Tacrolimus Metabolite M-III May Have Nephrotoxic and Myelotoxic Effects and Increase the Incidence of Infections in Kidney Transplant Recipients.

BACKGROUND: Tacrolimus (Tac) is one of the most commonly used immunosuppressive drugs after solid organ transplantation. Eight Tac metabolites have been described, but their clinical importance remains unclear. The aim of this study was quantification of the 2 major Tac metabolites, 13-O-demethyl (M-I) and 15-O-demethyl (M-III), in kidney transplant recipients and to link them with parameters of kidney and liver function, peripheral blood cell counts, and infection incidence. METHODS: In 81 kidney transplant recipients, concentrations of Tac, M-I, and M-III were measured with the use of liquid chromatography combined with tandem mass spectrometry (LC-MS-MS). RESULTS: There was a negative correlation between M-III levels and estimated glomerular filtration rate (eGFR; r = -0.244; P < .05). Also, a negative correlation between M-III concentrations and red blood cell count (RBC) was found (r = -0.349; P < .05). Neither concentrations of Tac nor of M-I correlated with eGFR or RBC. M-I, M-III, and Tac were not related to alanine aminotransferase activity. Significantly higher Tac and M-III concentrations in the group with all types of infections in comparison with the group without infections were observed (6.95 ± 2.09 ng/mL vs 5.73 ± 2.43 ng/mL [P = .03] and 0.27 ± 0.17 ng/mL vs 0.20 ± 0.11 ng/mL [P = .04], respectively). CONCLUSIONS: The results suggest that higher concentrations of M-III may have a nephrotoxic or myelotoxic effect and result in higher incidence of infections. Further studies are needed to confirm if monitoring of M-III could minimalize adverse effects such as nephrotoxicity or infections.

Hydroxylated, Hydroxymethylated, Dihydroxylated, and Trihydroxylated Cyclosporine Metabolites Can Be Nephrotoxic in Kidney Transplant Recipients.

BACKGROUND: Cyclosporine (CsA) is an immunosuppressive agent whose use is associated with adverse effects, including nephrotoxicity. There are reports indicating that some CsA metabolites may contribute to these effects. This study was aimed at evaluation of CsA metabolites and correlating them with kidney function. METHODS: In 62 kidney transplant recipients (41.9% women; overall mean age, 48.44 ± 11.75 years), concentrations of CsA and 4 groups of metabolites were assessed: hydroxylated (HCsA), hydroxymethylated (HMCsA), dihydroxylated (DHCsA), and trihydroxylated (THCsA). The results were normalized with the use of the metabolite-to-parent drug ratio, and results were linked with estimated glomerular filtration rate (eGFR) at 3 months before (-3M), point zero (0M), and after 3 (+3M) and 12 (+12M) months. RESULTS: Multivariate analysis demonstrated the negative influence of eGFR -3M on HMCsA/CsA (ß = -0.266; P < .05) and the negative influence of HCsA/CsA, HMCsA/CsA, DHCsA/CsA, and THCsA/CsA on eGFR +3M (ß = -0.339, ß = 0.396, ß = -0.314, and ß = -0.321, respectively; P < .005) and eGFR +12M (ß = -0.363, ß = -0.316, ß = -0.267, and ß = -0.312, respectively; P < .05). We did not detect such influence of CsA concentrations on eGFR +3M and +12M. The THCsA/CsA receiver operating characteristic cutoff value for prediction of improvement of kidney function at +12M was 0.143. CONCLUSIONS: Our results suggest that impaired function of the transplanted kidney affects the accumulation of HMCsA. It is possible that the increased metabolite (HCsA, HMCsA, DHCsA, and THCsA) to cyclosporine ratio could influence or could be a marker of cyclosporine nephrotoxicity. In this context, the most promising marker seems to be THCsA/CsA ratio, but its real significance requires further studies to determine.

Determination of Concentrations of Azathioprine Metabolites 6-Thioguanine and 6-Methylmercaptopurine in Whole Blood With the Use of Liquid Chromatography Combined With Mass Spectrometry.

