Ten-Year Efficacy and Safety of Once-Daily Tacrolimus in Kidney Transplant: A Prospective Cohort Study.

Tacrolimus is a cornerstone in the immunosuppressive therapy of kidney transplantation. The once-daily formulation of tacrolimus has been shown to improve adherence of patients without affecting short-term efficacy. However, long-term proof of once-daily tacrolimus efficacy and safety is still lacking. From January 2009 to November 2013, 170 clinically stable kidney transplant patients were offered to change from the ongoing twice-daily tacrolimus (TDT) formulation to a once-daily tacrolimus (ODT) regimen. Kidney transplant recipients agreeing to the change to be treated with an ODT regimen (n = 105, estimated glomerular filtration rate [eGFR] 57.1 ± 1.6 mL/min/1.73 m2) and patients continuing on a TDT formulation (n = 65, eGFR 52.0 ± 2.2 mL/min/1.73 m2) were prospectively followed (median follow-up time 10.4 and 12.6 years in the ODT and TDT groups, respectively, P = not significant). At the end of the follow-up, patients in both groups experienced similar eGFR (50.4 ± 2.2 vs 48.0 ± 2.7 mL/min/1.73 m2 in the ODT and TDT groups, respectively, P = not significant). No differences were observed in biopsy-proven acute rejection, overall graft survival, doubling of serum creatinine, and new onset of proteinuria. The 2 groups also had a comparable rate of death, sepsis, and neoplasia. In conclusion, ODT appears safe and effective in stable kidney graft recipients even 10 years after transplantation. These findings support the use of ODT as a primary tacrolimus formulation in patients with kidney transplantation.

Myostatin mediates abdominal aortic atherosclerosis progression by inducing vascular smooth muscle cell dysfunction and monocyte recruitment.

Myostatin (Mstn) is a skeletal muscle growth inhibitor involved in metabolic disorders and heart fibrosis. In this study we sought to verify whether Mstn is also operative in atherosclerosis of abdominal aorta. In human specimens, Mstn expression was almost absent in normal vessels, became detectable in the media of non-progressive lesions and increased with the severity of the damage. In progressive atherosclerotic lesions, Mstn was present in the media, neointima, plaque shoulder and in infiltrating macrophages. Mstn co-localized with α-smooth muscle actin (α-SMA) staining and with some CD45+ cells, indicating Mstn expression in VSMCs and bloodstream-derived leukocytes. In vitro, Mstn was tested in VSMCs and monocytes. In A7r5 VSMCs, Mstn downregulated proliferation and Smoothelin mRNA, induced cytoskeletal rearrangement, increased migratory rate and MCP-1/CCR2 expression. In monocytes (THP-1 cells and human monocytes), Mstn acted as a chemoattractant and increased the MCP-1-dependent chemotaxis, F-actin, α-SMA, MCP-1 and CCR2 expression; in turn, MCP-1 increased Mstn mRNA. Mstn induced JNK phosphorylation both in VSMCs and monocytes. Our results indicate that Mstn is overexpressed in abdominal aortic wall deterioration, affects VSMCs and monocyte biology and sustains a chronic inflammatory milieu. These findings propose to consider Mstn as a new playmaker in atherosclerosis progression.

Effect of supplementation with linseed or a blend of aromatic spices and time on feed on fatty acid composition, meat quality and consumer liking of meat from lambs fed dehydrated alfalfa or corn.

Cross-bred lambs (n=72) were fed finishing diets using a factorial arrangement of treatments: BASAL DIET (alfalfa pellets or corn), SUPPLEMENT (none, linseed or aromatic spices), TIME ON FEED (41 or 83days). Carcass and meat quality traits, fatty acid composition, color stability and consumer liking were determined. Feeding alfalfa improved sensory ratings and fatty acid composition of lamb. However, corn or longer alfalfa feeding would be recommended if heavier and fatter carcasses are sought. Consumer liking and fatty acid composition of lamb were improved with addition of spices and linseed, respectively. But additional antioxidant strategies should be considered to delay meat color deterioration during storage if lambs are fed corn-linseed for 83days. Although alfalfa basal diet and linseed supplementation improved fatty acid composition, feeding the basal diets for at least 41days resulted in low n-3 fatty acid concentrations in muscle.

