A systematic review of immunosuppressant adherence interventions in transplant recipients: Decoding the streetlight effect.

Non-adherence to immunosuppressant medications is an important risk factor for graft dysfunction. To evaluate the effectiveness of adherence-enhancing interventions, we reviewed adherence intervention studies in solid organ transplant recipients (all ages). Using the following databases: PsycINFO, PubMed, Scopus, and ScienceDirect, we identified 41 eligible studies. Only three non-randomized trials showed a possible positive effect on objective indicators of transplant outcomes (such as rejection, liver enzyme levels, kidney function). None of the 21 RCTs showed an improvement in transplant outcomes. Three studies showed a higher rate of adverse events in the intervention group as compared with controls, although this may be related to ascertainment bias. Improvement in adherence as measured indirectly (eg, with electronic monitoring devices) was not aligned with effects on transplant outcomes. We conclude that adherence interventions, to date, have largely been ineffective in improving transplant outcomes. To improve this track record, intervention efforts may wish to concentrate on non-adherent patients (rather than use convenience sampling, which excludes many of the patients who need the intervention), use direct measures of adherence to guide the interventions, and employ strategies that are intensive and yet engaging enough to ensure that non-adherent patients are able to participate.

The Medication Level Variability Index (MLVI) Predicts Poor Liver Transplant Outcomes: A Prospective Multi-Site Study.

Nonadherence to immunosuppressant medications is a leading cause of poor long-term outcomes in transplant recipients. The Medication Level Variability Index (MLVI) provides a vehicle for transplant outcome risk-stratification through continuous assessment of adherence. The MALT (Medication Adherence in children who had a Liver Transplant) prospective multi-site study evaluated whether MLVI predicts late acute rejection (LAR). Four hundred pediatric (1-17-year-old) liver transplant recipients were enrolled and followed for 2 years. The a-priori hypothesis was that a higher MLVI predicts LAR. Predefined secondary analyses evaluated other outcomes such as liver enzyme levels, and sensitivity analyses compared adolescents to pre-adolescents. In the primary analysis sample of 379 participants, a higher prerejection MLVI predicted LAR (mean prerejection MLVI with LAR: 2.4 [3.6 standard deviation] versus without LAR, 1.6 [1.1]; p = 0.026). Fifty-three percent of the adolescents with MLVI>2 in year 1 had LAR by the end of year 2, as compared with 6% of those with year 1 MLVI≤2. A higher MLVI was significantly associated with all secondary outcomes. MLVI, a marker of medication adherence that uses clinically derived information, predicts LAR in pediatric liver transplant recipients.

Hepatocyte nuclear factor-1alpha is an essential regulator of bile acid and plasma cholesterol metabolism.

Maturity-onset diabetes of the young type 3 (MODY3) is caused by haploinsufficiency of hepatocyte nuclear factor-1alpha (encoded by TCF1). Tcf1-/- mice have type 2 diabetes, dwarfism, renal Fanconi syndrome, hepatic dysfunction and hypercholestrolemia. Here we explore the molecular basis for the hypercholesterolemia using oligonucleotide microchip expression analysis. We demonstrate that Tcf1-/- mice have a defect in bile acid transport, increased bile acid and liver cholesterol synthesis, and impaired HDL metabolism. Tcf1-/- liver has decreased expression of the basolateral membrane bile acid transporters Slc10a1, Slc21a3 and Slc21a5, leading to impaired portal bile acid uptake and elevated plasma bile acid concentrations. In intestine and kidneys, Tcf1-/- mice lack expression of the ileal bile acid transporter (Slc10a2), resulting in increased fecal and urinary bile acid excretion. The Tcf1 protein (also known as HNF-1alpha) also regulates transcription of the gene (Nr1h4) encoding the farnesoid X receptor-1 (Fxr-1), thereby leading to reduced expression of small heterodimer partner-1 (Shp-1) and repression of Cyp7a1, the rate-limiting enzyme in the classic bile acid biosynthesis pathway. In addition, hepatocyte bile acid storage protein is absent from Tcf1-/- mice. Increased plasma cholesterol of Tcf1-/- mice resides predominantly in large, buoyant, high-density lipoprotein (HDL) particles. This is most likely due to reduced activity of the HDL-catabolic enzyme hepatic lipase (Lipc) and increased expression of HDL-cholesterol esterifying enzyme lecithin:cholesterol acyl transferase (Lcat). Our studies demonstrate that Tcf1, in addition to being an important regulator of insulin secretion, is an essential transcriptional regulator of bile acid and HDL-cholesterol metabolism.