BACKGROUND: 6-Mercaptopurine (6-MP) and its prodrug azathioprine (AZA) are used in many autoimmune diseases and after solid-organ transplantation. Their properties are mediated by active metabolites, 6-thioguanine nucleotides (6-TGN), and 6-methylmercaptopurine (6-MMP). The most common adverse effects are myelo- and hepato-toxicity. The aim of the study was quantification of 6-TG and 6-MMP, with the use of liquid chromatography combined with tandem mass spectrometry (LC/MS/MS) in solid-organ transplant recipients. METHODS: In 33 patients, kidney transplant recipient (n = 25) and liver transplant recipient (n = 8) intra-erythrocyte concentrations of 6-TG and 6-MMP were measured with the use of LC/MS/MS. RESULTS: The mean concentration of 6-TG was 205.35 ± 157.62 pmol/8 × 10(8) red blood cells (RBC); median concentration of 6-MMP was 1064.1 (35.78-11,552.9) pmol/8 × 10(8) RBC. There were no correlations between 6-TG levels and peripheral blood parameters (white blood cell count, WBC; hemoglobin, Hb concentration; PLT, blood platelet count) or alanine aminotransferase activity (AlAT) activity. Relationships between 6-MMP concentrations and peripheral blood parameters (WBC, Hb, PLT) or AlAT activity have not been found. Subgroups with leukopenia, anemia, thrombocytopenia, and liver dysfunction did not differ in concentrations of 6-TG or 6-MMP. We have observed a negative correlation between daily azathioprine dose and WBC count (r = -0.37, P = .04). CONCLUSIONS: Relationships between concentrations of azathioprine metabolites and myelotoxicity or hepatotoxicity have not been confirmed. Further studies on larger groups of patients would be helpful in a more accurate understanding of the impact of azathioprine metabolites on parameters of bone marrow and liver function.

Demonstration of an 8-dimensional modulation format with reduced inter-channel nonlinearities in a polarization multiplexed coherent system.

We demonstrate a polarization-managed 8-dimensional modulation format that is time domain coded to reduce inter-channel nonlinearity. Simulation results show a 2.3 dB improvement in maximum net system margin (NSM) relative to polarization multiplexed (PM)-BPSK, and a 1.0 dB improvement relative to time interleaved return-to-zero (RZ)-PM-BPSK, for five WDM channels propagating over 1600 km ELEAF with 90% inline optical dispersion compensation. In contrast to the other modulations considered, the new 8-dimensional format has negligible sensitivity to the polarization states of the neighboring WDM channels. High-density WDM (HD-WDM) measurements on a 5000 km dispersion-managed link show a 1.0 dB improvement in net system margin relative to PM-BPSK.

The trans-sphincteric posterior sagittal repair of recto-urinary and recto-vaginal fistulae using Surgisis™ mesh and fibrin sealant.

Recto-urinary, recto-vaginal and ileo-anal pouch-associated fistulae are rare yet a significant clinical problem due to their profound impact on patients' quality of life and are a challenge to repair. In this report, we describe repair of these complex fistulae using a modified trans-sphincteric posterior sagittal approach with Surgisis™ mesh and fibrin sealant and review our repair outcomes.

Cardiovascular assessment of asymptomatic patients with juvenile-onset localized and systemic scleroderma: 10 years prospective observation.

OBJECTIVES: The aim of the present study was non-invasive evaluation of the cardiovascular system in asymptomatic young adult patients with juvenile localized scleroderma (JLS) and juvenile systemic sclerosis (JSS). METHODS: A group of 34 consecutive children with scleroderma were prospectively observed in the study. The control group (CG) consisted of 20 healthy subjects. In each subject 12-lead electrocardiographic, echocardiographic, ECG Holter, and ambulatory blood pressure monitoring examinations were performed at the baseline visit and after 10 years. Additionally, B-type natriuretic peptide (BNP) concentrations were measured after 10 years. RESULTS: Examinations were performed in 13 patients with JLS and 15 with JSS at the final visit. Two children had died (one from each group). Four patients were alive but refused the final visit. After 10 years, a higher prevalence of ventricular extrasystoles (p = 0.01) and an elevated pulmonary arterial pressure (JLS: p = 0.04, JSS: p = 0.03) were observed in both groups, but in comparison with the controls there was no significant difference at the final visit. In JLS patients more cases of left ventricle diastolic dysfunction, hypertension, and sinus tachycardia were diagnosed at the final visit (p ≤ 0.05). More atrioventricular block episodes in both groups of scleroderma patients were observed. Over the 10 years, arterial hypertension was diagnosed in three patients from the JLS group and in two with JSS. There were no significant differences in BNP concentrations at the final visit. CONCLUSIONS: The results of the present study show that juvenile scleroderma seems to be more benign than adult-onset disease. This observational study shows subclinical, not severe, cardiac abnormalities in adult patients with juvenile-onset disease.

