Intrarenal gene expression of proinflammatory chemokines and cytokines in chronic proteinuric glomerulopathies.

Proteinuria has been recently shown to be an independent risk factor for the progression of chronic nephropathies, but the actual mechanisms by which urinary protein load damages renal tissue in humans remain unsolved. Using real-time RT-PCR method we evaluated intrarenal mRNA expression of various cytokines and chemokines in patients with biopsy-proven IgA nephropathy (IgAN, n=11), membranous nephropathy (MN, n=6) and focal and segmental glomerulosclerosis (FSGS, n=6) who exhibited proteinuria over 0.5 g/day. There was a significant positive correlation between the proteinuria extent and the intrarenal RANTES (regulated upon activation normal T cell expressed and secreted) mRNA expression in patients with IgAN, a similar trend was also observed in patients with MN and FSGS. There were no clear relationships between the proteinuria and intrarenal mRNA expression of tumor necrosis factor alpha, transforming growth factor beta1 and monocyte chemoattractant peptide-1. There were no differences in the pattern of cytokine mRNA expression between different glomerulopathies. In conclusion, our results support the hypothesis that lymphocytes, macrophages and their products provoke tissue injury in response to proteinuria independently of the nature of renal diseases in man.

[Post-transplantation lymphoproliferation in patients with intensive immunosuppression]. / Posttransplantacní lymfoproliferace u nemocného s intenzivní imunosupresí: kazuistika.

Organ allograft recipients are at higher risk for malignancies development. This risk is known to be different in different types of tumours. Skin cancers and lymphoproliferative disorders have been described to be ones the most frequent (comprising 15-25% of all malignancies). Here, we present the case of expansive formation localized near the renal allograft in patient, whose native kidneys failed as a consequence of long-term cyclosporine A therapy after orthotopic heart transplantation. The maintenance immunosuppression consisted of combination of cyclosporine A, mycophenolate mofetil and steroids. The expansion offside of transplanted kidney was detected by routine ultrasound examination. After indifferent neurological symptoms, sepsis, and then multiorgan failure occured. Shortly after acute surgery patient died. Autopsy and histopathology showed lymphoproliferative disorder--mo- nomorphic type of posttransplant lymphoproliferative disorder (PTLD). Occurence of PTLD in organ transplantation is discussed.

TGF-beta1 mRNA upregulation influences chronic renal allograft dysfunction.

Acute rejection (AR) is a dominant risk factor for developing chronic allograft nephropathy (CAN) after kidney transplantation. CAN is characterized by progressive interstitial fibrosis. It has been associated with increased transforming growth factor (TGF)-beta1 expression, however, kinetic studies are absent. We investigated whether intragraft TGF-beta1 expression in various causes of early graft dysfunction may influence late renal allograft dysfunction. A total of 174 human renal biopsies were quantified for TGF-beta1 mRNA expression using real-time reverse transcriptase-polymerase chain reaction. Expression levels were correlated with the Banff histopathological grades, TGF-beta1 immunohistology, and clinical follow-up. TGF-beta1 was most markedly upregulated in AR, CAN, and acute tubular necrosis - delayed graft function compared to non-rejecting controls (P < 0.001). TGF-beta1 expression was heightened in borderline changes (P < 0.01), recurrence of glomerulonephritis, and cyclosporine toxicity (P < 0.05). There was no correlation between intragraft TGF-beta1 expression during AR and short-term outcome of a rejection episode. TGF-beta1 gene overexpression during CAN has been shown to be associated with the increased risk for renal allograft dysfunction 18 months after biopsy (odds ratios 9.9 vs 3.2, respectively). Intragraft TGF-beta1 mRNA expression is significantly upregulated in both AR and CAN. Thus, our results support the hypothesis that TGF-beta1 might play a key role in chronic allograft dysfunction.

Cytokines and chemokine gene expression in human kidney transplantation.

