Allocation of renal grafts to older recipients does not result in loss of functioning graft-years

BACKGROUND

Most deceased donor kidney allocation protocols are based on waiting time and do not take into account either recipient's life expectancy. This study investigates whether graft survival is affected by patient life expectancy.

METHODS

A total of 640 adult kidney transplants were performed. Recipients were divided in group A (patients ≤ 50 years) and group B (patients > 50 years). The status of graft+recipient combination was characterized as: a) deceased recipient with functional graft, b) alive recipient with functional graft and c) deceased or alive recipient with nonfunctional graft.

RESULTS

Mean kidney recipient survival was 15.15 (95% CI: 14.54, 15.77) and 12.40 (95% CI: 11.47, 13.33) years for groups A and B respectively (p < 0.0001). Mean graft survival was 13.62 (95% CI: 12.81, 14.43) and 12.42 (95% CI: 11.59, 13.25) years for groups A and B respectively (p=0.6516). Non-functional grafts were identified in 18.4% (n=57) and 16.4% (n=54) of group A and B respectively.

CONCLUSIONS

Allocation of renal grafts to older patients does not result in significant loss of graft-years. Recipients' life expectancy has a small impact on graft survival. We should not deviate from the basic principles of equality, when kidney allocation systems are designed.

The characteristics of inguinal hernia recurrence in the modern era and the long-term outcomes after re-operation

BACKGROUND

Re-operative hernia surgery has become more technically challenging due to the use of mesh. In addition, there has been a paucity of clinical studies. A common recommendation has been to avoid the previous site and to use a different approach.

METHODS

In this study of 218 patients, the anatomical characteristics of inguinal hernia recurrences were studied in relation to the previous technique of repair, including Mesh (n = 100), Laparoscopic (n = 61) and Shouldice (n = 57).

RESULTS

The most common site of recurrence was direct (58.5%) in all three groups. Femoral recurrences were significantly lower in the Laparoscopic group. Indirect and multiple recurrences were significantly lower in the Shouldice group. The operative time in the Mesh group was significantly longer due to the dissection required of the previous mesh. A pro-peritoneal mesh repair was performed for the re-operation in 13.8%, while a Shouldice repair was performed in the others. The overall follow-up rate was 75.2% for a mean of 4.8 years. The re-recurrence rate was 1.8%.

CONCLUSION

The distinct patterns of recurrence reflect the relative strengths and weaknesses of the different techniques of repair and present the anatomical and technical basis for future improvements. A safe and durable repair of an inguinal hernia recurrence can be achieved through an anterior trans-inguinal approach.

A rare adverse skin reaction after 8 Gy of radiation therapy to the thoracic spine: case report and review of the literature

A 60-year-old woman with breast cancer metastatic to the bones experienced no adverse skin reaction at the lumbar spine after a single 8-Gy photon-beam fraction prescribed to a depth of 5 cm. However, a subsequent treatment to the thoracic spine using the same dose, fractionation, and technique resulted in skin erythema and permanent hyperpigmentation. After careful investigation, no differences were identified in her concurrent use of possibly radiosensitizing medications during the various radiotherapy treatments nor in possible errors of treatment planning and radiation delivery. To our knowledge, this is the first case report to document that, with similar medications, a previous skin response to a given radiotherapy dose, fraction, and technique may not be predictive of subsequent skin response to similar radiotherapy.

The Jak inhibitor CP-690,550 preserves the function of CD4CD25FoxP3 regulatory T cells and inhibits effector T cells

The Jak inhibitor CP-690,550 inhibits alloreactivity and is currently being investigated for prevention of allograft rejection after transplantation. In this study, we examined the effect of CP-690,550 on IL-2-mediated Jak/STAT5 phosphorylation by CD4(+)CD25(bright)FoxP3(+)CD127(-/low) T cells (Treg) and CD4(+)CD25(neg) effector T cells (Teff) in kidney transplant (KTx) patients. Phosphospecific flow cytometry was used to study the effect of CP-690,550 on IL-2-induced intracellular STAT5-phosphorylation. IL-2-induced phosphorylation of STAT5 (P-STAT5) in both Treg and Teff, which was significantly higher for CD4(+)CD25(bright) Treg (increased by 71%, mean) than for CD4(+)CD25(neg) Teff (increased by 42%). In the presence of 100 ng/mL CP-690,550, a clinically relevant exposure, IL-2-induced P-STAT5 was partially inhibited in CD4(+)CD25(bright)Treg (% inhibition; 51%), while almost completely blocked in Teff (%inhibition; 84%, p = 0.03). The IC(50) was 2-3 times higher for Treg (104 ng/mL) than for Teff (40 ng/mL, p = 0.02). In the presence of CP-690,550, Treg exhibited additional suppressive activities on the alloactivated proliferation of Teff (56%, mean). In addition, CD4(+)CD25(bright) Treg from KTx-patients receiving CP-690,550 vigorously suppressed the proliferation of Teff (87%, mean). Our findings show that CP-690,550 effectively inhibits Teff function but preserves the suppressive activity of CD4(+)CD25(bright) regulatory T cells.