Pediatric transplantation in the United States, 1997-2006.

This article represents the sixth annual review of the current state of pediatric transplantation in the United States from the Scientific Registry of Transplant Recipients (SRTR). It presents updated trends, discussion of analyses presented during the year by the SRTR to the committees of the Organ Procurement and Transplantation Network (OPTN) and discussion of important issues currently facing pediatric organ transplantation. Unless otherwise stated, the statistics in this article are drawn from the reference tables of the 2007 OPTN/SRTR Annual Report. In this article, pediatric patients are defined as candidates, recipients or donors aged 17 years or less. Data for both graft and patient survival are reported as unadjusted survival, unless otherwise stated (adjusted patient and graft survival are available in the reference tables). Short-term survival (3 month and 1 year) reflects outcomes for transplants performed in 2004 and 2005; 3-year survival reflects transplants from 2002 to 2005; and 5-year survival reports on transplants performed from 2000 to 2005. Details on the methods of analysis employed may be found in the reference tables themselves or in the technical notes of the 2007 OTPN/SRTR Annual Report, both available online at http://www.ustransplant.org.

Improving adherence to medications in pediatric liver transplant recipients.

We describe results from a clinical program, which aimed at improving adherence to medications in children who had a liver transplant. We followed the medical outcomes of 23 children and adolescents who participated in a clinical adherence-improvement protocol during the years 2001-2002. The protocol included identification of non-adherent patients by examining tacrolimus blood levels and intervention by increasing the frequency of clinic visits for non-adherent patients. In the two-yr preintervention (1999-2000), there was no improvement in any of the outcomes. After the intervention, the number of patients with high alanine aminotransferase levels (100 and above) decreased significantly, from eight before the intervention to four afterwards. Other outcomes, including the number of rejection episodes (three before, none after) and the degree of adherence to tacrolimus, also improved, but the improvement did not reach statistical significance. Although non-adherent patients were called to clinic more often under the protocol, the intervention did not lead to increased outpatient costs. This adherence--improvement intervention appears to be promising in improving outcomes in pediatric liver transplant recipients. Larger, controlled studies are needed to establish the efficacy of this or other approaches.

Cloning and molecular characterization of the ontogeny of a rat ileal sodium-dependent bile acid transporter.

Sodium-dependent bile acid transport in the rat ileum is abruptly expressed at weaning. Degenerate oligonucleotides, based on amino acid sequence identities between the rat liver and hamster ileal transporters, were used to amplify a rat ileal probe. A 1.2-kb cDNA clone, which contains the full coding region (348 amino acids, 38 kD), was isolated by hybridization screening. In vitro translation yielded a 38-kD protein which glycosylated to 48 kD. Sodium-dependent uptake of taurocholate was observed in oocytes injected with cRNA. Northern blot analysis revealed a 5.0-kb mRNA in ileum, kidney, and cecum. A 48-kD protein was detected in ileal brush border membranes and localized to the apical border of villus ileal enterocytes. mRNA and protein expression, which were negligible before weaning, increased dramatically at weaning. Nuclear transcription rates for the transporter increased 15-fold between postnatal days 7 and 28. The apparent molecular weight of the transporter also increased between days 19 and 28. In summary, the developmental regulation of the rat ileal sodium-dependent bile acid cotransporter is characterized by transcriptionally regulated increases in mRNA and protein levels at the time of weaning with changes in apparent molecular weight of the protein after weaning.

Prospective longitudinal analysis of quantitative Epstein-Barr virus polymerase chain reaction in pediatric liver transplant recipients.