Despite advances in immunosuppression in past decades, allograft rejection remains the main reason for kidney graft failure. Recently, despite great improvements in understanding of molecular basis of allograft rejections, renal histology remains the primary method to monitor the onset of graft rejection. The aim of the present study was to ascertain whether cytokine and chemokine expression profiles in kidney allografts contributed to the diagnosis of graft dysfunction. We analyzed mRNA expression in 174 kidney graft biopsies for the following cytokines: TGF-beta1, TNF-alpha, IL-10, and chemokine RANTES. Based on the expression levels obtained by real-time RT-PCR, we correlated data with the results of morphologic examinations. All tested cytokines and chemokines were upregulated (P < .001) during acute rejection compared to nonrejecting controls. Upregulation was also found in chronic allograft nephropathy (CAN) group for TGF-beta1, IL-10 (P < .001), TNF-alpha, and RANTES (P < .01). Upregulated expression of IL-10 (P < .001), TGF-beta1, (P < .01) and RANTES (P < .05) showed borderline changes. Higher expression levels (P < .001) of TGF-beta1 and IL-10 were also found during ATN. IL-10 was upregulated (P < .01) in specimens with recurrent glomerulonephritis. Weakly increased (P < .05) expressions of TGF-beta1 were found during CsA toxicity. Distinctive expression levels between acute rejection and CAN were only found for IL-10 (P < .01). TNF-alpha showed a different expression profile in acute rejection versus ATN (P < .001). These findings suggest that distinct cytokine and chemokine expression profiles in grafts may contribute to the diagnosis for and elucidation of the immunopathologic process during graft dysfunction.

Effect of cytokines and chemokines (TGF-beta, TNF-alpha, IL-6, IL-10, MCP-1, RANTES) gene polymorphisms in kidney recipients on posttransplantation outcome: influence of donor-recipient match.

Posttransplantation alloantigen-dependent and alloantigen-independent processes are both mediated by cytokines and chemokines. Recently cytokines and chemokines, as well as their receptors, have been shown to be highly polymorphic. The cytokine and chemokine gene polymorphisms are associated with variable production, activity, expression, or ligand-receptor affinity. The aim of our study was to analyze the relation between selected cytokine and chemokine gene polymorphisms in kidney donors and recipients as a function of donor-recipient match and posttransplantation outcome. Polymorphisms transforming growth factor-beta (TGF-beta); tumor necrosis factor-alpha (TNF-alpha); interleukin (IL)-6, and IL-10; monocyte chemoattractant protein-1 (MCP-1); and RANTES (regulated upon activation, normal T-cell expressed and secreted) genes were determined using DNA polymerase chain reaction technology in 268 healthy volunteers, 345 kidney transplant recipients (1997 to 1999), and 298 cadaveric donors. Patients were followed up for 4 to 6 years. The distribution of alleles of selected genes was identical in control subjects, cadaveric donors, and recipients. Low TGF-beta production in both the donor and recipient genotypes was associated with risk for early rejection (6 months) and worse graft function at 4 years. The only tendency for worse graft outcome was observed among donor-recipient combinations mismatched for TGF-beta genotype. Genetic determination of TNF-alpha and IL-10 production was associated with delayed graft function and rejection. IL-6 gene polymorphisms had no effect on the incidence of early acute rejections, but was associated with worse 5-year outcomes. Determinations of MCP-1 overproduction and RANTES-109 TT allele were associated with significant deterioration of graft function. Our data support the hypothesis that the strength of the alloimmune response after transplantation is in part genetically determined. Donor-recipient matching of cytokine gene polymorphisms has a marginal effect.

[Ischemia of the large intestine after simultaneous kidney transplantation and aortic replacement with a fresh graft in an abdominal aortic aneurysm]. / Ischemie tlustého streva po soucasné transplantaci ledviny a náhrade výdute brisní aorty cerstvým tepenným stepem.