Kidney Intragraft Homing of De Novo Donor-Specific HLA Antibodies Is an Essential Step of Antibody-Mediated Damage but Not Per Se Predictive of Graft Loss.

Donor-specific HLA antibody (DSA)-mediated graft injury is the major cause of kidney loss. Among DSA characteristics, graft homing has been suggested as an indicator of severe tissue damage. We analyzed the role of de novo DSA (dnDSA) graft homing on kidney transplantation outcome. Graft biopsy specimens and parallel sera from 48 nonsensitized pediatric kidney recipients were analyzed. Serum samples and eluates from graft biopsy specimens were tested for the presence of dnDSAs with flow bead technology. Intragraft dnDSAs (gDSAs) were never detected in the absence of serum dnDSAs (sDSAs), whereas in the presence of sDSAs, gDSAs were demonstrated in 72% of biopsy specimens. A significantly higher homing capability was expressed by class II sDSAs endowed with high mean fluorescence intensity and C3d- and/or C1q-fixing properties. In patients with available sequential biopsy specimens, we detected gDSAs before the appearance of antibody-mediated rejection. In sDSA-positive patients, gDSA positivity did not allow stratification for antibody-mediated graft lesions and graft loss. However, a consistent detection of skewed unique DSA specificities was observed over time within the graft, likely responsible for the damage. Our results indicate that gDSAs could represent an instrumental tool to identify, among sDSAs, clinically relevant antibody specificities requiring monitoring and possibly guiding patient management.

Acquisition of C3d-Binding Activity by De Novo Donor-Specific HLA Antibodies Correlates With Graft Loss in Nonsensitized Pediatric Kidney Recipients.

Alloantibody-mediated graft injury is a major cause of kidney dysfunction and loss. The complement-binding ability of de novo donor-specific antibodies (dnDSAs) has been suggested as a prognostic tool to stratify patients for clinical risk. In this study, we analyzed posttransplant kinetics of complement-fixing dnDSAs and their role in antibody-mediated rejection development and graft loss. A total of 114 pediatric nonsensitized recipients of first kidney allograft were periodically monitored for dnDSAs using flow bead assays, followed by C3d and C1q assay in case of positivity. Overall, 39 patients developed dnDSAs, which were C1q(+) and C3d(+) in 25 and nine patients, respectively. At follow-up, progressive acquisition over time of dnDSA C1q and C3d binding ability, within the same antigenic specificity, was observed, paralleled by an increase in mean fluorescence intensity that correlated with clinical outcome. C3d-fixing dnDSAs were better fit to stratify graft loss risk when the different dnDSA categories were evaluated in combined models because the 10-year graft survival probability was lower in patients with C3d-binding dnDSA than in those without dnDSAs or with C1q(+) /C3d(-) or non-complement-binding dnDSAs (40% vs. 94%, 100%, and 100%, respectively). Based on the kinetics profile, we favor dnDSA removal or modulation at first confirmed positivity, with treatment intensification guided by dnDSA biological characteristics.

Effects of peritoneal dialysis on protein metabolism.

Protein-energy wasting is relatively common in renal patients treated with haemodialysis or peritoneal dialysis (PD) and is associated with worse outcome. In this article, we review the current state of our knowledge regarding the effects of PD on protein metabolism and the possible interactions between PD-induced changes in protein turnover and the uraemia-induced alterations in protein metabolism. Available evidence shows that PD induces a new state in muscle protein dynamics, which is characterized by decreased turnover rates and a reduced efficiency of protein turnover, a condition which may be harmful in stress conditions, when nutrient intake is diminished or during superimposed catabolic illnesses. There is a need to develop more effective treatments to enhance the nutritional status of PD patients. New approaches include the use of amino acid/keto acids-containing supplements combined with physical exercise, incremental doses of intraperitoneal amino acids, vitamin D and myostatin antagonism for malnourished patients refractory to standard nutritional therapy.