BACKGROUND: Posttransplant lymphoproliferative disease (PTLD) remains a significant cause of morbidity and mortality in pediatric liver transplant recipients. Epstein-Barr Virus (EBV) mismatch associated with more prevalent use of split-liver, reduced size, and living-related transplants has increased the risk of primary EBV infection and subsequent PTLD. Early identification of EBV viremia may reduce the risk of PTLD, because it allows for early adjustment of immunosuppression and antiviral therapy. METHODS: EBV viral load was measured monthly by quantitative competitive polymerase chain reactions in three pediatric liver transplant recipients. RESULTS: Onset of EBV viremia was documented in one recipient. Established EBV viremia was followed in the other two recipients (one with chronic rejection and one with PTLD) who were initially tested once monitoring was initiated in our program. CONCLUSIONS: EBV quantitative competitive polymerase chain reactions may represent a promising way to follow EBV viral load and potentially prevent the development of PTLD.

CMV-IVIG for prevention of Epstein Barr virus disease and posttransplant lymphoproliferative disease in pediatric liver transplant recipients.

A randomized controlled trial of CMV-IVIG (cytomegalovirus-intravenous immunoglobulin) for prevention of Epstein Barr virus (EBV) posttransplant lymphoproliferative disease (PTLD) in pediatric liver transplantation (PLTx) recipients was begun in Pittsburgh and subsequently expanded to four additional sites. Protocol EB viral loads were obtained in a blinded fashion; additional loads could be obtained for clinical indications. Patients were followed for 2 years post-LTx. Eighty-two evaluable patients (39 CMV-IVIG, 43 placebo) developed 18 episodes of EBV disease (7 CMV-IVIG, 11 placebo) including nine cases of PTLD (three CMV-IVIG, six placebo). No significant differences were seen in the adjusted 2-year EBV disease-free rate (CMV-IVIG 79%, placebo 71%) and PTLD-free rate (CMV-IVIG 91%, placebo 84%) between treatment and placebo groups at 2 years (p > 0.20). The absence of significant effect of CMV-IVIG may be explained by a lack of efficacy of the drug or limitations of sample size.

Favorable long-term outcome after liver-kidney transplant for recurrent hemolytic uremic syndrome associated with a factor H mutation.

A male child initially presented with atypical hemolytic uremic syndrome (HUS) at the age of 4 months and progressed within weeks to end stage renal disease (ESRD). At the age of 2 years he received a live-related kidney transplant from his mother, which, despite initial good function, was lost to recurrent disease after 2 weeks. Complement factor H analysis showed low serum levels and the presence of two mutations on different alleles (c.2918G > A, Cys973Tyr and c.3590T > C, Val1197Ala). His survival on dialysis was at risk because of access failure and recurrent bacteremic episodes. Therefore, at the age of 5 years he received a combined liver-kidney transplant with pre-operative plasma exchange. Initial function of both grafts was excellent and this has been maintained for over 2 years. This report suggests that despite setbacks in previous experience, combined liver-kidney transplantation offers the prospect of a favorable long-term outcome for patients with HUS associated with complement factor H mutations.

Neonatal liver failure.

Neonatal liver failure (NLF) is a distinct and unusual clinical syndrome that requires a specialized approach to its management. This review establishes a definition of NLF and provides a literature-supported differential diagnosis. A specific approach to the diagnostic work-up of an infant with NLF based on this differential diagnosis is outlined. The role of mitochondrial-based diseases in the genesis of NLF is reviewed as well as current advances in the diagnosis and management of neonatal hemochromatosis. The unique range of diseases that cause NLF are associated with specific therapies, which are summarized.

Intestinal bile acid transport: biology, physiology, and pathophysiology.

