Hepatorenal syndrome: a decade later.

Hepatorenal syndrome is a unique form of acute kidney injury seen in patients with acute liver failure or chronic liver disease in absence of any other identifiable cause of renal failure. It is primarily a diagnosis of exclusion. Despite of good pathophysiological understanding and better available therapeutic options for management of hepatorenal syndrome, it is still associated with significant morbidity and mortality. Liver transplantation forms the cornerstone for its management. In this review article, we have attempted to assimilate and summarise the advances made in the previous decade with regards to pathophysiology, classification and management of this entity.

Influenza antigen-sparing by immune stimulation with Gram-positive enhancer matrix (GEM) particles.

Gram-positive enhancer matrix (GEM) particles, produced from non-genetically modified Lactococcus lactis bacteria have an inherent immunostimulatory activity. It was investigated whether co-administration of GEM particles can reduce the amount of influenza subunit vaccine (HA) necessary to protect mice from viral infection. Decreasing HA amounts of 5, 1, 0.2 and 0.04µg admixed with GEM particles were tested in intramuscular immunizations. Combinations of GEM and seasonal HA (A/Wisconsin/67/2005 [H3N2]) induced significantly higher systemic and better Th1/Th2-type balanced immune responses than HA alone. Addition of GEM to 0.04µg HA resulted in similar HI titers as 1-5µg non-adjuvanted HA. To test the protective efficacy of the adjuvanted combination, mice were immunized with influenza subunit vaccine A/PR/8/34 (H1N1) and then challenged with live virus (A/PR/8/34). Mice immunized with 1µg HA+GEM showed undetectable virus titers in the lungs 5 days after challenge, whereas mice immunized with 1µg HA alone showed detectable levels of virus in the lungs. Interestingly, mice vaccinated with the 0.04µg HA+GEM vaccine demonstrated reduced lung virus titers and a reduction in weight that was similar as that in mice vaccinated with 1µg non-adjuvanted HA. These results indicate that the use of GEM as immunostimulant allows for a strong reduction in the antigen dose as compared to the benchmark vaccine by using GEM particles. Thus, addition of GEM can strongly potentiate immunogenicity of influenza subunit vaccine both quantitatively and qualitatively.

Gastro-intestinal delivery of influenza subunit vaccine formulation adjuvanted with Gram-positive enhancer matrix (GEM) particles.

In this study, a liquid formulation of influenza subunit vaccine admixed with Gram-positive enhancer matrix (GEM) particles as adjuvant was delivered to upper and lower parts of intestinal tract. The aim was to determine the most effective immunization site in the intestines. Mice were vaccinated with a liquid formulation of GEM and influenza subunit vaccine orally and rectally. The oral administration of the vaccine with GEM particles induced a better systemic and mucosal immune response than oral (vaccine only) and rectal (with and without adjuvant) immunizations. Rectal administration elicited high IgG1 responses but little IgG2a, indicating a Th2 dominated immune response. In contrast, the oral immunization with GEM particles elicited a balanced IgG1 and IgG2a response. In conclusion, our results demonstrate that GEM-adjuvanted influenza vaccine should be targeted to the upper part of the intestinal tract.

A comparison between spray drying and spray freeze drying to produce an influenza subunit vaccine powder for inhalation.

The aim of this study was to investigate two different processes to produce a stable influenza subunit vaccine powder for pulmonary immunization i.e. spray drying (SD) and spray freeze drying (SFD). The formulations were analyzed by proteolytic assay, single radial immunodiffusion assay (SRID), cascade impactor analysis, and immunization studies in Balb/c mice. Proteolytic assay and SRID analysis showed that antigen integrity after SFD was best conserved when the formulation was buffered by Hepes buffer saline (HBS). Surprisingly, antigen integrity after SD was better conserved when the formulation was buffered by phosphate buffer saline (PBS) rather than by HBS. The dispersion from the dry powder inhaler, the Twincer, resulted in a fine particle fraction (aerodynamic particle size <5microm) of 37% and 23% for spray dried and spray freeze dried powders, respectively. Immunogenicity of both vaccine formulations (SFD/HBS and SD/PBS) was similar to conventional liquid formulation after i.m. immunization. In addition, compared to i.m. immunizations, the pulmonary immunization with the dry powders resulted in significantly higher IgG titers. Furthermore, both the formulations remained biochemically and physically stable for at least 3years of storage at 20 degrees C. Our results demonstrate that both optimized formulations are stable and have good inhalation characteristics.

Pulmonary delivery of an inulin-stabilized influenza subunit vaccine prepared by spray-freeze drying induces systemic, mucosal humoral as well as cell-mediated immune responses in BALB/c mice.

In this study pulmonary vaccination with a new influenza subunit vaccine powder was evaluated. Vaccine powder was produced by spray-freeze drying (SFD) using the oligosaccharide inulin as stabilizer. Immune responses after pulmonary vaccination of BALB/c mice with vaccine powder were determined and compared to those induced by intramuscular and pulmonary vaccination with a conventional liquid subunit vaccine. All vaccinations were performed without adjuvant. Pulmonary vaccination with liquid subunit vaccine resulted in systemic humoral (IgG) immune responses similar to intramuscular immunization. In contrast, the vaccine powder delivered by the pulmonary route, induced not only systemic humoral (IgG) responses, but also cell-mediated (Il-4, IFN-gamma) and mucosal immune responses (IgA, IgG). This study demonstrates that the combination of pulmonary antigen delivery and antigen powder production by SFD improves the immunogenic potential of (influenza subunit) antigen. In conclusion, vaccination with a non-adjuvanted SFD subunit vaccine powder by inhalation might be feasible and could be an alternative to conventional parenteral vaccine administration.