Posttransplant de novo donor-specific hla antibodies identify pediatric kidney recipients at risk for late antibody-mediated rejection.

The emerging role of humoral immunity in the pathogenesis of chronic allograft damage has prompted research aimed at assessing the role of anti-HLA antibody (Ab) monitoring as a tool to predict allograft outcome. Data on the natural history of allografts in children developing de novo Ab after transplantation are limited. Utilizing sera collected pretransplant, and serially posttransplant, we retrospectively evaluated 82 consecutive primary pediatric kidney recipients, without pretransplant donor-specific antibodies (DSA), for de novo Ab occurrence, and compared results with clinical-pathologic data. At 4.3-year follow up, 19 patients (23%) developed de novo DSA whereas 24 had de novo non-DSA (NDSA, 29%). DSA appeared at a median time of 24 months after transplantation and were mostly directed to HLA-DQ antigens. Among the 82 patients, eight developed late/chronic active C4d+ antibody-mediated rejection (AMR), and four C4d-negative AMR. Late AMR correlated with DSA (p < 0.01), whose development preceded AMR by 1-year median time. Patients with DSA had a median serum creatinine of 1.44 mg/dL at follow up, significantly higher than NDSA and Ab-negative patients (p < 0.005). In our pediatric cohort, DSA identify patients at risk of renal dysfunction, AMR and graft loss; treatment started at Ab emergence might prevent AMR occurrence and/or progression to graft failure.

Evaluation of metabolic acidosis in patients with a kidney graft: comparison of the bicarbonate-based and strong ion-based methods.

BACKGROUND: According to the traditional bicarbonate-based approach, metabolic acidosis is highly prevalent in kidney transplant recipients. However, the bicarbonate-based approach has been questioned by intensivists using strong ion difference-based methods. METHODS: We compared the results obtained by the strong ion-based with the traditional approach based on bicarbonate among a cohort of 83 kidney transplant recipients. RESULTS: Fifty-five percent of the patients were acidotic based on venous bicarbonate (<23 mmol/L) and 49% by the use of the effective strong ion difference (SID(effective)) (<37 mmol/L). Bicarbonate and SID(effective) were linearly correlated (r=0.94; P<.0001), with a slope close to 1. A greater percentage of patients presented with an increase in unexplained anions by the strong ion gap (SIG) than by the anion gap corrected (AG(corrected)) method (42 vs 32%, respectively). AG(corrected) and SIG were directly related (r=0.919; P<.0001), but the best fit of the relationship was polynomial with a progressively greater effect on SIG with increased AG(corrected), suggesting that as anions progressively accumulate, their detection by SIG increases. By multiple regression analysis, plasma chloride, potassium, uric acid, and phosphate predicted blood bicarbonate. Analogously, chloride, potassium and uric acid predicted SID(effective). Age was a predictor of changes in AG(corrected), whereas age and plasma urea predicted SIG. CONCLUSIONS: The use of the SID yielded results that were similar to the traditional bicarbonate-based approach. Conversely, SIG appeared to be more sensitive than AG for detection of anion accumulation among patients with a kidney graft.

Apoptosis in the kidneys of patients with type II diabetic nephropathy.

The occurrence and extent of apoptosis in the kidneys of patients with diabetic nephropathy is largely unknown. We evaluated apoptosis in renal biopsies obtained from patients with early or advanced type II diabetic nephropathy. Apoptosis was about 6- and 3-fold higher, respectively, in glomeruli and tubules in kidneys of patients with early nephropathy than in the normal kidney and this was not further increased in advanced diabetic nephropathy. Glomerular apoptosis was related directly to hemoglobin A1(c) and systolic blood pressure, whereas tubular cell apoptosis correlated to diabetes duration and low-density lipoprotein-cholesterol. Fas, Fas ligand, and p38 mitogen-activated protein kinase expressions were enhanced in glomeruli and tubules; however, this did not correlate with apoptosis. In patients with proteinuria, apoptosis was associated with the subsequent loss of kidney function. When these parameters were subjected to multivariate analysis, only glomerular apoptosis retained a significant independent predictive value. Our findings suggest that apoptosis might be a clinically relevant mechanism of glomerular and tubular cell loss in proteinuric type II diabetic patients.

