Molecular and Functional Characterization of GABA Receptor Subunits GRD and LCCH3 from Human Louse Pediculus Humanus Humanus.

Human louse Pediculus humanus is a cosmopolitan obligatory blood-feeding ectoparasite causing pediculosis and transmitting many bacterial pathogens. Control of infestation is difficult due to the developed resistance to insecticides that mainly target GABA (γ-aminobutyric acid) receptors. Previous work showed that Pediculus humanus humanus (Phh) GABA receptor subunit resistance to dieldrin (RDL) is the target of lotilaner, a synthetic molecule of the isoxazoline chemical class. To enhance our understanding of how insecticides act on GABA receptors, two other GABA receptor subunits were cloned and characterized: three variants of Phh-grd (glycine-like receptor of Drosophila) and one variant of Phh-lcch3 (ligand-gated chloride channel homolog 3). Relative mRNA expression levels of Phh-rdl, Phh-grd, and Phh-lcch3 revealed that they were expressed throughout the developmental stages (eggs, larvae, adults) and in the different parts of adult lice (head, thorax, and abdomen). When expressed individually in the Xenopus oocyte heterologous expression system, Phh-GRD1, Phh-GRD2, Phh-GRD3, and Phh-LCCH3 were unable to reconstitute functional channels, whereas the subunit combinations Phh-GRD1/Phh-LCCH3, Phh-GRD1/Phh-RDL, and Phh-LCCH3/Phh-RDL responded to GABA in a concentration-dependent manner. The three heteromeric receptors were similarly sensitive to the antagonistic effect of picrotoxin and fipronil, whereas Phh-GRD1/Phh-RDL and Phh-LCCH3/Phh-RDL were respectively about 2.5-fold and 5-fold more sensitive to ivermectin than Phh-GRD1/Phh-LCCH3. Moreover, the heteropentameric receptor constituted by Phh-GRD1/Phh-LCCH3 was found to be permeable and highly sensitive to the extracellular sodium concentration. These findings provided valuable additions to our knowledge of the complex nature of GABA receptors in human louse that could help in understanding the resistance pattern to commonly used pediculicides. SIGNIFICANCE STATEMENT: Human louse is an ectoparasite that causes pediculosis and transmits several bacterial pathogens. Emerging strains developed resistance to the commonly used insecticides, especially those targeting GABA receptors. To understand the molecular mechanisms underlying this resistance, two subunits of GABA receptors were cloned and described: Phh-grd and Phh-lcch3. The heteromeric receptor reconstituted with the two subunits was functional in Xenopus oocytes and sensitive to commercially available insecticides. Moreover, both subunits were transcribed throughout the parasite lifecycle.

Identification and Spatiotemporal Expression of a Putative New GABA Receptor Subunit in the Human Body Louse Pediculus humanus humanus.

The human louse (Pediculus humanus) is an obligatory blood feeding ectoparasite with two ecotypes: the human body louse (Pediculus humanus humanus), a competent vector of several bacterial pathogens, and the human head louse (Pediculus humanus capitis), responsible for pediculosis and affecting millions of people around the globe. GABA (γ-aminobutyric acid) receptors, members of the cys-loop ligand gated ion channel superfamily, are among the main pharmacological targets for insecticides. In insects, there are four subunits of GABA receptors: resistant-to-dieldrin (RDL), glycin-like receptor of drosophila (GRD), ligand-gated chloride channel homologue3 (LCCH3), and 8916 are well described and form distinct phylogenetic clades revealing orthologous relationships. Our previous studies in the human body louse confirmed that subunits Phh-RDL, Phh-GRD, and Phh-LCCH3 are well clustered in their corresponding clades. In the present work, we cloned and characterized a putative new GABA receptor subunit in the human body louse that we named HoCas, for Homologous to Cys-loop α like subunit. Extending our analysis to arthropods, HoCas was found to be conserved and clustered in a new (fifth) phylogenetic clade. Interestingly, the gene encoding this subunit is ancestral and has been lost in some insect orders. Compared to the other studied GABA receptor subunits, HoCas exhibited a relatively higher expression level in all development stages and in different tissues of human body louse. These findings improved our understanding of the complex nature of GABA receptors in Pediculus humanus and more generally in arthropods.

