA administration. tPA and PAI-2 concentrations as well as uPA activity did not significantly differ between the studied groups. We showed a significant decrease in uPA plasma concentration in patients treated with azathioprine. The significance of this finding is unknown.

Clinical course of concomitant Hbv and Hcv infection in renal allograft recipients

We evaluated the impact of concomitant infection with Hepatitis B virus (HBV) and Hepatitis C virus (HCV) on the clinical course after renal transplantation (Tx). In 335 patients (pts) transplanted between 1991 and 1993 we found 30 (9%) recipients who were positive for Hepatitis B surface antigen (HBsAg) (ELISA, Organon) and anti-HCV antibodies (immunoblot assay Lia Tek) preTx. Chronic liver disease (CLD) (two-fold or greater increase in serum ALT and AST levels for at least six months) developed in 40.7% coinfected pts as compared to 24.4% and 25.7% pts infected only with HCV or HBV, respectively. Maintenance immunosuppression consisted of P + Aza + CsA, mean follow-up time was 28 +/- 15 months. The mean time of the onset of CLD was 3.0 months (range: 1-18 months) after Tx. Percutaneous liver biopsy performed in 5 CLD pts revealed chronic active hepatitis (CAH) in 4 and chronic persistent hepatitis (CPH) in 1 pt. Four pts who had CAH and were positive for HCV RNA (RT PCR) in serum and for HBcAg in liver tissue, received interferon-alpha therapy for 6 months. Clinical improvement of liver function was observed in all of them, but none cleared HBsAg or HCV RNA. One pt lost his graft due to acute rejection. Concomitant infection with HBV and HCV is associated with the high risk of development of CLD early after Tx. We recommend that pretransplant evaluation of both anti-HCV and HBsAg positive pts should include liver biopsy to exclude potential recipients with CAH.

Higher exposure to cyclosporine A with unchanged tolerability in patients converted from Sandimmun to Sandimmun Neoral

Neoral (NEO) is claimed to have better pharmacokinetics than standard preparation of cyclosporine (SIM) thus providing more reliable immunosuppression. We estimated safety and tolerability of NEO and compared pharmacokinetic parameters in 20 stable renal allograft recipients (RARs) converted from SIM to NEO treatment. Another 20 stable RARs continuously treated with SIM created a control group. Whole blood through CsA level (C0) did not differ after conversion (SIM: 136.2 +/- 33 ng/ml and NEO: 142.6 +/- 34 ng/ml). During therapy with NEO peak blood concentration (Cmax) was significantly higher (935.6 +/- 368 ng/ml) and occurred earlier (Tmax 1 hr. 36 min. +/- 30 min) as compared to the period on SIM (Cmax 598 +/- 309 ng/ml, p = 0.01), Tmax = 3 hr. +/- 1 h 36 min., (p = 0.01) respectively. AUC increased from 2975.4 +/- 1020 ngxhr/ml to 4236.1 +/- 1188 ngxhr/ml (p < 0.0001). Correlation coefficient between AUC and C0 was higher during NEO (r = 0.52) than SIM therapy (r = 0.32). The only noticeable change in laboratory tests after switch to NEO was slight increase of serum triglyceride concentration (119.5 +/- 44.7 mg/dL vs. 148.4 +/- 67.0 mg/dl). The mean serum creatinine concentration did not change significantly (1.42 +/- 0.32 mg/dL and 1.46 +/- 0.31 mg/dL). Tolerance of NEO was good and 1:1 switch from SIM to NEO is clinically safe. Higher bioavailability of NEO was not associated with decreased tolerability or increased nephrotoxicity. Better correlation between C0 and AUC during NEO administration makes CsA treatment monitoring more reliable.

Intraglomerular fibronectin and laminin turn-over in chronically rejected kidney allografts in humans

Chronic rejection is primarily responsible for the late loss of allografted organs and remains an important clinical problem. Chronic rejection in the kidney is characterised by arteriolosclerosis and nephrosclerosis, glomerulonephritis and interstitial fibrosis. Recently, a large number of studies have indicated that proteolytic enzymes play important roles as mediators of glomerular injury. The aim of the study was to assess intraglomerular fibronectin and laminin contents as well as cysteine proteinases in activity chronically rejected human kidneys. We investigated kidney tissue from graftectomy specimens obtained from 11 patients with end-stage renal disease following chronic rejection. A group of 9 patients undergoing nephrectomy because of cancer served as a control group, but only not involved parts of the kidneys were used. When intraglomerular laminin contents were related to DNA content, significant accumulation in chronically rejected allografts was found in comparison to controls (382 +/- 171 micrograms per microgram DNA and 190 +/- 82 micrograms per microgram DNA, respectively, p < 0.01. The accumulation of fibronectin was higher than in controls, however the difference was not significant. When proteinase activity was related to intraglomerular DNA content, significantly enhanced cathepsin B and L activity was found in rejected kidney allografts (57 +/- 16 nmol AMC/min per mg DNA) in comparison to controls (15 +/- 2 nmol AMC/min per mg DNA). Summarizing, we observed accumulation of fibronectin and laminin in glomeruli and simultaneously an excess of proteolytic activity in human chronically rejected kidneys. The above phenomenon indicates that a very active metabolic process takes place in glomeruli during rejection.