Peripheral tissue release of interleukin-6 in patients with chronic kidney diseases: effects of end-stage renal disease and microinflammatory state.

To examine if uremia influences muscle interleukin-6 (IL-6) metabolism we studied the exchange of IL-6 across the forearm in 16 patients with chronic kidney disease (CKD) (stages 3 and 4), in 15 hemodialysis (HD)-treated end-stage renal disease (ESRD) patients (n=15), and in six healthy controls. In addition, we performed an analysis of both IL-6 protein and IL-6 mRNA expression in muscle of CKD (stage 4) patients showing evidence of inflammation and in controls. A release of IL-6 from the forearm was observed in patients with elevated IL-6 plasma levels. Arterial IL-6 was directly related to released IL-6 (r=0.69; P<0.004) in HD patients. Both IL-6 protein and IL-6 mRNA expression were increased in muscle of inflamed CKD patients vs controls (P<0.05). Although muscle net protein balance was similar in all patients, it was significantly more negative in HD patients with high than in those with low IL-6 plasma levels (P<0.05). In addition, net protein balance was related to the forearm release of IL-6 in HD patients only (r=0.47; P<0.038). These data demonstrate that IL-6 expression is upregulated in muscle, and that muscle tissue, by releasing this cytokine, may contribute to the inflammatory response in HD patients. The release of IL-6 from peripheral tissues is associated with an increase in muscle protein loss in HD patients, suggesting that muscle release of IL-6 is linked to protein catabolism in these patients. The release of IL-6 from peripheral tissues may act as a signal for the inflammatory response and contribute to functional dysregulation in uremia.

[Census 2004 of the Italian Renal and Dialysis Units--Piemonte, Liguria and Valle d'Aosta]. / Censimento 2004 dei Centri di Nefrologia e Dialisi italiani. Piemonte--Liguria--Valle d'Aosta.

The Italian Society of Nephrology (SIN) promoted a national survey in order to obtain detailed information from all Renal and/or Dialysis Units using the on-line questionnaire (158 items) regarding structural and technological resources, medical workforce organisation and activity features. The purposes of this initiative were to obtain regional benchmarks as references for renal units and to describe the current Italian renal network in order to plan further interventions for the next 5 years. In this paper data of the first three Italian Regions (Piemonte, Liguria and Valle d'Aosta) which completed the survey (100% of the units) are reported. Main findings in the 3 Regions. A) Epidemiology: prevalence of dialysis patients = 709, 720, 787 pmp (per million population); prevalence of transplanted patients = 325, 387, 279 pmp; incidence of dialysis patients = 166, 191, 156 pmp; gross mortality of dialysis patients = 13.7, 15.0, 13.0%; distribution of vascular access in prevalent dialysis patients: arteriovenous fistula = 74, 83, 76%, central venous catheter = 18, 12, 15%, vascular graft = 8, 5, 9%. B) Structural resources: hospital's number of beds = 49, 72, 49 pmp, dialysis places = 166, 158, 164 pmp. C) Personnel resources: renal physicians = 44, 47, 41 pmp, renal nurses = 186, 194, 205 pmp; each renal physician takes care of 16, 15, 19 dialysis patients and each renal nurse cares for 3.8, 3.7, 3.8 dialysis patients. D) Activity: admission to hospital = 1507, 2392, 1606 pmp, renal biopsies = 109, 133, 57 pmp. Despite discrepancies in population density in the three Regions, most indexes are surprisingly similar and show the satisfactory level of renal care attained in the Northwestern Italian area. Further improvements in health care management can be predicted as a consequence of a direct comparison between needs and results in the various Regions of the Country.

[Metabolic acidosis in patients with chronic kidney diseases: why and when to treat it?]. / Acidosi nell'insufficienza renale: perche' e quando trattarla.