Fresh arterial grafts obtained during multi-organ excisions widen a spectrum of treatment possibilities for obliterating arterial disorders of low extremities or for the abdominal aortic aneurysm in patients waiting for organ transplantation. Between the year 1998 and the end of the year 2002, our work-team performed parallel reconstructions of the abdominal aorta using fresh grafts and cadaverous kidney transplantations in a group of five patients. The simultaneous surgical treatment of the both disorders during a single hospitalization as well as a considerable decrease of the artificial blood vessel prosthesis infection risk during chronic imunosuppression, represent the biggest advantage of this method. On the other hand, the risk of possible surgical complications is increased in these patients. During the operation and postoperation period, our four patients suffered from no serious complications. In case of one patient, ischemic colitis occurred which required surgical revision and subtotal colectomy. In this article, the authors describe the postoperation course of the patient condition with the above complication, which required a close cooperation of surgeons, anesthesiologists and nephrologists, in full detail.

[Initial experience with protocol biopsies in transplanted kidneys]. / Nase první zkusenosti s protokolární biopsií transplantovaných ledvin.

BACKGROUND: The aim of protocol biopsy after renal transplantation was to assess the prevalence of chronic allograft nephropathy (CTN) and to correlate the degree of CTN with clinical and laboratory data. METHODS AND RESULTS: In 105 patients with a stabilized graft function, a protocol biopsy was carried out at 1 year after transplantation. CAN was found in 75% of patients, and in 6% an acute subclinical rejection was revealed. Statistically significant correlation was confirmed between CAN and recipient's age, development of acute rejection in the first year posttransplant, serum creatinine, clearance of creatinine, and proteinuria. There was no significant difference in CAN degree distribution between patients treated with cyclosporine-A or with tacrolimus. Twelve months after the biopsy, there was no significant change in kidney graft function. In patients treated with tacrolimus, cholesterol and triglycerides levels were significantly lower than in cyclosporine treated patients Over the next year, these values significantly decreased in both subgroups. CONCLUSIONS: The CAN was found in the majority of protocol biopsies at 1 year after kidney transplantation; subclinical acute rejection was revealed rarely.

TGF-beta1 expression and chronic allograft nephropathy in protocol kidney graft biopsy.

Chronic allograft nephropathy (CAN) represents a frequent and irreversible cause of long-term renal graft loss. TGF-beta1 is a key profibrogenic cytokine associated with CAN pathogenesis. Because of clinical diagnostic inaccuracy, protocol biopsy has been suggested to be a beneficial method for early CAN detection. Protocol core biopsy was carried out in 67 consecutive cyclosporine-based immunosuppression-treated kidney transplant recipients with stable renal function 12 months after renal transplantation. Biopsy specimens were analyzed morphologically according to Banff-97' criteria and immunohistologically for TGF-beta1 staining. The data obtained were correlated with plasma TGF-beta1 levels and clinical data. CAN (grade I-III) was found in 51 patients (76 %). CAN grade I was found to be the most frequent one (44 %). A normal finding within the graft was made in only 12 patients (18 %). Clinically silent acute rejection Banff IA was present in 4 patients (6 %). In 8 patients (12 %) with CAN, borderline changes were present. We found a significant correlation between CAN grade and creatinine clearance, as measured by the Cockroft-Gault formula (p<0.01) as well as body mass index (p<0.01). There was a significant correlation between chronic vasculopathy (Banff cv) and creatinine clearance, and between the degree of TGF-beta1 staining and chronic vasculopathy (p<0.01). There were no relations between morphological findings and TGF-beta1 plasma levels, cyclosporine levels, plasma lipids, HLA-mismatches, panel reactive antibodies (PRA), proteinuria, and the donor's age. In conclusion, CAN is a frequent finding in protocol kidney graft biopsies 12 months after transplantation. TGF-beta1 tissue expression is linked with chronic vasculopathy.