Therapeutic potential of Buddleja Polystachya Fresen (stem and leaves) extracts: antimicrobial and cytotoxic properties for ocular disease management.

This study on Buddleja polystachya highlights its phytochemical composition, antimicrobial activity, and cytotoxic impacts. The study emphasizes the plant's potential to treat ocular diseases by identifying important compounds involved in the bioactivity through GC-MS analysis. This study explores the antimicrobial and cytotoxic potential of Buddleja polystachya (stem and leaves) extracts, with a focus on their application in treating bacterial ocular infections and their efficacy against MCF7, HT29, and HepG2 cancer cells. Through comprehensive GC-MS analysis, a diverse array of phytochemicals was identified within Buddleja polystachya stem and leaves extracts, including carbohydrates, phenolic derivatives, fatty acids, and steroidal components. The extracts were then evaluated for their biological activities, revealing significant antimicrobial properties against a range of bacterial strains implicated in ocular infections. The research findings demonstrate that stem extracts derived from Buddleja polystachya demonstrated high to moderate cytotoxic effects on cancer cell lines MCF7, HT29, and HepG2. Notably, these effects were characterized by varying IC50 values, which suggest distinct levels of sensitivity. In contrast, leaf extracts exhibited reduced cytotoxicity when tested against all these cell lines, although they did so with a significantly higher cytotoxicity aganist HepG2 cells. The results of this investigation highlight the potential therapeutic utilization of Buddleja polystachya extracts in the management of ocular infections and cancer. These results support the need for additional research to elucidate the underlying mechanisms of action of these extracts and explore their potential as drugs.

In-vitro Cytotoxicity Investigations for Phytoconstituents of Saudi Medicinal Plants With Putative Ocular Effects.

BACKGROUND: Metastatic secondary ocular tumors spread from systemic malignancies, including breast cancer. This study aimed to evaluate the cytotoxicity of extracts from 5 medicinal plants native to Saudi Arabia. METHODS: For preliminary activity screening, cytotoxicity using the MTT assay and selectivity index determinations were made for medicinal plant extracts against various cancer cell-lines. The most promising extract was subjected to GC-MS analysis to determine the phytochemical composition. Clonogenic assays were performed using the most promising extract to confirm the initial results. Finally, western blot analysis was used to determine the modulation in expression of survivin and P27 suppressor genes in the human breast adenocarcinoma (MCF7) cell-line to understand the potential mechanistic properties of the active plant extract. RESULTS: The 5 plant extracts showed various cytotoxic activity levels using IC50. The most active extract was found to be the leaves of Capparis spinosa L. (BEP-07 extract) against the MCF7 breast cancer cell-line (IC50 = 3.61 ± 0.99 µg/ml) and selectivity index of 1.17 compared to the normal human fetal lung fibroblast (MRC5) cells. BEP-07 extract showed a dose dependent clonogenic effect against the MCF7 colonies which was comparable with the effect of doxorubicin. BEP-07 extract caused a significant decrease of survivin and increase in P27 expression compared to control GAPDH at its highest dose (14 µg/ml). The GC-MS chromatogram of Capparis spinosa L. (BEP-07 extract) revealed the existence of 145 compounds, belonging to the diverse classes of phytoconstituents. Fatty acids and their derivatives represent 15.4%, whilst octadecanoic acid, 2,3-dihydroxypropyl ester was the principal component (7.9%) detected. CONCLUSION: Leaves of Capparis spinosa L. (BEP-07 extract) exhibited a significant cytotoxic effect particularly against breast cancer cells. It exhibited this effect through survivin inhibition and via P27 upregulation. The detected phytoconstituents in the plant extract might be involved in tested cytotoxic activity, while further investigations are required to complete the drug candidate profile.

Assessment of living kidney donors and adherence to national live donor guidelines in the UK.