Calcineurin-inhibitor-free immunosuppression based on the JAK inhibitor CP-690,550: a pilot study in de novo kidney allograft recipients

This randomized, pilot study compared the Janus kinase inhibitor CP-690,550 (15 mg BID [CP15] and 30 mg BID [CP30], n = 20 each) with tacrolimus (n = 21) in de novo kidney allograft recipients. Patients received an IL-2 receptor antagonist, concomitant mycophenolate mofetil (MMF) and corticosteroids. CP-690,550 doses were reduced after 6 months. Due to a high incidence of BK virus nephropathy (BKN) in CP30, MMF was discontinued in this group. The 6-month biopsy-proven acute rejection rates were 1 of 20, 4 of 20 and 1 of 21 for CP15, CP30 and tacrolimus groups, respectively. BKN developed in 4 of 20 patients in CP30 group. The 6-month rates of cytomegalovirus disease were 2 of 20, 4 of 20 and none of 21 for CP15, CP30 and tacrolimus groups, respectively. Estimated glomerular filtration rate was >70 mL/min at 6 and 12 months (all groups). NK cells were reduced by </=77% in CP-690,550-treated patients. In the CP-690,550 arms, there were modest lipid elevations and a trend toward more frequent anemia and neutropenia during the first 6 months. These data suggest that coadministration of CP-690,550 30 mg BID with MMF is associated with overimmunosuppression. At 15 mg BID, the efficacy/safety profile was comparable to the tacrolimus control group, excepting a higher rate of viral infection. Further dose-ranging evaluation of CP-690,550 is warranted.

Calcineurin-inhibitor-free immunosuppression based on the JAK inhibitor CP-690,550: a pilot study in de novo kidney allograft recipients

This randomized, pilot study compared the Janus kinase inhibitor CP-690,550 (15 mg BID [CP15] and 30 mg BID [CP30], n = 20 each) with tacrolimus (n = 21) in de novo kidney allograft recipients. Patients received an IL-2 receptor antagonist, concomitant mycophenolate mofetil (MMF) and corticosteroids. CP-690,550 doses were reduced after 6 months. Due to a high incidence of BK virus nephropathy (BKN) in CP30, MMF was discontinued in this group. The 6-month biopsy-proven acute rejection rates were 1 of 20, 4 of 20 and 1 of 21 for CP15, CP30 and tacrolimus groups, respectively. BKN developed in 4 of 20 patients in CP30 group. The 6-month rates of cytomegalovirus disease were 2 of 20, 4 of 20 and none of 21 for CP15, CP30 and tacrolimus groups, respectively. Estimated glomerular filtration rate was >70 mL/min at 6 and 12 months (all groups). NK cells were reduced by </=77% in CP-690,550-treated patients. In the CP-690,550 arms, there were modest lipid elevations and a trend toward more frequent anemia and neutropenia during the first 6 months. These data suggest that coadministration of CP-690,550 30 mg BID with MMF is associated with overimmunosuppression. At 15 mg BID, the efficacy/safety profile was comparable to the tacrolimus control group, excepting a higher rate of viral infection. Further dose-ranging evaluation of CP-690,550 is warranted.