Metabolic acidosis is a common complication in patients with advanced chronic renal diseases and dialytic treatments are unable to correct it completely. In hemodialysis (HD) patients, severe metabolic acidosis is associated with an increased risk of death. Evidence from several experimental studies suggests that even mild metabolic acidosis is associated with systemic effects. Acidosis is implicated in endocrine changes and has negative repercussions on bone and protein metabolism. In addition, recent observations suggest that acidosis triggers inflammation and accelerates the progression of chronic kidney diseases. As a contradictory finding, acidosis can reduce circulating leptin. Clinical studies on the nutritional effects of metabolic acidosis correction have shown mildly favorable effects. Taking into account the systemic effects of metabolic acidosis it is suggested that even mild metabolic acidosis is corrected. However, the new findings concerning the systemic effects of acidosis must be evaluated in controlled trials.

Gender and the progression of chronic renal diseases: does apoptosis make the difference?

Several studies in patients with chronic kidney diseases have shown that men have a more rapid disease progression than women. Also, with ageing, men exhibit greater decrements in renal function and increased glomerular sclerosis than women. Data from meta-analysis studies indicate that women with several non-diabetic renal diseases such as membranous nephropathy, IgA nephropathy and polycystic kidney disease present a slower progression, but in diabetic renal disease this is not yet established. Thus, men appear to be at greater risk for renal injury than are women, but the underlying mechanisms are unknown. Sex hormones may mediate the effects of gender on chronic renal disease, through the interaction with the renin-angiotensin system, the modulation of nitric oxide synthesis and the downregulation of collagen degradation. New observations indicate that androgens may contribute to continuous loss of kidney cells though the stimulation of apoptotic pathways. Apoptosis is an unique type of programmed cell death which is activated in several chronic kidney diseases. Studies in vitro indicate that androgens prime a Fas/FasL dependent apoptotic pathway in kidney tubule cells. This apoptotic cell death pathway is receptor-linked and interacts with the mitochondrial pathway, which may be activated by other mechanisms, such as toxins and ischemia. Therefore, the mechanisms to cell death which are primed by androgens may interact with others occurring in several conditions leading to the loss of renal cells. These findings are consistent with a role for androgens to promote chronic renal injury in men.

[Complications of the nephrotic syndrome]. / Le complicanze della sindrome nefrosica.

We described the case of a 27-year-old man presenting pulmonary embolism and hyperlipidaemia. Subsequent investigation revealed that he was affected by renal vein thrombosis and nephrotic syndrome due to membranous glomeruloephritis. Nephrotic syndrome complications are numerous and may represent the first sign of the syndrome. Among these complications we find thromboembolism, infections, negative nitrogen balance and renal failure. There are very few prognostic indicators that enable the prediction of nephrotic syndrome complications. Recent advances in the understanding of alterations in the metabolism of circulating and somatic proteins associated with proteinuria and hypooncotic condition have led to new insights into the pathophysiologic processes associated with the syndrome.

[Acute effects of peritoneal dialysis on muscle protein turnover]. / Effetti acuti della dialisi peritoneale sul metabolismo proteico.