BACKGROUND: As in most industrialized countries, living kidney donation has increased considerably in the UK and now amounts to 38% of the total UK kidney transplant activity. Living kidney donation guidelines have been formulated by the relevant national societies. We were interested to study whether or not renal units across the UK adhere to those guidelines and to delineate areas of inconsistency and controversy. METHODS: Twenty-four adult kidney transplant centres and 50 adult non-transplant renal units across the UK were contacted by a postal questionnaire from January to April 2011. RESULTS: Twenty-one of 24 (88%) transplanting units and 23 of 50 (46%) non-transplanting units responded. Eighty-one per cent of the responding transplanting units and only 30% of the non-transplanting units have a dedicated live donor clinic. Eighty-six per cent of all units are without a set upper age limit for donors, whereas 7% of units excluded all potential donors older than 70 years. Twenty per cent of units accept donors with body mass indices (BMIs) up to 35, whereas 9% of units did not have an upper limit for BMI. Thirty-two per cent of centres exclude hypertensive donors on more than one antihypertensive drug, whereas 64% of units exclude donors only if they are on more than two anti-hypertensive drugs. of units rely on a spot urine sample to assess proteinuria, while 30% of units still perform 24 h urine collection. Sixty one per cent of units perform computed tomography (CT) angiography to assess the renal vessels prior to donation, while 32% use magnetic resonance (MR) angiography. Seventy-five per cent of centres assess split kidney function by radionuclide testing in all cases, whereas 25% perform this test only if there is a discrepancy in kidney size. The practice of suspension of recipients with potential living donor from the deceased waiting list is also remarkably inconsistent, whereby some centres suspend once a decision for living donation has been made in principle, whereas others suspend the recipient only once a date for surgery has been agreed. CONCLUSIONS: We demonstrate significant variability in accepting living kidney donors, particularly regarding age, BMI, and hypertension. Infrastructure setting for living donation and the live donor assessment are also remarkably inconsistent across the UK. It remains unclear as to why nephrologists decide not to adhere to established guidelines and further research should aim to find the lacking evidence in areas causing inconsistency in living donor assessment.

Medical Students' Perception of Virtual Simulation-Based Learning in Pharmacology.

Virtual simulation-based learning has opened a vista for surmounting ethical issues with the use of animals in compliance with one of the '3Rs' in ethical principles for animal use, which is 'replacement.' It's effective in terms of time, place, and cost. For instance, the time for drug application in cancer models would be less with virtual simulations, and the cost of maintenance and update of the software is less than that of breeding and feeding experimental animals. This paper examines the effects of utilizing a virtual computer tool simulating real pharmacology laboratory equipment in the second semester of a large-scale basic medical course. We looked at the theories of education and instructional designs and used them to develop a virtual computer lab that could help our students meet the intended learning outcomes. We analyzed, developed, implemented, and finally evaluated the students' reactions (at the Kirkpatrick level) using a self-administered questionnaire with responses on a three-point Likert scale. Feedback was obtained from 60 out of 82 (73.2 %) level 4 medical undergraduate students of both sexes, 39/60 (65%) were from the male section of the college. Sixty percent of the students admitted that the software is simple. Sixty percent agreed that it was good. Fifty-seven percent denied previous exposure to the simulation lab. Fifty-two percent reported that the practical lab's content was good, 53.3% rated the achievement of the practical objectives as good, 48.3% rated the practical enforcement of theoretical knowledge as good, 61.7% estimated getting realistic results, 48.3% agreed that the simulation lab encourages formulating a live experiment to test the hypothesis, and 51.7 % decided that the time framework was long. Thirty-eight percent appreciated the learning experience, and 45% felt that it should be repeated elsewhere. Students from the female section opted to record different determinations. The experience of using the virtual computer lab as part of the teaching program in pharmacology confirms the educational value of simulation. By adding a flexible reliable teaching method, we believe it served as a valuable tool for assisting teaching and learning in our context. Moreover, it is perceived as favorable by a good number of our students.

The use of medicinal plants in common ophthalmic disorders: A systematic review with meta-analysis.

