Clinical treatment and management of invasive fungal disease in recipients of solid organ transplantation / 器官移植

With widespread application of solid organ transplantation (SOT), the incidence of postoperative invasive fungal disease (IFD) in SOT recipients has been increased year by year. In recent years, the awareness of preventive antifungal therapy for SOT recipients has been gradually strengthened. However, the problem of fungal resistance has also emerged, leading to unsatisfactory efficacy of original standardized antifungal regimens. Drug-drug interaction and hepatorenal toxicity induced by drugs are also challenges facing clinicians. In this article, the characteristics of drug-drug interaction and hepatorenal toxicity among triazole, echinocandin and polyene antifungal drugs and immunosuppressants were reviewed, and postoperative preventive strategies for IFD in different types of SOT recipients and treatment strategies for IFD caused by infection of different pathogens were summarized, aiming to provide reference for physicians in organ transplantation and related disciplines.

Research progress on determination of intracellular concentration of immunosuppressant / 器官移植

Currently, extracellular concentration measurement is the major approach of therapeutic drug monitoring (TDM) of clinical immunosuppressant in organ transplantation. Its correlation with the efficacy of immunosuppressant remains elusive. With widespread application of liquid chromatography, the detection technology of intracellular concentration of immunosuppressant is gradually mature. Theoretically, it may more accurately reflect the efficacy of immunosuppressant due to that the level of drug exposure in target cells can be directly measured. In this article, the history and present situation of the determination of intracellular concentration of immunosuppressant were summarized, and the association between the determination methods of intracellular concentration of immunosuppressant and drug efficacy was emphatically analyzed. Detection of intracellular concentration of immunosuppressant possesses better application value in clinical practice, which is worthy of promotion in clinical settings.

Negative regulation on allograft immune response induced with up-regulated expression of IDO mediated by 3,4-DAA / 中华器官移植杂志

Objective To investigate role of N-(30,40-dimethoxycinnamonyl) anthranilic acid (3,4-DAA) in mediating the negative immune regulation by indoleamine 2,3-dioxygenase in mice skin transplantation.Method The mice skin transplant model was established.T lymphocytes were isolated from mice splenocytes,and serum was collected.ELISA was applied to detect the IL-2 and IFN-γ concentrations in culture supernates of mice spleen lymphocytes and serum.Flow cytometry was applied to examine the phenotypes of T lymphocytes and RT-PCR to analyze the IDO mRNA transcription.Results T lymphocyte proliferation was significantly decreased by 3,4-DAA and the concentrations of IL-2 and IFN-γ were apparently decreased in 3,4-DAA group as compared with those in control group.The percentages of CD3 +,CD4 + and CD8 + T lymphocytes were lower,and the percentage of CD4 + CD25 + T lymphocytes was higher in 3,4-DAA disposal group than in control group,but there was no significant difference.IDO mRNA expression showed obvious increase in 3,4-DAA group as compared with control group.Conclusion 3,4-DAA can up-regulate the IDO expression to induce the increasing metabolism of tryptophan,subsequently inhibiting T cell proliferation and showing specific property of negative immune regulation.

Intravenous immunoglobin for treating pneumonia following kidney transplantation / 中华器官移植杂志

Objective To investigate the adjunctive therapeutic effects and safety of intravenous immunoglobin (IVIG) for treating pneumonia following kidney transplantation.Methods Sixteen cases of pulmonary infection after kidney transplantation were divided into two groups.Twenty-eight cases were subjected to IVIG therapy (0.2 g·kg-1 ·day-1) for 7-10 days besides the standard specific anti-bacterial,anti-fungal,and anti-virus treatment and regular immunosuppressive regimen with dose adjustment (IVIG group),and the control group was only treated with standard specific anti-pathogen therapy.The incidence and mortality ofsevere pulmonary infection,levels of serum IgG,T lymphocyte subsets,and creatinine in the two groups were observed.Results The effective power of IVIG group and control group was 100 ％ and 93.75 ％ (P＜0.05).The incidence of severe pneumonia in IVIG and control groups was 0 and 12.5％,respectively (P＜0.05),with the mortality being 0 and 6.25％,respectively (P＜ 0.05).The levels of serum IgG were significantly increased in IVIG group as compared with that before treatment and in control group.There were no significant adverse reactions associated with IVIG infusion.Conclusion As an adjunctive therapy,IVIG treatment for pulmonary infection can reduce the incidence of severe pulmonary infection and mortality after kidney transplantation,further increase the survival rate of patients after kidney transplantation.