[An unusual manifestation of tuberculosis in a female patient after kidney transplantation. Case report]. / Neobvyklá manifestace tuberkulózy u nemocné po transplantaci ledviny. Kazuistika.

Organ transplant recipients are at the increased risk of infection complications. Herein, we present a case of unusual localisation of tuberculosis in renal allograft recipient treated by combination of cyclosporine A, mycophenolate mofetil and steroids. After the non specific prodromes, surgery due to ileus discovered ileocaecal tumour. Microscopically tuberculosis inflammatory process with ulcerations of the intestinal mucosa and classification of the lymphatic nodes, instead of the expected lymphoma was proved to be present. We are discussing the incidence of tuberculosis in relation to immunosuppressive therapy as well as possible pathways of tuberculosis transmission.

Cytotoxic effector molecule gene expression in acute renal allograft rejection: correlation with clinical outcome; histopathology and function of the allograft.

BACKGROUND: Cytotoxic effector molecule expression in human renal allograft biopsies has been closely associated with acute rejection. Here we studied whether intragraft expression of perforin, granzyme B, and Fas ligand correlates with long-term clinical outcome of acute rejection episodes. Furthermore, we examined the relation to histopathology and function of the allograft during rejection. METHODS: Twenty-two human renal biopsies were quantified for mRNA expression of perforin, granzyme B, Fas ligand, and Fas with reverse transcription-polymerase chain reaction. Expression levels were correlated with clinical outcome after 12 months, Banff rejection grades, and allograft function in the course of acute rejection. RESULTS: Only Fas ligand, but not perforin or granzyme B, showed significantly higher up-regulation in seven samples with therapy-resistant acute rejections versus eight samples with therapy-sensitive acute rejection. We found no relation between cytotoxic marker expression and Banff rejection grades or serum creatinine peak levels. CONCLUSIONS: Fas ligand may be useful as an early marker of therapy-resistant acute rejection. Cells that express Fas ligand but not classical soluble cytotoxic molecules might influence clinical outcome of acute rejection episodes.

[The urinary tract in graft recipients and urologic complications after kidney transplantation]. / Vývodné mocové cesty príjemce a urologické komplikace po transplantaci ledviny.

BACKGROUND: Urological complications after renal transplantation condition reduce graft survival and function. It may be assumed that an important part, in addition to technical factors during removal and implantation of the organ may be played also by factors of the recipient. The authors investigated whether in the development of some urological complications (urinary fistulae and urinary tract dilatation) also pathological changes of the urinary tract of the recipient, kidney diseases leading to renal failure or the development of urinary flow rate during the first days after transplantation of the kidney participate. METHODS AND RESULTS: The authors investigated 77 patients after renal transplantation where during the period from Jan. 1992 till Dec. 1996 a urinary fistula developed (42 cases), dilatation of the urinary tract (32) or both complications (3). The control group was formed by 100 patients without urological complications who did not differ as to demographic data, basic immunosuppressive treatment and who had transplantations during the same period and by the same surgical techniques. The assembled data were evaluated statistically, the two groups being compared by means of t-test, chi 2 test and the non-parametric Mann-Whitney test resp. The authors investigated factors which might participate in the quality of the recipient urinary tract, in particular the recipient's age. In the group of urologically complicated cases there were significantly (p < 0.05) more patients above 55 years. There were also more males (67.5% vs. 32.5%, p < 0.05). In further factors such as the ratio of BMI ratio or the underlying kidney disease leading to renal failure and the presence of diabetes mellitus the authors did not record significant differences. The residual urinary flow rate, duration of dialysis treatment before transplantation and the number of transplantations did not differ significantly. The authors tried to evaluate the possible influence of urinary flow rate on the development of urological complications after transplantation of the kidney. CONCLUSIONS: The assembled findings support the idea that the development of a urinary fistula or dilatation of the urinary tract were not significantly influenced by changes in the urinary tract of the recipient conditioned by the period of the reduced function, as may be assumed on the basis of the time of dialysis treatment. The development of the investigated urological complications was not significantly influenced by the presence of underlying kidney diseases nor by increased urinary flow rate during the first days after transplantation. The authors did not confirm the risk of re-transplantation. An significant effect on the development of urological complications could be exerted by male sex and age above 55 years.