[Analysis of eyeball development in children between the fourth month and seventh year of life with regard to eyeball length, refraction value and fundus]. / Analiza rozwoju galki ocznej u dzieci w okresie od czwartego miesiaca do siódmego roku zycia w aspekcie dlugosci galki, wielkosci refrakcji i oceny dna oka.

An ophthalmologic screening of three-month-old infants was conducted between 1990 and 1993 in the province of Szczecin. The screening was aimed at early detection and treatment of vision defects and diseases of the eye. Attention was also focused on the appearance of the eyeballs. Approximately 50% of children had a retina of more or less "reduced density". The fundus appeared much like in the case of near-sightedness, raising the question whether such eye would continue towards myopia or would this just be a morphological trait of immature retina which will disappear with growth and development of the eyeball. The children were selected among those reporting for ophthalmologic screening and were divided into four groups: I--children with retina of "reduced density" and near-sightedness in the family (at least one parent had myopia), 45 children--90 eyes; II--children with retina of reduced density, whose parents did not have myopia, 45 children--90 eyes; III--children without changes in the fundus and with near-sightedness in the family, 30 children--60 eyes; IV--children without changes in the fundus, whose parents did not have myopia, 30 children--60 eyes. An additional group consisted of children without family history of near-sightedness, in whom myopia was -5.0 D sph or more during skiascopy with cycloplegia when the child finished six months of life (10 children--20 eyes). The following was examined in all children after three months of life: pupillary reflexes, fixation, anterior segment of eyeball, eyeball length, fundus, intraocular pressure, and refraction. The examination was repeated when the children finished three years, and six years ten months of life. Skiascopy was performed with prior cycloplegia. Statistics were done using Mann-Whitney test for unpaired and Wilcoxon's test for paired results. The following conclusions were made: 1. Length of the eyeball was not related to the appearance of fundus or family history of myopia (Tab. 1). Growth of the eyeball could be divided into two periods. The first was fast, lasting until the end of the third year of life. The second was slow and by the end of the seventh year, growth was almost complete. In children with inborn near-sightedness, the eyeballs were already longer in the fourth month of life. 2. Average size of refraction after cycloplegia in six-month-old infants does not depend on the appearance of eye fundus or family history of near-sightedness. Between six months and three years of life, a limited increase in refraction took place, whereas between the fourth and seventh year of life a decrease was observed. This decrease was significantly greater in children with a family history of near-sightedness. In children with inborn near-sightedness, there was no increase in refraction and decrease proceeded at a faster pace. In six-month-old infants, reversed astigmatism predominated, but between the seventh month and fourth year of life it declined and between the fourth and seventh year its axis changed (Tab. 3 and 4). 3. "Reduced density" found in three-month-old infants is a morphological trait of the retina and does not predispose to near-sightedness. It occurs more often in children with blue or light gray color of the iris, i.e. with little pigment in the stroma (Tab. 6). In most cases, "reduced density" disappeared before the end of the third year of life (Tab. 5). In children with inborn near-sightedness it was not possible to assess on the grounds of the eye speculum whether the observed reduced density was caused by lack of pigment in the pigmented layer of the eyeball or by near-sightedness, or both.

Galanin, galantide and galanin (1-14)-[alpha-aminobutyric acid8]-scyliorhinin-I: structure dependent effects on the rat isolated gastric fundus.