Protective effects of sinomenine on renal ischemia/reperfusion injury in mice / 中华器官移植杂志

Objective To evaluate the protective effect of sinomenine (SIN) on renal ischemia/reperfusion (I/R) in mice. Methods In the experiment one, 12 C57BL/6 mice were randomly divided into 2 groups: SIN group (mice were injected with 200 mg/kg SIN by tail vein) and control group (mice were injected with equal volume of saline). Six and 24 hs later, the serum was collected and the contents of alanine aminotransferase (ALT) and creatinine (SCr) were determined. In the experiment two, C57BL/6 mice were randomly divided into 3 groups: sham-operated (SO) group, SIN group (mice were injected with 200 mg/kg sinomenine just before ischemia induction) and saline group (mice were injected with equal volume of saline at the same time). At the 6th h after reperfusion, the sera and renal samples subject to IR injury were collected. The SCr and BUN levels in serum were determined and renal histological changes were also examined. The apoptosis of renal tubular epithelial cells was measured by using terminal deoxynucleotidyl transferase mediated dUTP nick end labeling assay. The infiltration of F4/80 positive macrophages was measured by using immunohistochemistry and that of neutrophils with myeloperoxidase (MPO) kits. The mRNA expression of tumor necrosis factor (TNF)-α, chemokine CXC ligand (CXCL)-10, intercellular adhesion molecule (ICAM)-1 and IL-17 was detected by using real-time reverse transcription PCR. The activation of transcription factor NF-κB was measured by using Western blotting. Results In the experiment one, there was no significant difference in ALT and SCr between the two groups at 6 or 24 h. In the experiment two,levels of SCr and BUN were lower in SIN group (P＜0. 05 or P＜0. 01 ), histological damage was milder (P＜0. 01 ), and apoptosis rate of renal tubular epithelial cells apoptosis was lower than in saline group (P＜0. 05). The infiltration of macrophages, neutrophils and the mRNA expression of TNF-α, CXCL-10, ICAM-1 and IL-17 in the renal tissue in SIN group were reduced as compared with saline group (P＜0. 05 or P＜0. 01 ). The activation of NF-κB in SIN group was significantly downregulated as compared with saline group. Conclusion SIN can ameliorate the renal IR injury without hepatic or renal toxicity, which is associated with inhibition of acute inflammatory response induced by reperfusion.

Long term survival improved by optimization of immunosuppression strategy in renal transplant ecepients: a single center experience / 中华器官移植杂志

Objective To investigate the influence of immunosuppression strategy optimization on the outcomes of the renal transplant recipients in the last decades. Methods Data from 404 renal transplant recipients from Jan. 1st, 2001 to Dec. 31st, 2010 were analyzed retrospectively. The patients were divided into early transplant group (n = 260) and late transplant group (n= 144). The change of immunosuppression strategy included a low dose antithymoglobin (ATG) induction, a quick corticosteroid reduction and mycophenolate mofetil therapeutic monitoring with calcineurin inhibitor minimization. Recipients' gender,age, donor type, induction therapy, immunosuppression regime, occurrences of biopsy-proven acute rejection (BPAR), severe pulmonary infection and patient/allograft survival were compared between groups. A Cox regression model was used to investigate the factors that influenced the allograft survival. Results The follow-up rate was 98. 3 % in this study. The median follow-up period was 65 month (1-112 months). The proportion of ATG induction in late transplant group was significantly higher than in early transplant group (78. 5 % versus 31. 9 %, P<0. 01). The severe pulmonary infection rate was lower in late transplant group, while the BPAR rate was comparable between two groups. The allograft survival rate was significantly higher in late transplant group. Severe pulmonary infection was correlated with patient/allograft survival in Cox regression model. Conclusion The improvement of outcome in renal transplant recipients in our center is related to the optimization of immunosuppression strategy that reduces the severe pulmonary infection rate with no increase in BPAR.

