TGF-ß is elevated in hyperuricemic individuals and mediates urate-induced hyperinflammatory phenotype in human mononuclear cells.

BACKGROUND: Soluble urate leads to a pro-inflammatory phenotype in human monocytes characterized by increased production of IL-1ß and downregulation of IL-1 receptor antagonist, the mechanism of which remains to be fully elucidated. Previous transcriptomic data identified differential expression of genes in the transforming growth factor (TGF)-ß pathway in monocytes exposed to urate in vitro. In this study, we explore the role of TGF-ß in urate-induced hyperinflammation in peripheral blood mononuclear cells (PBMCs). METHODS: TGF-ß mRNA in unstimulated PBMCs and protein levels in plasma were measured in individuals with normouricemia, hyperuricemia and gout. For in vitro validation, PBMCs of healthy volunteers were isolated and treated with a dose ranging concentration of urate for assessment of mRNA and pSMAD2. Urate and TGF-ß priming experiments were performed with three inhibitors of TGF-ß signalling: SB-505124, 5Z-7-oxozeaenol and a blocking antibody against TGF-ß receptor II. RESULTS: TGF-ß mRNA levels were elevated in gout patients compared to healthy controls. TGF-ß-LAP levels in serum were significantly higher in individuals with hyperuricemia compared to controls. In both cases, TGF-ß correlated positively to serum urate levels. In vitro, urate exposure of PBMCs did not directly induce TGF-ß but did enhance SMAD2 phosphorylation. The urate-induced pro-inflammatory phenotype of monocytes was partly reversed by blocking TGF-ß. CONCLUSIONS: TGF-ß is elevated in individuals with hyperuricemia and correlated to serum urate concentrations. In addition, the urate-induced pro-inflammatory phenotype in human monocytes is mediated by TGF-ß signalling. Future studies are warranted to explore the intracellular pathways involved and to assess the clinical significance of urate-TGF-ß relation.

Sub-3 mm, near-200 ps TOF/DOI-PET imaging with monolithic scintillator detectors in a 70 cm diameter tomographic setup.

Recently, a monolithic scintillator detector for time-of-flight (TOF)/depth-of-interaction (DOI) positron emission tomography (PET) was developed. It has a detector spatial resolution of ~1.7 mm full-width-at-half-maximum (FWHM), a coincidence resolving time (CRT) of ~215 ps FWHM, and ~4.7 mm FWHM DOI resolution. Here, we demonstrate, for the first time, the imaging performance of this detector in a 70 cm diameter PET geometry. We built a tomographic setup representative of a whole-body clinical scanner, comprising two coaxially rotating arms, each carrying a detector module, and a central, rotating phantom table. The fully automated setup sequentially acquires all possible lines of response (LORs) of a complete detector ring, using a step-and-shoot acquisition approach. The modules contained 2 × 2 detectors, each detector consisting of a 32 mm × 32 mm × 22 mm LYSO crystal and a digital silicon photomultiplier (dSiPM) array. The system spatial resolution was assessed using a Na-22 point source at different radial distances in the field-of-view (FOV). Using 2D filtered back projection (2D FBP, non-TOF), tangential and radial spatial resolutions of ~2.9 mm FWHM were obtained at the center of the FOV. The use of DOI information resulted in almost uniform spatial resolution throughout the FOV up to a radial distance of 25 cm, where the radial and tangential resolution are ~3.3 mm FWHM and ~4.7 mm FWHM, respectively, whereas without DOI the resolution deteriorates to ~9 mm FWHM. Additional measurements were performed with a Na-22 filled Derenzo-like phantom at different locations within the FOV. Images reconstructed with a TOF maximum-likelihood expectation-maximization (TOF ML-EM) algorithm show that the system is able to clearly resolve 3 mm diameter hot rods up to 25 cm radial distance. The excellent and uniform spatial resolution, combined with an energy resolution of 10.2% FWHM and a CRT of ~212 ps FWHM, indicates a great potential for monolithic scintillators as practical high-performance detectors in TOF/DOI-PET systems.

[Low cyclosporin levels induced by the brief use of rifampicin; immunosuppression may fail for several weeks]. / Lage ciclosporinespiegel na kort rifampicinegebruik; immuunsuppressie kan langdurig tekortschieten.

Cyclosporin is an immunosuppressive agent with a wide range of therapeutic uses. In transplant patients, it is used for the prevention of rejection and graft-versus-host reactions. The metabolism and bioavailability of cyclosporin can be significantly and persistently influenced through induction of CYP3A4 caused by the concomitant use of rifampicin. However, awareness of the need for the timely and frequent monitoring of cyclosporin levels during and especially after treatment with rifampicin has not fully been addressed. Here, we describe 3 patient cases concerning significant episodes of sub-therapeutic cyclosporin levels after short-term rifampicin therapy. Rifampicin was administered for three to five days and decreased cyclosporin levels were observed ± 7 days after the initiation of rifampicin, and continued during the following weeks even after the cessation of rifampicin therapy. Cyclosporin dosage-adjustments were made based on the cyclosporin blood levels and all 3 patients showed good therapeutic and clinical responses.