The study was undertaken using selected pharmacodynamic parameters to describe the effects of porcine galanin(1-29)-NH2; porcine galanin fragments; galantide; porcine galanin(1-14)-[alpha-aminobutyric acid8]scyliorhinin-I and the analogues of the latter peptides on rat isolated gastric fundus muscle. All tested peptides, apart from galanin(16-29)-NH2 evoked reproducible concentration-dependent contractions with significantly decreased activities in comparison to the potency of the native galanin(1-29)-NH2 molecule. The order of the contractile ability in the group of galanin(1-29)-NH2 short fragments was as follows: [lysine14]galanin(1-15)-NH2 > galanin(1-15)-OH > galanin(1-15)-NH2 > [glycine5] galanin(1-15)-NH2 > galanin(2-15)-NH2 > [glycine5,lysine14]galanin(1-15)-NH2. Aside from [lysine14]galanin(1-15)-NH2 which had a lower efficacy, none of the peptides showed significant changes in this respect in comparison to the intact galanin(1-29)-NH2 molecule. The concentration-response curves of the tested peptides were to the right and their slopes besides from: galanin(1-15)-OH; galanin(2-15)-NH2; [glycine5]galanin(1-15)-NH2 remained not significantly different from galanin(1-29)-NH2. Hill's coefficient for galanin(1-29)-NH2 is 1.03 indicating an interaction of one galanin(1-29)-NH2 molecule with one receptor, fulfilling criteria of classical receptor theory. For galanin fragments Hill's coefficients are < 1 implying that the rules of classical theory may not apply. Galantide and analogues exhibited a subsequent decrease in potency: [cycloleucine4] galantide > galantide > [homoserine6]galantide > [phenylalnine(4fluor)17] galantide. Galanin(1-14)-[alpha-aminobutyric acid8]-scyliorhinin-I and its analogues contracted the gastric fundus with a decline in strength: galanin(1-13)-[norleucine10]-scyliorhinin-I(3-10) > galanin(1-13)-[phenylalanine(4fluor)7]-scyliorhinin-I > galanin(1-14)-[alpha-aminobutyric acid8]-scyliorhinin-I > galanin(1-13)-[alpha-aminobutyric acid8, norleucine10]-scyliorhinin-I(3-10). They all displayed a greater efficacy than galanin(1-29)-NH2, and the concentration-response curves were slightly to the right, almost parallel to that of galanin(1-29)-NH2. Slopes of the curves were not significantly different from galanin(1-29)-NH2. Hill's coefficient for the galantide, [cycloleucine4]galantide; [homoserine6]galantide; [phenylalanine(4fluor)17]galantide and galanin(1-13)-[phenylalanine(4fluor)7]-scyliorhinin-I are < 1. Hill's coefficients for galanin(1-13)-[norleucine10]-scyliorhinin-I(3-10); galanin(1-14)-[alpha-aminobutyric acid8]-scyliorhinin-I; galanin(1-14)-[alpha-aminobutyric acid8, norleucine10]-scyliorhinin-I(3-10) are > 1. A Hill's coefficient markedly different from 1 might indicate that an activation of more than one type of receptors, negative or positive receptor cooperativity or multiple-step agonist-receptor reaction.

Pharmacological characterization of the contractile effects of galanin (1-29)-NH2, galantide and galanin (1-14)-(alpha-aminobutyric acid8)scyliorhinin-I in the rat gastric fundus.

Porcine galanin (1-29)-NH2, galantide (M15) and galanin (1-14)-(alpha-aminobutyric acid8)-scyliorhinin-I used in concentrations of 300, 1,000 and 3,000 nM respectively caused contractions of rat fundus strips. The contractile responses to galanin(1-29)-NH2 were not modified by atropine (10 microM), guanethidine (10 microM), naloxone (1 microM), a mixture of propranolol (10 microM) and phentolamine (10 microM), indomethacin (10 microM), a mixture of mepyramine (10 microM) and cimetidine (10 microM), saralasin (10 microM), and spantide (100 microM). The effects of M15 and galanin(1-14)-(alpha-aminobutyric acid8)-scyliorhinin-I were significantly decreased by atropine for 36 and 18% and by spantide for 37 and 26% respectively. Indomethacin inhibited the muscle response to M15 without influence on the galanin (1-14)-(alpha-aminobutyric acid8)-scyliorhinin-I-induced action. These results support findings that galanin (1-29)-NH2 contracts rat gastric fundus strips by stimulating specific receptors localized on the surface of smooth muscle cells. M15 and galanin(1-14)-(alpha-aminobutyric acid8)-scyliorhinin-I seem to contract smooth muscles not only by acting at galanin receptors, but by interacting with muscarinic or tachykinin receptors or modulating the release of acetylcholine and substance P. Diltiazem (EC50 825 nM), dantrolene (EC50 30.2 microM) and the phospholipase C inhibitors U-73122 (EC50 549 microM) and U-73343 (EC50 751 microM) lowered the contraction to galanin(1-29)-NH2 in a concentration-dependent manner. These observations imply that though the extracellular Ca2+ influx plays a major role in the action of galanin(1-29)-NH2, the release of Ca2+ ions from the intracellular stores contributes to the response of smooth muscles of galanin(1-29) NH2. Norepinephrine (30, 60, 100 and 300 nM) concentration-dependently reduced the Emax to galanin (1-29)-NH2 and reduced the slopes of the concentration-contraction curves, without a notable change in EC50. Pertussis toxin pre-treatment (10 and 30 mg/kg intravenous [i.v.]), 120 h before the experiment, notably increased the maximal response of the rat gastric fundus to galanin(1-29)-NH2, without a significant change in the properties of the concentration-contraction curves (EC50, slopes). The observations may suggest that pertussis toxin-sensitive GTP-binding proteins are involved in the modulation of the excitatory effects of galanin(1-29)-NH2 in the rat gastric fundus.