Adcances in CpG oligodeoxynucleotides in the cancer immunotherapy / 肿瘤

CpG oligodeoxynucleotides (ODN) have potent immunostimulatory effects and can enhance the anti-cancer activity of cancer treatments. CpG ODN directly induced the activation and maturation of plasmacytoid dendritic cells, stimulated the secretion of Th1-type cytokines, and enhanced the differentiation of B cells into antibody-secreting plasma cells. CpG oligodeoxynucleotides as vaccine adjuvants can enhance both the humoral and cellular responses to antigens in some clinical trails. CpG ODN was applied in several clinical trials as an adjuvant of tumor vaccine. CpG ODN alone had anti-tumor activity and had synergistic effects with other anti-tumor therapies including monoclonal antibodies, chemotherapy, radiotherapy, cytokines, etc. Compared with standard regimen, in the phase Ⅲ clinical trial CpG ODN did not prolong the median survival time and induced severe adverse reaction in the treatment of ⅢB-Ⅳ stage non-small cell lung cancer. But CpG ODN had definite anti-cancer activity in other clinical trials. The safety and efficacy of CpG ODN in anti-tumor therapy needs to be further verified in clinic.

Multidrug resistance 1 gene polymorphism affects early mycophenolate mofetil exposure in Chinese renal transplant recipients / 中华器官移植杂志

Objective To investigate the relationship between the polymorphism of human multidrug resistance 1 gene(MDR1)polymorphism and early MMF pharmacokinetics.Methods Twenty-eight Chinese primary renal transplant recipients were emrolled.On day 14 post-transplant,patients took the MMF orally on fast.Whole blood samples(2 ml)were obtained at the following time points:predose(G0)and 0.5,1,1.5,2,4,6,8,10 and 12 h(C0.5,C1,C1.5,G2,C4,C6,C8,C10,C12,respectively)postdose during the dosing interval.The MPA plasrna concentration was assayed by high performance liquid chromatography (HPLC).Pharmacokinetie parameters were determined by WINNOLIN 3.1.Three major single nucleotide polymorphisrrls(SNP),C1236 T,G2677 T/A,C3435 T of MDR1 were analyzed by PCR-RFLP.Pharmacokinetie parameters of MPA were compared between different MDR1 genotype and haplotype groups.Ailele frenqueneis were also compared in high(MPA area under concentratation-time curve 0～12 h,frequencies of 1236 TT,2677 TT/AA,3435 TT in three major MDR1 SNP positions,exons 12,21 and 26,were 0.368,0.184 and 0.211,respectively.MPA AUC was significantly higher in 1236 TT group than in 1236 CC/CT group(65.36±11.51 vs 53.33±13.77,P=0.032).On C1236 T SNP,TT genotype frequency showed significant difference between MPA high and low exposure groups(66.7%vs 15.4%,P=0.013,OR=2.526).T allele frequency was marginally higher in MPA high exposure group than that in low exposure group(83.3%vs 53.3%,P=0.072).Conclusion TT genotype on 1236 of MDR1 indicates a risk of early high exposure to MPA in Chinese renal transplant patients given by oral MMF,

Influence of matrix effect upon cyclosporine A test by fluorescence polarization immunoassay and enzyme-multiplied immunoassay technique methods / 中华检验医学杂志