ACE gene polymorphism and long-term renal graft function.

OBJECTIVES: The long-term outcome of transplanted kidneys has not changed substantially and only a minority of grafts survives more than 15 yr. The aim of this study was to determine the influence of ACE gene polymorphism on long-term outcome after renal transplantation. DESIGN AND METHODS: Using PCR, we evaluated ACE I/D gene polymorphism in a group of patients with long-term graft function (LTF) over 15 yr and compared it with control groups of transplant recipients and population sample. RESULTS: The distribution of genotypes in the LTF group differed from transplant controls (p < 0.05). Moreover, DD homozygotes in the LTF group had better creatinine clearance (DD: 1.1 +/- 0.3, ID: 0.96 +/- 0.3, II: 0.76 +/- 0.3 mL/s; p < 0.05). There were no differences in genotype distribution between transplant and population samples. CONCLUSIONS: Results of our study have demonstrated a possible connection between the DD variant of ACE I/D gene polymorphism and excellent long-term graft function.

TGF-beta I gene polymorphism in heart transplant recipients--effect on renal function.

Renal dysfunction is a severe late complication of heart transplantation (HTx). Transforming growth factor beta I (TGF beta I) is a potent multifunctional cytokine with profibrogeneic effect. TGF beta I gene polymorphism correlates with cytokine production. In the present study, we looked for a predictor of renal insufficiency after HTx. In 175 HTx pts and 268 controls, polymorphism in the signal peptide of the TGF beta gene, substitution of leucine-proline at codon 10 and arginine-proline at codon 25, was evaluated by PCR. Renal function was followed after HTx and was compared with the TGF beta I genotypes. There were no differences in the frequencies of alleles and genotypes of TGF beta I gene in the healthy population and HTx recipients; TGF beta I genotype distribution in recipients with ischemic heart disease and dilated cardiomyopathy was almost identical. Renal function was decreasing in most HTx recipients with time. Progression of renal insufficiency (RI) was worse in patients with Leu at codon 10 (LeuLeu vs. LeuPro p < 0.01, LeuLeu vs. ProPro; p < 0.01). RI progression was also more pronounced in individuals homozygous at codon 25 (ArgArg vs. ArgPro; p < 0.01). In individuals heterozygous at codon 10 (LeuPro), the genotype at codon 25 determined the progression of RI (LeuPro/ArgArg vs. LeuPro/ArgPro; p < 0.05). In our study, we have demonstrated the prognostic significance of TGF beta I gene polymorphism for renal insufficiency in heart transplant recipients.

Characterization of patient antibodies after kidney transplantation.

OBJECTIVE: The aim of this study was to characterize patient antibodies before and after cadaver and/or living-donor kidney transplantation and to correlate these data with the clinical course after transplantation. METHODS: Sera from 69 cadaver, 9 living-related and 2 patients waiting for living-donor kidney transplantation were analyzed by the complement dependent cytotoxicity (CDC) test, flow cytometry (FCXM) and ELISA. RESULTS: FCXM revealed that 15.0% of patients before transplantation and 16.7% after transplantation had antibodies to donor cells. 10.3% patients were positive before and after transplantation (+/+), while 6.8% developed antibodies early after transplantation (-/+). Analysis of the specificity of those antibodies by ELISA showed that it was directed to: 1) mismatched donor HLA antigens 2) antigens belonging to the same cross-reacting group (CREG) as the mismatched donor antigens 3) HLA antigens not expressed by donor cells or, probably, to non-HLA antigens. CONCLUSION: Anti-HLA antibodies were detected in patients before and after transplantation and in most cases their anti-HLA specificity could be determined. Fast and precise characterization of antibodies in patients before and after transplantation can be performed by both sensitive methods--FCXM and ELISA--which may help predict the onset of immunological complications and, consequently, improve the prognosis after organ transplantation.