Recovery of normal body weight in adolescents with anorexia nervosa: the nurses' perspective on effective interventions.

PROBLEM: Little is known about effective nursing interventions for adolescents with anorexia nervosa. The purpose of this study was to discover which aspects of nursing care are most effective, according to nurses, in recovery of normal body weight in adolescents with anorexia nervosa. METHODS: A qualitative descriptive research design was applied with individual in-depth interviews and a focus group. Thematic analysis was used to analyze the data. FINDINGS: Nurses state that they are in a key position in guiding patients with anorexia nervosa toward a path of weight recovery. A good therapeutic relationship is essential to the implementation of targeted nursing interventions in the areas of eating and exercising, social support, and parent counseling. CONCLUSIONS: The results of this research can be used to define more detailed nursing interventions, the effectiveness of which can be tested in follow-up research.

[DRESS syndrome as a result of sulfasalazine use]. / Het DRESS-syndroom bij gebruik van sulfasalazine.

A 24-year-old female developed DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) as a result of sulfasalazine use. The DRESS syndrome is a severe and acute hypersensitivity reaction that can be caused by a variety of drugs. The clinical presentation is diverse; the most common symptoms are fever, exanthema and lymphadenopathy. Haematologic abnormalities such as leukocytosis, accompanied primarily with eosinophilia, and sometimes atypical lymphocytes are also frequently reported. In most cases the DRESS syndrome needs no further treatment after discontinuation of the associated drug. However, 20% of patients are severely affected and the DRESS syndrome is potentially life-threatening. The patient was successfully treated with a glucocorticoid and an antihistamine.

Using the LCP: bereaved relatives' assessments of communication and bereavement.

The Liverpool Care Pathway (LCP) is aimed at improving care and communication in the dying phase. The authors studied whether use of the LCP affects relatives' retrospective evaluation of communication and their level of bereavement. An intervention study was conducted. During the baseline period, usual care was provided to dying patients. During the intervention period, the LCP was used for 79% of the patients. In total, bereaved relatives filled in a questionnaire for 57% of the patients, on average 4 months after death. In the intervention period, relatives had lower bereavement levels when compared with relatives in the baseline period (P = .01). Communication was evaluated similarly for both periods. We conclude that LCP use during the dying phase seems to moderately contribute to lower levels of bereavement in relatives.

Differentiation between chronic rejection and chronic cyclosporine toxicity by analysis of renal cortical mRNA.

BACKGROUND: In kidney transplantation, chronic allograft nephropathy (CAN) is the major cause of graft loss. Causes of CAN include chronic rejection and chronic cyclosporine A (CsA) nephrotoxicity. It is necessary to differentiate between these two entities in order to apply the appropriate therapeutic regimen for the individual patient, but this is hampered by the lack of discriminating functional and morphologic parameters. We investigated whether renal cortical mRNA levels for several matrix proteins can serve as discriminating parameters. METHODS: Patients with chronic rejection (N= 19) and chronic CsA toxicity (N= 17) were selected by clinical and histologic criteria. Protocol biopsies without histologic abnormalities, taken at 6 months after transplantation from patients receiving CsA, were used as controls (N= 6). Total RNA was extracted from the renal biopsy tissue, and mRNA levels of transforming growth factor-beta (TGF-beta) and the extracellular matrix (ECM) molecules collagen Ialpha1, IIIalpha1, IValpha3, decorin, fibronectin, and laminin beta2 were measured by real-time polymerase chain reaction (PCR). RESULTS: In both patient groups, the mean collagen IValpha3 and fibronectin mRNA levels were significantly elevated compared to those in controls, whereas only in CsA toxicity were the laminin beta2 and TGF-beta mRNA levels significantly increased. The increase of laminin beta2 and TGF-beta mRNA levels was significantly higher in the CsA toxicity group than in the chronic rejection group (P < 0.001 and P= 0.004, respectively). Receiver-operating characteristic (ROC) curve analysis showed that with a 15.6-fold increase in laminin beta2 mRNA expression as cut-off point, the presence of CsA toxicity could be predicted with an 87% sensitivity and an 88% specificity. CONCLUSION: Renal laminin beta2 and TGF-beta mRNA levels can be used to differentiate between chronic rejection and chronic CsA toxicity in renal transplants. The method of mRNA quantification might be applicable as an additional diagnostic tool in clinical practice.

Conversion from cyclosporine to azathioprine at three months reduces the incidence of chronic allograft nephropathy.