Purpose: This study aimed to assess and compile the available research articles about medicinal plants used for ocular diseases. Principal results: A total of 2949 articles were retrieved, 35 full-text articles were assessed for eligibility, and seven studies (4 observational and three experimental) with low to moderate quality were eligible and involved in the systematic review, with a total of 600 plants from 4 countries. Among the 600 plants, only 24 (4%) were used to assess the status. Both the fixed and random models of the studies showed that the included studies tended to predict the results for the observational studies (OR = 0.062, CI = 0.043-0.090 OR = 0.039, CI = 0.012-0.122) for different plants used for ocular diseases. High heterogeneity (estimated as I2 = 87.078, Tau2 = 1.161 and Q-value = 23.217 with a p-value of 0.000), while for experimental studies (I2 = 94.928, Tau2 = 23.211 and Q-value = 39.434 with a p-value of 0.000) and publication bias were reported. Conclusion: Few articles representing approximately 600 plants of low to moderate quality reported using medicinal plants for ocular diseases. The meta-analysis confirmed the systematic review findings regarding the plants' traditional use with high heterogeneity and publication bias. A considerable gap was proven in the use of medicinal plants in ocular diseases requiring intensive research.

Optimized immunosuppression to prevent graft failure in renal transplant recipients with HLA antibodies (OuTSMART): a randomised controlled trial.

Background: 3% of kidney transplant recipients return to dialysis annually upon allograft failure. Development of antibodies (Ab) against human leukocyte antigens (HLA) is a validated prognostic biomarker of allograft failure. We tested whether screening for HLA Ab, combined with an intervention to improve adherence and optimization of immunosuppression could prevent allograft failure. Methods: Prospective, open-labelled randomised biomarker-based strategy (hybrid) trial in 13 UK transplant centres [EudraCT (2012-004308-36) and ISRCTN (46157828)]. Patients were randomly allocated (1:1) to unblinded or double-blinded arms and screened every 8 months. Unblinded HLA Ab+ patients were interviewed to encourage medication adherence and had tailored optimisation of Tacrolimus, Mycophenolate mofetil and Prednisolone. The primary outcome was time to graft failure in an intention to treat analysis. The trial had 80% power to detect a hazard ratio of 0.49 in donor specific antibody (DSA)+ patients. Findings: From 11/9/13 to 27/10/16, 5519 were screened for eligibility and 2037 randomised (1028 to unblinded care and 1009 to double blinded care). We identified 198 with DSA and 818 with non-DSA. Development of DSA, but not non-DSA was predictive of graft failure. HRs for graft failure in unblinded DSA+ and non-DSA+ groups were 1.54 (95% CI: 0.72 to 3.30) and 0.97 (0.54-1.74) respectively, providing no evidence of an intervention effect. Non-inferiority for the overall unblinded versus blinded comparison was not demonstrated as the upper confidence limit of the HR for graft failure exceeded 1.4 (1.02, 95% CI: 0.72 to 1.44). The only secondary endpoint reduced in the unblinded arm was biopsy-proven rejection. Interpretation: Intervention to improve adherence and optimize immunosuppression does not delay failure of renal transplants after development of DSA. Whilst DSA predicts increased risk of allograft failure, novel interventions are needed before screening can be used to direct therapy. Funding: The National Institute for Health Research Efficacy and Mechanism Evaluation programme grant (ref 11/100/34).

The nature and prognosis of renal diseases in chronic hepatitis-C-infected diabetic Egyptian patients: The role of renal biopsy.