Intestinal reabsorption of bile salts plays a crucial role in human health and disease. This process is primarily localized to the terminal ileum and is mediated by a 48-kd sodium-dependent bile acid cotransporter (SLC10A2 = ASBT). ASBT is also expressed in renal tubule cells, cholangiocytes, and the gallbladder. Exon skipping leads to a truncated version of ASBT, which sorts to the basolateral surface and mediates efflux of bile salts. Inherited mutation of ASBT leads to congenital diarrhea secondary to bile acid malabsorption. Partial inhibition of ASBT may be useful in the treatment of hypercholesterolemia and intrahepatic cholestasis. During normal development in the rat ileum, ASBT undergoes a biphasic pattern of expression with a prenatal onset, postnatal repression, and reinduction at the time of weaning. The bile acid responsiveness of the ASBT gene is not clear and may be dependent on both the experimental model used and the species being investigated. Future studies of the transcriptional and posttranscriptional regulation of the ASBT gene and analysis of ASBT knockout mice will provide further insight into the biology, physiology, and pathophysiology of intestinal bile acid transport.

Characterization of endogenous carrier-mediated taurocholate efflux from Xenopus laevis oocytes.

Taurocholate efflux was studied in Xenopus laevis oocytes and is consistent with a carrier-mediated process. This carrier can be competitively inhibited and trans stimulated by glycocholate. Transport is also trans stimulated by taurochenodeoxycholate and S-hexylglutathione, but not taurolithocholate or daunomycin, reflecting a range of specificity including substrates of both the hepatic canalicular bile acid transporter and the multispecific organic anion transporter. In addition, ATP added to the outside of the oocyte results in an increase in the maximal velocity of this transport process. The physiologic function of this endogenous carrier is not known, but it may act as a generalized system for the efflux of potentially toxic organic anions.

Fetal and neonatal expression of the apical sodium-dependent bile acid transporter in the rat ileum and kidney.

Previous investigations in rats older than 7 d have shown that apical sodium-dependent bile acid transport in the ileum is abruptly expressed at the time of weaning, whereas it is constitutively expressed in the kidney. The current study was designed to characterize the expression of sodium-dependent bile acid transport in late gestation and in the immediate postnatal period in the rat. Sodium-dependent bile acid transport was measured by rapid filtration using [3H]taurocholate and crude brush border membrane vesicles. Apical sodium-dependent bile acid transporter (ASBT) and ileal lipid binding protein (ILBP) expression were analyzed by Western and Northern blotting. Ileal bile acid content was measured by gas chromatography/mass spectrometry. In the ileum significantly greater sodium-dependent taurocholate uptake was measured in fetal d 22 (E22) membrane vesicles compared with postnatal d 7 (E22 17.0 +/- 5.7. P7 3.9 +/- 2.1 pmol/mg/60 s mean +/- SD, n = 3, p = 0.02). Gas chromatography/mass spectrometry revealed significant quantities of ileal bile acids at E22. Western and northern blotting of fetal ileum revealed ASBT but not ILBP. ASBT expression was suppressed by P7 and then reinduced by P21, whereas ILBP appeared to be first expressed postnatally. In contrast ASBT expression in the kidney was less age-dependent. Therefore, it appears that functional expression of the ASBT gene in the rat ileum is biphasic with a prenatal onset of expression, followed by repression in the early postnatal period and then marked reinduction at weaning.

The effects of bile acid feeding on the development of ileal bile acid transport.

Sodium-dependent bile acid uptake is developmentally regulated in the rat ileum. Transport activity is abruptly expressed on postnatal d 17, although the mechanisms controlling this expression are poorly understood. Changes in bile salt metabolism and hepatic transport result in a marked increase in bile flow before postnatal d 17, and thus this study examined the effects of bile salt feeding on the development of ileal bile acid transport. Twelve-d-old rat pups were gavage-fed saline, taurocholate, or mannitol on a daily basis for 3 d. Sodium-dependent bile acid transport was studied by rapid filtration using ileal brush-border membrane vesicles prepared from the various experimental groups. Taurocholate feeding resulted in precocious development of sodium-dependent bile acid transport and induction of sucrase activity. Mannitol feeding, used as a control for the effects of diarrhea-induced stress, resulted in similar sucrase activity, yet sodium-dependent bile acid transport was induced to only half the level observed in taurocholate-fed animals (3.2 +/- 1.6 versus 6.9 +/- 2.0 pmol/mg protein/45 s, p < 0.001). Serum corticosterone levels were similar in the mannitol- and taurocholate-fed animals (3.8 +/- 1.3 versus 4.6 +/- 1.8 micrograms/dL). Both feedings lead to histologic maturation of the ileum, with a more pronounced effect in the taurocholate-fed pups. Bile salt feeding induces precocious expression of ileal bile acid transport, apparently by both diarrhea-induced stress and a bile salt-specific effect.