Objective To explore the matrix effect on cyclosporine A (CsA) test by fluorescence polarization immunoassay (FPIA) and enzyme-multiplied immunoassay technique (EMIT), explain the discrepancy of external quality control results between these two methods and find the corrective action.Methods One hundred whole blood samples with various concentrations were adopted and CsA levels were detected by FPIA and EMIT.The results were compared with each other.Moreover, the influence of residual metal ions upon immunoreactions was assessed by adding Cu2+ and Zn2+.The effect of non-whole blood matrix on extraction efficiency for quality control materials and CsA calibrator was evaluated by adding identical volume of Hb-rich reagents followed with re-extraction.Results There is good correlation between results measured with FPIA(X) and EMIT(Y) methods ( Y=0.926 8X -8.115,R2 =0.996 9).Neither FPIA nor EMIT was affected by residual metal ions ( P ＞ 0.05 ). Non-whole blood matrix decreased the extraction efficiency of two methods, but it could be corrected by supplementation of the Hb-rich reagents (≥30 g/L).Conclusions Non-whole blood matrix may be the main reason for the inconsistent results measured by FPIA and EMIT methods.It could be corrected by using Hb-rich reagents.In addition,we should consider the influence of low lib on CsA test,espocially for organ transplant patients with lower Hb ( ＜30 g/L).

Effects of immunosuppressants on co-stimulated lymphocyte's Th1/Th2 cytokine production / 中华泌尿外科杂志

Objective To analyze the effect of cyclosporin A(CsA), rapamycin(RPM) and macophenolic acid(MPA) on the co-stimulated lymphocytes, CD28 and CD40, and their production of Th1/Th2 cytokine, IL-2, IFN-γ, IL-4, IL-10 and IL-12. Methods The experimental groups were divided into ①mono-stimulating and co-stimulating groups: CD3 mAb mono-stimulating (group a),CD3 mAb+CD28 mAb co-stimulating (group b), CD3 mAb+CD28 mAb+CD40 L mAb co-stimulating(group c), CD3 mAb+CD28 mAb+CTLA4 mAb co-stimulating (group d). ②CsA groups: 300 ng/ml of CsA was added to group a, b, c and d. ③RPM groups: 300 ng/ml of RPM was added to group a,b, c and d. ④MPA groups:300 ng/ml of MPA was added to group a, b, c and d. The cytokine production was measured by ELISA.Results The co-stimulated CD28 and CD40 Th1/Th2 cytokines production of IFN-γ, IL-2, IL-4 and IL-10 were significantly increased. Compared with group a, IFN-γ increased from (248.91±11.20)ng/ml to (555.08±24.42)ng/ml and (548.19±33.06)ng/ml, IL-2 increased from (29.48±8.61)ng/ml to (1100.82±99.29)ng/ml and (842.23±29.31)ng/ml, IL-4 increased from (32.29±6.76)ng/ml to (116.02±15.03)ng/ml and (147.28±18.07)ng/ml, IL-10 increased from (147.01±10.47)ng/ml to (291.79±12.47)ng/ml and (302.52±35.18)ng/ml,respectively, P＜0. 01. Compared group b with group c, the Th1 cytokines production was decreased.IL-2 and IL-12 decreased (P＜0.05). The Th2 cytokine IL-4 production was increased (P＜0. 05).CTLA4 mAb and three other immunosuppressants, CsA, RPM and MPA, inhibited co-stimulated lymphocyte's both cytokines Th1 and Th2 production. The inhibitory effect of CsA on Th1/Th2 cytokine production was more significant than RPM and MPA did. The co-inhibitory effect of CTLA4 mAb and CsA was observed as well. The increased co-stimulated CD28 and CD40 IL-12 production could be suppressed by MPA. CsA and RPM had no inhibitory effect on the IL-12 production.Conclusions CD28/CD40 co-stimulatory pathway plays the key role in lymphocyte activation and Th1/Th2 cytokine production. CsA, RPM and MPA can inhibit co-stimulated lymphocyte's Th1 and Th2 cytokine production. CsA and CTLA4 mAb have co-inhibitory effect on co-stimulated lymphocyte's Th1/Th2 cytokines production. CD40 L mAb decreases the Th1 cytokines production(including IL-12) and increases the Th2 (mainly IL-4) production, which may be the mechanism of its longevity effect on allograft.

Evaluation of the practicability of limited sampling strategies for the estimation of mycophenolic acid exposure in Chinese adult renal recipients.