BACKGROUND AND AIMS: Egypt has a wide prevalence of Diabetes and chronic HCV infection. The relationship between diabetes and HCV is bidirectional and both have their impact on kidney. The aim is to study the exact diagnostic and prognostic significance of renal biopsy in Diabetic HCV-infected patients with renal disease. MATERIAL AND METHODS: In this cross-sectional study, we compared the clinical and histopathological characteristics of sixty-five patients all of them presented with evidence of kidney injury. The main study group included twenty patients who had DM and hepatitis c virus (DM-HCV); the other two groups were included as diseased control, twenty hepatitis c virus (HCV) patients, and twenty-five diabetic non-HCV patients (DM). RESULTS: DM-HCV patients had a statistically significantly higher percentage of sclerosed glomeruli (Median Value of 44.5% versus 7% in DM and 7% in HCV). The tendency toward diffuse (20%) and global (75%) patterns of sclerosis as well as moderate to severe tubular atrophy (45%), moderate to severe interstitial fibrosis (55%) were reported in the DM-HCV group. Electron microscopic showed a significantly higher frequency of podocytopathies (70% in DM-HCV versus 12% in DM). CONCLUSION: These results confirmed the diagnostic and prognostic significance of histopathological evaluation in guiding the management plan which cannot be replaced by just relying on clinical prediction.

Organ donation, transplantation and religion.

Religious concerns may be an important reason why patients decline listing for a renal transplant. These issues may be equally, or even more, important when live donation is discussed. There is good reason to believe that religious concerns play a significant role much more often than clinicians and transplant teams believe. The issue is certainly further compounded by the fact that a few, if any, patients come forward with their religious concerns, not least because issue of transplantation is new to them anyway and because they meet with transplant teams whom they do not know. Health professionals, on the other hand, may wish to avoid this sensitive issue altogether or may lack knowledge on religious issues pertaining to transplantation. Some may be entirely unaware. We encountered a case in clinic that revealed our remarkable lack of knowledge in this regard. Here, we aim to provide an overview on how the different religions view transplantation and organ donation, with an emphasis on practical points for health care professionals who are involved in transplant listing, organ donation and retrieval, and transplantation itself. Knowledge of these facts may provide a background to deal with these issues professionally and appropriately and to increase transplant numbers.

Stopping renin-angiotensin system inhibitors in chronic kidney disease: predictors of response.

BACKGROUND/AIMS: Renin-angiotensin system (RAS) inhibitors are considered first-line agents for hypertensive patients with progressive chronic kidney disease (CKD). In a previous study, we showed that stopping RAS inhibitors increased estimated glomerular filtration rate (eGFR) in a significant number of advanced CKD patients. The present study tries to address who would benefit and whether this benefit is predictable. METHODS: Forty-three CKD stage 4 patients had RAS inhibitors stopped and were followed for at least 24 months. Compared outcome groups were 'alive', 'renal replacement therapy (RRT)' or 'died'. Improvement in eGFR was used in a receiver-operating characteristic curve and finds the best predictor for surviving without RRT. RESULTS: Patients who survived without RRT were all hypertensive and had a higher eGFR increment after stopping the drugs. Those with eGFR improvement ≥5 ml/min/1.73 m(2) were the most likely to survive long term without RRT (log-rank test, p = 0.03). They had a significant increment in blood pressure that correlated with eGFR improvement (r = 0.403, p = 0.013). CONCLUSION: A significant increase in eGFR after stopping RAS inhibitors suggests that long-term survival without RRT is more likely. Our findings question the universal preemptive indication of RAS inhibitors in advanced CKD and suggest that they can be safely stopped, at least in some patients.

Evaluation of the clinical outcome of captopril use for hypertensive urgency in Khartoum State's emergency centres.

BACKGROUND: Captopril is an important drug and is used to control hypertensive urgency world-wide. But there is very little data available regarding the evaluation of its outcomes in hypertensive urgency among African patients. This study aimed to evaluate the clinical outcomes of captopril use for hypertensive urgency at a selection of Sudanese emergency centres. METHODS: This was a cross-sectional study, conducted between 15 to 30 November 2015. A total of 50 patients, attending a selection of Khartoum State hospital emergency centres, with a clinical diagnosis of hypertensive urgency were approached by investigators for the study. Dose regimen, prognosis, and reduction in systolic and diastolic blood pressure were collected alongside a questionaire to patients regarding their care (compliance, etc.). Data were analysed using the Chi-square Test to compare the mean differences for various results. Differences were considered to be significant at P < 0.05. RESULTS: Around two-thirds (60%) of participants were female, and 28% were non-compliant with treatment. A 25mg dose of captopril was the most frequently used dose. Most of the patients (66%) did not have pre-existing disease. The majority of patients showed an improved blood pressure: both systolic and diastolic blood pressures were reduced by 16-25% and 5-15%, respectively. CONCLUSION: The study concluded that the dose of 25 mg of captopril is effective in managing hypertensive urgency and controlling the blood pressure. We also recommend that patients receiving captopril must be observed in the emergency centre for further evaluation.