An ontogenically regulated 48-kDa protein is a component of the Na(+)-bile acid cotransporter of rat liver.

Recent evidence suggests that the Na(+)-coupled carrier mechanism for bile acids on the hepatocyte basolateral plasma membrane is a polypeptide in the molecular weight range of 48,000-50,000. In this study we used a strategy for the identification and isolation of this transport protein based on the observation that Na(+)-dependent transport activity is abruptly expressed in fetal rat liver just before birth [Suchy et al. Am. J. Physiol. 251 (Gastrointest. Liver Physiol. 14): G665-G673, 1986]. Analysis of basolateral plasma membranes by SDS-PAGE revealed that a protein of apparent molecular weight 48,000 was absent from fetal rat liver on day 19 of gestation, barely detectable on day 20, and thereafter increased progressively with postnatal development. Monospecific, polyclonal antibodies raised against the 48-kDa protein but not preimmune antibodies significantly inhibited the initial rate of Na(+)-dependent taurocholate uptake by isolated rat hepatocytes. In contrast, Na(+)-independent taurocholate transport and uptake of another anion, 35SO4(2-), were not affected by antibody treatment. When an extract containing the total complement of basolateral proteins was incorporated into asolectin liposomes, Na+ gradient-dependent uptake of taurocholate was observed, including a 2- to 2.5-fold accumulation of substrate above its equilibrium concentration (overshoot). However, if the membrane extract was first selectively depleted of the 48-kDa protein by immunoprecipitation with the anti-48-kDa antibody before reconstitution, Na(+)-dependent stimulation of taurocholate transport was completely abolished. These studies indicate that an ontogenically regulated 48-kDa protein is a component of the basolateral Na(+)-dependent transport system for bile acids.

Glucocorticoids upregulate taurocholate transport by ileal brush-border membrane.

The regulation of the enterohepatic circulation of bile acids has not been fully elucidated. Substrate availability has been shown to have a regulatory role on the ileal uptake of taurocholate (TC) by a positive feedback mechanism. Other mechanisms are likely to be involved in regulating ileal bile acid uptake. The present study was designed to test the hypothesis that the ileal bile acid transporter (iBAT) is glucocorticoid sensitive and that changes in expression are mediated by changes in iBAT synthesis. Adult Sprague-Dawley rats (300-400 g) received intraperitoneal injections with either corticosterone (5 mg/ 100 g body weight) or an equivalent vehicle (control) daily for 3 days. On day 4, ileal brush-border membrane vesicles (BBMV) and hepatic basolateral membrane vesicles (BLMV) were prepared, and TC transport was performed using the rapid filtration technique. Initial velocity was measured at selected time points, and kinetics were calculated over a range of TC concentrations. Ileal RNA was isolated, and Northern analysis of steady-state iBAT mRNA levels was determined. Western blot analysis was performed to quantitate the level of the 48-kDa iBAT protein. The initial velocity of Na(+)-dependent TC uptake at 30 s by ileal BBMV was higher in treated animals (264.3 +/- 64.6 pmol/mg protein) compared with control animals (148.3 +/- 41.1 pmol/mg protein; P = 0.07). The maximal velocity of uptake (Vmax) was significantly higher in treated vs. control animals (1,091 +/- 62.7 vs. 689.1 +/- 55.0 pmol.min-1.mg protein-1, respectively; P = 0.002), whereas there was no significant difference in the Michaelis constant (Km) between the control and treated animals (43.3 +/- 7.2 vs. 35.3 +/- 8.7 microM, respectively; P = not significant). Steady-state iBAT mRNA levels were increased twofold in the treated vs. control groups. Western blot analysis showed that the abundance of the 48-kDa iBAT protein was eightfold higher in the treated animals compared with control. Kinetic analysis of hepatic Na(+)-dependent TC uptake revealed nearly identical Vmax and Km between the study and control animals. Therefore, we conclude that TC transport by ileal BBMV is upregulated by administration of glucocorticoids. The increase in BBMV transport Vmax corresponds to an increase in both iBAT transcript and protein.