BACKGROUND: Conversion from cyclosporine to azathioprine after renal transplantation has been shown to be beneficial in terms of allograft function, cardiovascular risk factor profile, and the incidence of gout. A higher incidence of acute rejection, however, has also been reported and uncertainty still exists about the long-term outcome after conversion. We report on the extended follow-up of an open-label, randomized trial that examined conversion to azathioprine as early as three months after transplantation. METHODS: One hundred twenty-eight patients were enrolled in this single-center study. Three months after transplantation they were randomly assigned to continue cyclosporine treatment (N = 68), or they were converted to azathioprine (N = 60). The steroid dose was temporarily increased in the patients who were converted. RESULTS: Patient survival was not different in the two groups. Graft survival tended to be lower (64.7% vs. 76.5% at 15 years) in the cyclosporine continuation group (P = 0.14) when data were analyzed on an intention to treat basis. The graft survival of the patients that stayed on their assigned treatment was significantly higher in the azathioprine arm, starting at two years' post-transplantation. The glomerular filtration rate was significantly higher in the patients who were converted to azathioprine. More allograft biopsies were taken from patients remaining on cyclosporine for suspicion of cyclosporine-related nephrotoxicity and prompted a high rate of late conversions (19%). The relative risk of chronic allograft nephropathy was significantly higher in the group that continued cyclosporine [relative risk, 4.3 (95% CI, 1.4 to 12.9); P = 0.009]. Conversion to azathioprine reduced the need of blood pressure and lipid-lowering drugs. CONCLUSION: Conversion to a calcineurin inhibitor-free immunosuppressive regiment three months after renal transplantation improved allograft function, reduced the need of cardiovascular risk factor-controlling medication, and reduced the incidence of chronic allograft nephropathy.

Early interstitial accumulation of collagen type I discriminates chronic rejection from chronic cyclosporine nephrotoxicity.

Little is known regarding the composition of the interstitial extracellular matrix of kidney allografts with deteriorating function. Collagen I, III, and IV, the collagen IV alpha3 chain, and the laminin beta2 chain were investigated in biopsies of allografted kidneys with chronic cyclosporine A nephrotoxicity (CsAT) (n = 17), chronic rejection (CR) (n = 12), or chronic allograft nephropathy (CAN) (n = 19). alpha-Smooth muscle actin expression was also examined. Normal native kidneys were used as control samples (n = 11). Biopsy samples were studied with routine light microscopy and immunostaining. The mean interstitial fibrosis scores were significantly higher for the CR and CAN groups, compared with the chronic CsAT group. The cortical tubulointerstitial areas of the CR and CAN groups, but not the chronic CsAT group, contained more collagen I than did normal control samples. Differences were noted even in biopsies with mild fibrosis. Accumulation of collagen III, IV, and IV alpha3 was increased in all patient groups. Collagen III accumulation was greater in the CR and CAN groups than in the chronic CsAT group. Receiver-operating characteristic curve analysis demonstrated that collagen I staining had the best discriminatory value in differentiating CR from chronic CsAT, with a sensitivity of 63% and a specificity of 94% at a cutoff value of 19%. Laminin beta2 staining did not differentiate CR from CsAT. Increased alpha-smooth muscle actin staining did not differ among the three groups. It was concluded that, during chronic CsAT, collagen III and IV were preferentially accumulated in the tubulointerstitium. Early increases in the deposition of collagen I, with collagen III and IV, were more specific for CR. CR seems to elicit a more pronounced fibrotic response than does chronic CsAT.

Renal tubular epithelial cell death and cyclosporin A.

BACKGROUND: The pathogenesis of chronic cyclosporin A (CsA) nephrotoxicity is largely unknown. In this study we examined whether CsA produces cell death through necrosis or apoptosis of either cultured human proximal tubular epithelial cells (PTEC) or the porcine tubular cell line LLC-PK(1). METHODS: Primary isolates of human PTEC and LLC-PK(1) cells were treated for various time periods with CsA at concentrations of 0.01-100 microg/ml. Apoptosis was studied by the assessment of annexin binding and propidium iodide uptake, the measurement of cellular DNA content and cell cycle analysis, and by the evaluation of nuclear morphology. Cell death was studied by the trypan blue exclusion method. Hypoxic conditions were simulated through chemical ATP depletion. RESULTS: In human PTEC, cell death was observed at CsA concentrations higher than 10 microg/ml; at these concentrations PTEC died as a result of necrosis and the toxicity of its vehicle Cremophore EL, and not as a result of CsA inducing apoptosis. The addition of cycloheximide to relieve a possible block in the apoptotic process had no effect on human PTEC, but did result in apoptosis of LLC-PK(1). In human PTEC, CsA did not augment cell death induced by chemical ATP depletion. CONCLUSIONS: The results of this in vitro study do not support the hypothesis that CsA directly induces cell death of proximal tubular epithelial cells.