The impact of stopping inhibitors of the renin-angiotensin system in patients with advanced chronic kidney disease.

BACKGROUND: Inhibition of the renin-angiotensin-aldosterone system (RAAS) has shown to slow chronic kidney disease (CKD) progression. This is most notable at the earlier stages of diabetic and proteinuric nephropathies. Objective. Here, we observed the impact of discontinuation of angiotensin converting enzyme inhibitors (ACEi)/angiotensin receptors blockers (ARB) in patients with advanced kidney disease. METHODS: 52 patients (21 females and 31 males) with advanced CKD (stages 4 and 5), who attended our low clearance clinic (LCC) in preparation for renal replacement therapy (RRT). Mean age was 73.3 ± 1.8 years with an estimated glomerular filtration rate (eGFR) of 16.38 ± 1 ml/min/1.73 m(2). Baseline urine protein:creatinine ratio (PCR) was 77 ± 20 mg/mmol. 46% suffered from diabetes mellitus. Patients were followed for at least 12 months before and after ACEi/ARB were stopped. RESULTS: 12 months after discontinuation of ACEi/ARB eGFR increased significantly to 26.6 ± 2.2 ml/min/ 1.73 m(2) (p = 0.0001). 61.5% of patients had more than a 25% increase in eGFR, whilst 36.5% had an increase exceeding 50%. There was a significant decline in the eGFR slope -0.39 ± 0.07 in the 12 months preceding discontinuation. The negative slope was reversed +0.48 ± 0.1 (p = 0.0001). Mean arterial blood pressure (MAP) increased from 90 ± 1.8 mmHg to 94 ± 1.3 mmHg (p = 0.02), however ≥50% of patients remained within target. Overall proteinuria was not affected (PCR before = 77 ± 20 and after = 121.6 ± 33.6 mg/mmol). CONCLUSION: Discontinuation of ACEi/ARB has undoubtedly delayed the onset of RRT in the majority of those studied. This observation may justify a rethink of our approach to the inhibition of the RAAS in patients with advanced CKD who are nearing the start of RRT.

Significance of ambulatory blood pressure monitoring in assessment of potential living kidney donors.

The most recent British Transplant Society (BTS) guidelines recommend that office blood pressure (BP) monitoring in living donors is sufficient for the assessment of hypertension (HTN) and those with BP >140/90 should be further assessed using ambulatory BP monitoring (ABPM). ABPM can detect diurnal and nocturnal variation in BP, thus it can identify masked HTN. The aim of the current study is to assess reliability of ABPM vesus office BP monitoring for assessment in living kidney donors. Office and ABPM of all potential kidney donors at a single center from April 2009 to March 2017 were retrospectively reviewed and compared. Age, sex, body mass index, kidney function, and echocardiography results were collected and analyzed. Two hundred and sixteen kidney donors were stratified based on their BP readings into four groups; group 1 (masked HTN: normotensive in office and hypertensive in ABPM), group 2 (sustained normotension: normotensive in office and in ABPM), group 3 (sustained HTN: hypertensive in office and in ABPM), group 4 (white-coat HTN: hypertensive in office and normotensive in ABPM). Thirteen percent of patients were diagnosed with masked HTN. Office systolic BP monitoring was significantly higher in patients older than 50 years old compared to other younger populations. However, this significant difference in systolic BP was diminished when assessment with ABPM was performed. In conclusion, ABPM is a reliable modality for the identification of masked HTN and white coat HTN. Masked HTN is correlated with increased risk of end organ damage and risk of death in potential kidney donors. Transplant physicians cannot rely solely on office BP monitoring in the assessment of potential living kidney donors. ABPM should be integral part of routine assessment of potential living kidney donors.