Erythropoietin production after kidney transplantation

We studied production of erythropoietin (EPO) in long-term renal allograft recipients with posttransplant erythrocytosis (PTE). Among 951 recipients we found 74 patients with persistent elevation of hematocrit (Htc) value (female > 50%, male > 55%). However, only 63.5% of them had increased red-cell mass ( = "true" erythrocytosis). In all recipients with PTE known causes of secondary erythrocytosis were not found. EPO titer in peripheral blood was significantly higher in recipients with PTE (median 13.5 mIU/mL, range: 0.1-71.5 mIU/mL) as compared to healthy blood donors (median 5.75 mIU/mL, range: 0.1-19.5 mIU/mL) but not different from the group of renal allograft recipients without PTE (median 13.0, range 0.1-71.7 mIU/mL). However, EPO level measured in pretransplant sera was significantly higher in patients who developed PTE (median 16.4 mIU/mL, range: 1.0-281.2 mIU/mL) than in recipients without PTE (median 8.3, range: 1.0-50.3 mIU/mL). A significant difference in EPO level between systemic and effluent blood from native kidneys was found in 6 out of 14 recipients with PTE who underwent catheterization. After phlebotomy patients with PTE responded with higher increase in peak EPO titer than healthy blood donors (527 +/- 473% versus 194.5 +/- 44.2%, p < 0.05). Our results suggest that PTE develops spontaneously due to increased EPO production. Despite elevated EPO levels, regulation of EPO release remains preserved.

Long-term results of treatment of chronic hepatitis B, C and D with interferon-alpha in renal allograft recipients

The aim of this study was to evaluate the efficacy and safety of interferon-alpha (IFN-alpha) therapy of chronic hepatitis B, C and D (HBV, HCV and HDV, respectively) in renal transplant recipients. A group of 42 patients (30 males, 12 females, mean age 38 years) with documented viraemia and chronic active hepatitis (CAH) were studied, of whom 1 had HBV infection alone, 11 had HCV infection alone, 3 had HBV and HDV infection concomitantly, 12 had HBV and HCV infection concomitantly, and 2 had HBV, HCV and HDV infection concomitantly. Patients received 3 MU IFN-alpha three times weekly for 6 months. After IFN-alpha therapy, 18 patients (43%) achieved normal alanine aminotransferase (ALT) activity and a partial response was observed in 12 (29%) patients. Two patients relapsed (one with HCV and one with HBV + HCV infection) immediately after the cessation of IFN-alpha therapy. Repeated liver biopsy was performed in 16 patients after 6-24 months of therapy and revealed progression to cirrhosis in five patients, remission in two and stable disease in nine. None of the patients cleared HCV RNA, four patients cleared HBeAg (two also HDV), and one both HBV and HCV. Five patients died during IFN-alpha therapy (one as a consequence of liver failure), and four died during the 6 months after therapy (two as a consequence of liver failure). During IFN-alpha therapy renal allograft function remained stable in 31 patients and acute rejection episodes occurred in 7, of whom 5 lost their graft and all had experienced rejection episodes before. In 16 patients normalization of ALT continued during long-term follow-up (median 22 months, range 0-84 months). IFN-alpha seemed to be moderately effective in the treatment of chronic HBV or HCV infections, but cannot be recommended for recipients infected with both HBV and HCV.

Cyclosporine A blood concentration during pregnancy in renal allograft recipients

Pregnancy-induced changes increase hazards associated with cyclosporine (CsA) treatment. Blood CsA trough levels (C0) were estimated in 15 pregnant renal allograft recipients treated with prednisolone + CsA + azathioprine using the TDx Abbott fluorescent polarization immunoassay. Despite therapeutical dose levels of CsA administered during pregnancy (3.52-3.67 and 3.59 mg/kg body weight in the first, second, and third trimesters, respectively), C0 significantly decreased (first trimester 130.8 +/- 36.9, second 92.0 +/- 32.7, and third 99.0 +/- 36.9 ng/ml). The mean increase of patient's body weight in mid-pregnancy was 3.0 +/- 2.19 kg and was associated with a significant (P < 0.05) fall in a hematocrit value (from 42 +/- 4.9% prior to pregnancy to 34 +/- 6% at the 20th week). We postulate that C0 concentration does not reflect the true exposure to CsA as no episodes of acute graft rejection were observed during pregnancy.