Urinary tract infection in patients with urological complications after renal transplantation with respect to long-term function and allograft survival.

Urological complications after renal transplantation (urinary fistula, urinary tract dilatation) are frequently associated with urinary tract infections (UTI). We tried to analyse whether urinary tract infection was one of the factors which participated in the lower allograft survival rates and reduced allograft function in urologically complicated (UC) patients. We observed 77 patients after renal transplantation (Tx) of whom 42 had urinary fistula, 32 had urinary tract dilatation a 3 had both complications (I/1992-XII/1996). 100 patients without urological complications represented a control group (N). Obtained data was statistically evaluated using t-test, chi 2-test, correlation analysis. Graft and patient survival rates were assessed using the Kaplan-Meier method. We have found that UC patients after Tx had a worse renal function compared with patients not suffering from this complication. Using Kaplan-Meier methods we have found that graft survival rate in patients with UC is significantly lower than that in the control group (5-year graft survival 0.6 vs 0.82, p < 0.01). On the other hand there were no differences in the 5-year patients survival rate between the followed groups of patients (0.74 vs 0.83). There was no significant correlation between predicted creatinine clearance and followed indicators of UTI--total time of positive urine bacterial cultivation, number of infectious periods and total time of antibiotic therapy. There were no significant differences in graft survival during 5 years between patients with UTI and without UTI. Our results suggest that patients with UC are at increased risk of urinary tract infection. Our findings are in keeping with the assumption that UTI in patients with UC do not significantly participate in the decreased level of graft function and the shorter graft survival rates.

MRP 8/14 and procalcitonin serum levels in organ transplantations.

OBJECTIVES: MRP8/14 is a heterodimer of two myeloid calcium-binding proteins associated with different types of acute inflammatory processes. We studied MRP8/14 together with procalcitonin (PCT) serum levels in order to diagnose infectious complications or the rejection process affecting kidney or heart allograft. METHODS: A total of 419 serum samples was evaluated. MRP8/14 levels were measured by ELISA (BMA Biomed), PCT by a sensitive immunoluminiscent assay ILMA (Brahms Diagn.) RESULTS: Both parameters showed very low basal levels in healthy subjects (range 303-1,660 ng/ml of MRP8/14; less than 0.08 ng/ml of PCT). A rapid increase in serum levels occurred in response to bacterial infections (MRP8/14 up to 6,230 ng/ml; PCT up to 297 ng/ml). Serum PCT concentration remained low in the presence of kidney allograft rejection, where MRP8/14 levels were increased. An uncomplicated outcome of kidney or heart transplantation did not change basal serum MRP8/14 and PCT levels. CONCLUSIONS: We conclude that 1) both MRP8/14 and PCT are very sensitive markers of complications in organ transplant recipients (normal values in uncomplicated outcome) 2) combination of both parameters is useful to discriminate between rejection (increased MRP8/14 with normal PCT) and systemic bacterial infection (both parameters increased).

[Chronic renal allograft rejection. Part 2. Therapeutic possibilities] . / Chronická rejekce renálního allostepu. Cást 2. Terapeutické moznosti.

Chronic rejection represents an important cause of renal allograft loss in the long term follow up. New insights into etiopathogenesis of the chronic rejection offer possibilities for experimental therapy. Novel immunosuppressants, such as mycophenolic acid, tacrolimus or rapamycin as well as lipid lowering drugs, angiotensin-converting enzyme inhibitors or AT-1 receptor blockers, may reduce of effects the risk factors on the progression of chronic rejection. In the future, gene therapy may offer additional possibilities to prevent chronic rejection. This review deals with possibilities of prevention of the chronic renal allograft rejection based on experimental evidences and current therapeutic concepts and puts these options into a rational perspective.