The outcome of kidney transplant from living donors with pelvi-ureteric junction dysfunction.

PURPOSE: To assess the effect of receiving a kidney with PUJ dysfunction on the recipient renal graft function. METHODOLOGY: 198 patients, who underwent renal transplantation from 1st January 2004 to 31st December 2014 in a single Center in the North West of England, were retrospectively reviewed using a computerized database. Split kidney function and the PUJ dysfunction for the donors were assessed using Tc-99 m MAG3 renogram. Each recipient with PUJ dysfunction was matched with a control recipient by age, gender, and number of days after transplantation. Both groups were followed up for 3.5 years post-transplantation. RESULTS: Of the 198 recipients included in the study, 19 recipients received kidneys from donors with PUJ dysfunction. Prevalence of PUJ dysfunction was 9.5% and it was more common in males than females. There was no difference between the case group and the control group in terms of age, gender, and follow-up time post-transplantation. There was also no difference between the case group and the control group in mean creatinine (130 µmol/l and 138 µmol/l respectively, p = 0.305) or the mean eGFR (48.6 ml/min and 47.5 ml/min respectively, p = 0.054) at 3.5 year post-kidney transplantation. CONCLUSION: This study showed that PUJ dysfunction of renal allograft has a negligible effect on graft function over 3.5 years period post-transplantation. A prospective randomized trial is needed to test these findings. In the presence of widened gap between demand and supply in renal transplantation, PUJ dysfunction in potential donors should not preclude them from donation.

Update to the study protocol, including statistical analysis plan, for the multicentre, randomised controlled OuTSMART trial: a combined screening/treatment programme to prevent premature failure of renal transplants due to chronic rejection in patients with HLA antibodies.

BACKGROUND: Chronic rejection is the single biggest cause of premature kidney graft failure. HLA antibodies (Ab) are an established prognostic biomarker for premature graft failure so there is a need to test whether treatment decisions based on the presence of the biomarker can alter prognosis. The Optimised TacrolimuS and MMF for HLA Antibodies after Renal Transplantation (OuTSMART) trial combines two elements. Firstly, testing whether a routine screening programme for HLA Ab in all kidney transplant recipients is useful by comparing blinding versus unblinding of HLA Ab status. Secondly, for those found to be HLA Ab+, testing whether the introduction of a standard optimisation treatment protocol can reduce graft failure rates. METHODS: OuTSMART is a prospective, open-labelled, randomised biomarker-based strategy (hybrid) trial, with two arms stratified by biomarker (HLA Ab) status. The primary outcome was amended from graft failure rates at 3 years to time to graft failure to increase power and require fewer participants to be recruited. Length of follow-up subsequently is variable, with all participants followed up for at least 43 months up to a maximum of 89 months. The primary outcome will be analysed using Cox regression adjusting for stratification factors. Analyses will be according to the intention-to-treat using all participants as randomised. Outcomes will be analysed comparing standard care versus biomarker-led care groups within the HLA Ab+ participants (including those who become HLA Ab+ through re-screening) as well as between HLA-Ab-unblinded and HLA-Ab-blinded groups using all participants. DISCUSSION: Changes to the primary outcome permit recruitment of fewer participants to achieve the same statistical power. Pre-stating the statistical analysis plan guards against changes to the analysis methods at the point of analysis that might otherwise introduce bias through knowledge of the data. Any deviations from the analysis plan will be justified in the final report. TRIAL REGISTRATION: ISRCTN registry, ID: ISRCTN46157828 . Registered on 26 March 2013; EudraCT 2012-004308-36 . Registered on 10 December 2012.

Recurrence of Tubulointerstitial Nephritis Without Uveitis, in a Patient with Previous Tubulointerstitial Nephritis and Uveitis Syndrome After Transplant.