The immunosuppressive potential of mycophenolic acid (MPA) correlates well with MPA exposure [area under the concentration-time curve (AUC)]. Monitoring MPA AUC is important and helpful for maintaining the efficacy of mycophenolate mofetil while minimizing its side effects, but full MPA AUC monitoring is laborious, cost prohibitive, and impractical. Limited sampling strategies have been proposed as an alternative method for estimating MPA exposure. The objective of this study was to evaluate the practicability of different limited sampling strategies for the estimation of MPA exposure. A total of 56 pharmacokinetic profiles from 53 adult renal recipients were used to evaluate the practicability of 10 published models. Standard correlation and linear regression analysis were used to compare the estimated MPA AUCs and corresponding full MPA AUCs, and the percentage of profiles for which prediction error fell within +/-20% was also used to assess the practicability of these models. Agreement between the estimated MPA AUCs and full MPA AUCs was further tested by Bland and Altman analysis. The model, based on four sampling time points, used the formula AUC = 12.61 + 0.37 x C0.5 + 0.49 x C1 + 3.22 x C4 + 8.17 x C10, was superior to all other evaluated models, with the highest coefficient of determination (r = 0.88), a low percentage prediction error (2.79%), and good agreement according to Bland and Altman analysis. Prediction errors of 87.5% (49/56) of profiles were within 20%, which was the highest of all the models. This algorithm can be reliably used for estimating MPA exposure in adult renal transplant patients treated with cyclosporine as concomitant immunosuppressant. Another model based on the formula AUC = 8.22 + 3.16 x C0 + 0.99 x C1 + 1.33 x C2 + 4.18 x C4 also has acceptable predictive performance, and it may also be practical, especially in outpatient settings, in view of its distribution of time points.

Investigation on pharmacokinetics of mycophenolic acid in Chinese adult renal transplant patients.

AIMS: To characterize the pharmacokinetics of mycophenolic acid (MPA) in Chinese renal transplant patients. METHODS: Thirty-one renal transplant patients (17 male, 14 female) receiving mycophenolate mofetil (MMF) 1.0 g twice daily were included in this study. A pharmacokinetic study was performed during an interval in dosing after steady state had been reached within 2 months after transplantation. The plasma MPA concentration were measured by high-performance liquid chromatography (HPLC) at 0.5, 1, 1.5, 2, 4, 6, 8, 10 and 12 h after the administration of a single dose. Pharmacokinetic parameters were calculated with 3P97 software. SAS software was used for statistical analysis. Multiple linear regression analysis was used to determine limited sampling approaches. RESULTS: The mean peak plasma concentration (C(max)) and area under the concentration-time curve (AUC(0-12)) were 19.67 +/- 8.21 microg ml(-1) and 52.16 +/- 12.50 microg h ml(-1), but there was large variability in these pharmacokinetic parameters. Regression analysis between each plasma concentration and AUC for the limited sampling strategy of MMF therapeutic drug monitoring demonstrated that each of the concentrations at 0.5, 1, 4 and 10 h was positively correlated with AUC (r = 0.60, P = 0.0004; r = 0.60, P = 0.0003; r = 0.61, P = 0.0003; r = 0.64, P = 0.0001, respectively). The combined use of these four samples explained over 90% of the variance in the total (nine-point) AUC(0-12). A formula was obtained for the assessment of MPA AUC based on four samples: MPA AUC = 12.61 + 0.37 x C(0.5) + 0.49 x C(1) + 3.22 x C(4) + 8.17 x C(10). CONCLUSIONS: Chinese renal transplant patients had higher median AUCs than caucasians and African-Americans. As in other studies, there was large interindividual variability. A limited four-point AUC was in good agreement with the 12-h AUC and provided the basis of a predictive formula.