Neither intestinal sequestration of bile acids nor common bile duct ligation modulate the expression and function of the rat ileal bile acid transporter.

The regulatory responses of bile acid (BA) transport in the terminal ileum to perturbations in BA homeostasis are complex, and conflicting results have been reported by different investigators. These studies were designed to examine the response of this system to a reduction in ileal bile salt concentrations at both a functional and molecular level. Common bile duct ligation (BDL) or feeding of a novel bile acid-binding compound, GT31-104HB, for 7 days were used to reduce ileal apical membrane bile salt flux. Apical bile acid transport function was assessed by examining sodium-dependent uptake of [3H]-taurocholate (TC) into brush border membrane vesicles (BBMV). Expression of the apical sodium-dependent bile acid transporter (ASBT) and the ileal lipid-binding protein (ILBP) were assessed by Western blotting with quantitation using [125I]-labeled secondary antibody and a phosphorimager. Neither common BDL nor intestinal sequestration of BA led to a change in ileal bile acid transport function or the expression of the ASBT or the ILBP. These results indicate that a reduction in presentation of bile salts to the apical surface of the terminal ileum does not modulate the expression of the genes involved in their transport.

Comparative analysis of the ontogeny of a sodium-dependent bile acid transporter in rat kidney and ileum.

An apical sodium-dependent bile acid transporter (ASBT) has recently been cloned and characterized in the rat ileum. Northern and Western blotting revealed both the ASBT mRNA and protein in rat kidney. The coding sequence of the kidney transcript was found to be identical to the previously cloned ileal ASBT. Indirect immunofluorescence studies localized the ASBT protein to the apical membrane of the renal proximal convoluted tubule. Kinetic analysis of sodium-dependent taurocholate uptake using membrane vesicles revealed a similar Michaelis-Menten constant value for taurocholate in the kidney and intestine. ASBT protein and function were present in the kidney but not the ileum from 7-day-old rats. On postnatal day 7, there was a sevenfold increase in ASBT steady-state mRNA levels in the kidney relative to the ileum, yet nuclear run-on assays revealed that the nascent transcription rates at this age were virtually the same. This suggests that the difference in the neonatal expression of the ASBT gene in the kidney and ileum may be in part due to differences in mRNA stability.

The role of quantitative Epstein-Barr virus polymerase chain reaction and preemptive immunosuppression reduction in pediatric liver transplantation: a preliminary experience.

BACKGROUND: Risk factors for the development of posttransplant lymphoproliferative disease (PTLD), a major cause of morbidity and mortality after pediatric liver transplantation, are primary Epstein-Barr virus (EBV) infection and intensity of immunosuppression. The authors assessed monitoring of EBV replication and preemptive immunosuppression reduction in pediatric liver transplant recipients. METHODS: The authors prospectively followed monthly EBV-quantitative competitive polymerase chain reaction to measure EBV replication in 23 patients who underwent liver transplant between July 1997 and November 1998. Preemptive immunosuppression reduction was instituted for significant EBV replication. Patients were followed up for at least 1 year and divided in two groups for analysis (group 1, pretransplant seronegative for EBV [13 patients]; group 2, seropositive for EBV [10 patients]). RESULTS: In group 1, 9 of 13 patients had positive polymerase chain reaction results at a mean time of 22.4 weeks after transplantation. All but one of these patients were asymptomatic. In seven of nine patients, preemptive immunosuppression reduction was undertaken without development of PTLD or rejection. In two of nine patients, immunosuppression could not be continuously reduced, and both patients experienced low-grade and medically responsive PTLD. In no patient in group 2 did an EBV-positive viral load or PTLD develop. CONCLUSIONS: Prospective longitudinal measurement of EBV by quantitative competitive polymerase chain reaction permits early detection of asymptomatic viral replication. Subsequent preemptive reduction of immunosuppression may prevent the progression to PTLD.