We report a case of recurrent tubulointerstitial nephritis without uveitis in a patient with previous tubulointerstitial nephritis and uveitis syndrome after transplant. A 26-year-old male patient who had been diagnosed with tubulointerstitial nephritis and uveitis syndrome at 8 years of age developed end-stage renal failure and subsequently underwent living-donor related renal transplant at 17 years old. The 1st recurrence of tubulointerstitial nephritis and uveitis occurred 36 months after transplant, which was treated with increased immunosuppressive drugs. Graft function worsened again to estimated glomerular filtration rate of 25 mL/min/1.73 m² at 76 months after transplant. Transplant ultrasonography was unremarkable. Virology tests (including cytomegalovirus, BK virus, and Epstein-Barr virus tests) were all negative, with negative donor-specific antibodies. Urine protein creatinine ratio was unremarkable. A biopsy showed chronic allograft rejection and graft sclerosis, and immunosuppressive medications were subsequently decreased. The patient's renal function continued to decline over the next 3 months, with estimated glomerular filtration rate showing 18 mL/min/1.73 m², prompting a further renal biopsy that showed granulomatous interstitial nephritis and moderate interstitial fibrosis. This was consistent with a further relapse of tubulointerstitial nephritis but without uveitis. His renal function improved over the next few months after tacrolimus was reintroduced.

Effect of Long-Term, Low-Dose Aspirin Therapy on Renal Graft Function.

OBJECTIVES: Despite improvements in immunosuppressive protocols for renal transplant, long-term success of renal transplant is still limited by the occurrence of interstitial fibrosis and tubular atrophy. Some studies have shown that aspirin decreases the severity of kidney ischemia-reperfusion injury and the development of tubular atrophy in animal models. This study aimed to assess the effects of aspirin therapy started at the time of transplant on long-term graft function. MATERIALS AND METHODS: We compared renal graft function of 82 patients on low-dose aspirin 75 mg once daily who underwent renal transplant between 1 January 2000 and 31 December 2010 from a single center with 65 patients not taking aspirin. For each patient, the following measurements were collected: age, sex, creatinine level, type of donor, cold ischemia time, occurrence of acute allograft rejections, number of HLA mismatches, first transplant, intake of statins, number of antihypertensive medications, and number of days posttransplant. Patients were excluded from the study who were on aspirin before transplant or who had coronary artery disease. RESULTS: Multilevel modelling was used to compare renal allograft function, as measured by serum creatinine levels, between patients taking and not taking aspirin after kidney transplant. Aspirin was not significantly associated with creatinine levels (P = .59) after adjusting for other relevant variables. CONCLUSIONS: Low-dose aspirin started at the time of transplant has a negligible effect on renal allograft function over the 15-year study period posttransplant.

Erratum to: Assessment of physical activity in patients with chronic kidney disease and renal replacement therapy.

[This corrects the article DOI: 10.1186/s40064-015-1338-3.].

Should We STOP Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers in Advanced Kidney Disease?

Chronic kidney disease (CKD) is a worldwide public health problem associated with a high prevalence of cardiovascular disease (CVD) and impaired quality of life. Previous research for preventing loss of glomerular filtration rate (GFR) has focused on reducing blood pressure (BP) and proteinuria. Angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor antagonists (ARB) are commonly used in patients with early CKD, but their value in advanced CKD (estimated GFR (eGFR) ≤30 ml/min/1.73 m2) is unknown. There remains a debate about the omission of ACEi/ARB in patients with advanced CKD and their use in association with CVD or heart failure. Does the potential gain in eGFR with ACEi/ARB cessation outweigh the potential adverse cardiovascular outcomes? This paper reviews the current literature that addresses this issue. Several controversies are discussed. Although lowering BP reduces cardiovascular events, evidence suggests that ACEi/ARBs are not superior to other antihypertensive agents. There are no studies assessing the benefits of ACEi/ARB therapy in cardiovascular risk reduction in advanced non-dialysis CKD. The STOP ACEi trial will strengthen the evidence base and shed light on the potential merits and dangers of ACEi/ARB use in advanced CKD on renal function and cardiovascular outcomes.