Clinical diagnosis and treatment of BK virus infection in renal transplant recipients / 中华器官移植杂志

Objective To investigate the prevalence of BK virus(BKV) infection in renal transplant recipients and the methods for its clinical diagnosis and treatment.Methods The urine and blood samples of 64 renal transplant recipients were taken for the BKV cytological and PCR tests.Five clinical factors were investigated to find the etiologic risks of BKV infection in renal transplant recipients.Four BKV infected recipients received experimental treatment.Results The occurrence of urine decoy cell,BKV viruria and viremia in all patients was(28.7 %),(17.2 %) and(6.3 %),respectively.The occurrence of urine decoy cell in serum creatinine(SCR) level elevated recipients was higher than that in SCR stable recipients(P=(0.04)).No significant relationships were found between the five clinical factors(gender,age,induction therapy,acute rejection episode,renal function after transplantation) and the occurrence of urine decoy cell,viruria and viremia.Ganciclovir treatment showed effective in four BKV infected recipients.Conclusions BKV monitoring is necessary for those recipients with evaluated SCR levels after renal transplantation.BKV viremia test can be used as a screening test.The efficacy of ganciclovir in the treatment of BKV infection should be further investigated.

Blockade of CD40/CD154 and B7/CD28 costimulatory pathways induces alloantigen-specific anergic state / 中华器官移植杂志

Objective To investigate the possibility of inducing anergy by blocking the CD40/CD154 and B7/CD28 costimulatory pathways and the reversal condition of anergic cells. Methods Splenocyte proliferation in primary mixed lymphocyte reaction (MLR) consisting of BALB/c as responder and C3H as stimulator was measured by the addition of different levels of anti-CD154 and anti-CD80 monocolonal antibody (mAb). To test the reversal condition of anergic cells induced by combined anti-CD154 and anti-CD80 mAbs blocking, C3H or C57BL/6J spleenocytes were irradiated, or different concentrations of recombinant mouse interleukin-2 (rmIL-2), or both C3H splenocytes and rmIL-2 were added to the anergic cells. Results The proliferation of anergic cells treated with both mAbs in the primary MLR was strongly inhibited in a dose-dependent manner. The cells proliferated in response to third party (C57BL/6J) stimulator. The cells did not respond to original (C3H) stimulator, and they also failed to proliferated in response to the addition of exogenous IL-2. Furthermore, the anergic state was reversed by both original (C3H) stimulator and the addition of exogenous rmIL-2. Conclusion The blockade of CD40/CD154 and B7/CD28 costimulatory pathways induces alloantigen-specific anergy, and the anergic state can be reversed by both antigen restimulation and the addition of exogenous IL-2.

Alloantigen-specific immunoregulatory function of anergic cells induced by the blockade of CD40-CD154 and CD28-B7 costimulatory pathways / 中国免疫学杂志

Objective:To investigate alloantigen-specific immunoregulatory function and phenotype of anergic cells induced by combined anti-CD154 and anti-CD80 monocolonal antibody(mAb) blocking.Methods:Anergic cells were generated in vitro by the addition of anti-CD154 and anti-CD80 mAbs to primary MLR (mixed lymphocyte reaction) consisting of BALB/C as responder and C3H as stimulator. Anergic or control cells were added to a newly formed MLR of naive BALB/C spleenocytes against the original (C3H) stimulator spleenocytes in assessing the regulatory capacity of anergic cells .Antigen specificity of the regulatory phenomenon was examined in MLR performed with third-party stimulator spleenocytes(C57BL/6J). To test the reversal condition of anergic cells,irradiated C3H spleenocytes,or recombinant mouse interleukin-2 (rmIL-2),or both C3H spleenocytes and rmIL-2 were added to the anergic cells. Anergic cells were phenotypically analyzed by double labeling procedure. Results:Anergic cells strongly suppressed the proliferation of naive BALB/C spleenocytes against the original (C3H) stimulator spleenocytes in a dose-dependent manner,but they failed to suppress the proliferation of naive BALB/C spleenocytes against the third-party stimulator spleenocytes(C57BL/6J).The anergic state was reversed by both original(C3H)stimulator and the addition of exogenous IL-2. There was an increased number of CD25 +CD4 +T cells observed in anergic cells,whereas there was no difference of CD45RB low CD4 + and CD28-CD8 +T cells between anergic and control cells.Conclusion:Anergic cells induced by the blockade of CD40-CD154 and CD28-B7 costimulatory pathways possess the alloantigen-specific immunoregulatory function and suppress the lymphocyte proliferation via infectious tolerance.