BACKGROUND: Despite continuing glucose absorption and stimulation of insulin secretion, wasting is common in patients with chronic renal failure (CRF) treated with peritoneal dialysis. METHODS: To evaluate if peritoneal dialysis per se has any effect(s) on muscle protein turnover we employed the forearm perfusion method associated with the kinetics of 3H-phenylalanine in seventeen patients with CRF in the basal state and: a) during the systemic hyperinsulinemia associated with peritoneal dialysis (6 patients) (200-240 min); b) during locally-induced hyperinsulinemia, without systemic effects on aminoacid (AA) availability (6 patients) (80-120 min); c) in time-controls (5 patients) (80-240 min). RESULTS: Peritoneal dialysis and local infusion of insulin in the brachial artery (0.01 mU/min/kg) induced a similar degree of systemic or local, moderate hyperinsulinemia (19+/-4 e 21+/-3 microU/ml, respectively). During both protocols an insulin-related inhibition of muscle protein degradation occurred; however peritoneal dialysis caused a 20% decrease in forearm phenylalanine rate of disposal (an index of muscle protein synthesis), which correlated with the decline of arterial BCAA and potassium, which were removed via the peritoneal fluid. Furthermore, a persistent negative net phenylalanine and AA balance across the forearm was observed during peritoneal dialysis, while the negative basal net phenylalanine and AA balance was reversed to a positive or neutral one during local hyperinsulinemia. CONCLUSIONS: We conclude that in CRF patients even a modest elevation in local insulin levels is followed by an anabolic muscle response, while the same effect is not observed during the systemic hyperinsulinemia associated with substrate removal which occurs during peritoneal dialysis. In this setting the antiproteolytic effect of hyperinsulinemia is offset by a decrease in muscle protein synthesis which is accounted for by a decrease in AA availability. Our data indicate that protein metabolism during peritoneal dialysis is characterized not only by decreased, but also less efficient, turnover rates.

Apoptosis induced by serum withdrawal in human mesangial cells. Role of IGFBP-3.

Apoptosis has been reported to occur both during the course of kidney development and the progression of kidney injury to scarring. Insulin-like growth factor binding protein-3 (IGFBP-3), a component of the IGF system, has been shown to induce apoptosis in cancer cell lines. However, if IGFBP-3 has similar effects in human mesangial cells (HMC) remains unknown. The purpose of this study was to examine the expression of IGFBP-3 and its possible effect on the induction of apoptosis in HMC during serum deprivation. We have observed that IGFBP-3 accumulates progressively in HMC in which serum has been withdrawn. In these cells, an increase of IGFBP-3 is observed before the production of apoptosis suggesting a link between these phenomena. Furthermore, the addition of IGFBP-3 in physiological amounts (from 100 to 400 ng/ml) to culture medium devoid of growth factors accelerates and increases the apoptotic process with a dose-dependent effect. These findings suggest that IGFBP-3 is a mediator of cell death in human mesangial cells when the availability of growth factors is curtailed. These data also suggest that IGFBP-3 could contribute to apoptotic processes observed in human disease.

Plasma protein synthesis in patients with low-grade nephrotic proteinuria.

Overt nephrotic syndrome is characterized by albumin and fibrinogen hyperproduction and reduced very low density lipoprotein apolipoprotein B-100 (VLDL apoB-100) clearance. Whether similar changes also occur in low-grade proteinuria is not known. Thus we measured albumin, fibrinogen, and VLDL apoB-100 kinetics in six patients with modest proteinuria and normal creatinine clearance (P) and in ten control subjects (C) by leucine tracer infusion and precursor-product relationships. In P, plasma albumin concentration was decreased (P < 0.003), whereas concentrations of fibrinogen and VLDL apoB-100 were increased (P < 0.001). In P, albumin fractional secretion rate (FSR) was increased (P < 0.01), fibrinogen FSR was normal, and VLDL apoB-100 FSR was decreased (P < 0.03). As a result, in P, absolute secretion rates (ASR) of albumin and fibrinogen were increased (P < 0.03), whereas VLDL apoB-100 ASR was normal. Albumin FSR was inversely correlated to oncotic pressure in P but not in C. These findings suggest that low-grade nephrotic proteinuria is characterized by simultaneous multiple alterations in turnover rates of albumin, fibrinogen, and VLDL apoB-100. Their pathogenesis, however, appears to be multifactorial.

Interorgan amino acid exchange.

This review is concerned with the status of our current research related to the exchange of amino acids across organs. Accumulation of knowledge regarding how amino acid pools are maintained within the body remains a work in progress. In recent years, the use of organ balance measurement techniques in combination with isotopic tracers has much increased our understanding of the role of the kidney and splanchnic organs in amino acid metabolism, and in kidney and liver gluconeogenesis from amino acids. An interorgan cooperation between the kidney and splanchnic organs for leucine-ketoisocaproate metabolism has also been demonstrated.