Activity of ofatumumab, a novel CD20 mAb, and prior rituximab exposure in patients with fludarabine- and alemtuzumab-refractory or bulky fludarabine-refractory chronic lymphocytic leukemia (CLL)

7044^

Background: Salvage therapy has limited activity (20–26% overall response rate [ORR]) in patients (pts) with CLL refractory to fludarabine and alemtuzumab (double-refractory, DR) or refractory to fludarabine with bulky (>5 cm) lymphadenopathy (bulky fludarabine-refractory, BFR). Ofatumumab (OFA) is a fully human mAb that targets a unique small-loop epitope of CD20 close to the cell surface and elicits more potent in vitro complement-dependent cytotoxicity of B-cell lines and tumor cells vs rituximab (RTX). To determine whether prior RTX exposure impacted activity of OFA in pts with DR or BFR CLL, an analysis was performed to assess efficacy by prior RTX exposure in pts treated with OFA in an international, pivotal study. Methods: Pts with DR or BFR CLL received 8 weekly infusions of OFA followed by 4 monthly infusions (Dose 1, 300 mg; Doses 2–12, 2,000 mg). Primary endpoint was ORR (1996 NCI-WG criteria) assessed by an Independent Review Committee over 24 weeks. Secondary efficacy endpoints included progression-free survival (PFS) and overall survival (OS). Results: Among 138 treated pts (DR, N=59; BFR, N=79) at the planned interim analysis, the ORR (99% CI) was 58% (40, 74%) in the DR group and 47% (32, 62%) in the BFR group. Median PFS (95% CI) was 5.7 mo (4.5, 8.0) and 5.9 mo (4.9, 6.4), and median OS (95% CI) was 13.7 mo (9.4, NYR) and 15.4 mo (10.2, 20.2), respectively. 59% and 54% of DR and BFR pts, respectively, previously received RTX-containing regimens. Both ORR and median PFS were similar in the prior RTX and no prior RTX subgroups (Table), and were comparable to efficacy data for the overall study population. ORR and median PFS were also similar in pts refractory to fludarabine in combination with RTX with or without cyclophosphamide. Conclusions: Single-agent therapy with OFA is effective in pts with DR or BFR CLL, irrespective of prior CD20 mAb therapy with RTX.

[Table: see text]

[Table: see text]

ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Clinical improvement with a novel CD20 mAb, ofatumumab, in fludarabine-refractory chronic lymphocytic leukemia (CLL) also refractory to alemtuzumab or with bulky lymphadenopathy

7043

Background: Patients (pts) with CLL refractory tofludarabine and alemtuzumab (double-refractory, DR) or refractory to fludarabine with bulky (>5 cm) lymphadenopathy (bulky fludarabine-refractory, BFR) have a poor prognosis. Ofatumumab is a human mAb specific for a distinctive small-loop epitope of CD20 that appears more potent than rituximab in eliciting complement-dependent lysis of B cells in vitro. We report, for the first time, results from the planned interim analysis of the clinical benefit observed in pts with DR or BFR CLL treated with ofatumumab in an international pivotal clinical study. Methods: Pts with DR or BFR CLL received 8 weekly then 4 monthly ofatumumab infusions (Dose 1, 300 mg; Doses 2–12, 2,000 mg). Primary endpoint was overall response rate (ORR; 1996 NCI-WG criteria), as assessed by an Independent Review Committee, over 24 wks. Results: Of 138 treated pts (DR: N = 59; BFR: N = 79; median age 64 and 62 yrs, respectively), 63% had Rai stage III/IV disease at screening. Pts had a median of 5 prior therapies. ORR (99% CI) was 58% (40, 74%) in the DR and 47% (32, 62%) in the BFR groups, and median overall survival (95% CI) was 13.7 mo (9.4, NR) and 15.4 mo (10.2, 20.2), respectively. Resolution of disease symptoms (maintained for ≥2 mo) were observed in a large proportion of pts (Table), including in pts considered nonresponders by NCI-WG criteria. Improvements in hematologic values were also observed in some pts with abnormal baseline values, particularly for platelet counts. Pts with thrombocytopenia at baseline (n = 73) experienced sustained increases in median platelet counts from 65 × 109/L to over 100 × 109/L by Wk 8; a similar pattern of rapid improvement was observed in Hgb values. Conclusions: Ofatumumab as single-agent achieves high ORR, and improves disease symptoms and hematologic parameters in heavily pretreated pts with DR and BFR disease who lack standard treatment options.

[Table: see text]

[Table: see text]

Standard of care for type 2 diabetic patients in a public hospital general medical clinic: report of a self-audit

We audited the standard of care provided to 200 consecutive type 2 diabetic patients attending our hospital general medical clinic. Data on diabetes related processes and outcome measures were collected. Annual testing rates (blood pressure 100%, fasting lipid profile 91.8%, HbA1c 69%) were higher compared to complications screening rates (Eye 69%, albuminuria 51%, foot 22.4%). Lifestyle intervention was lacking with BMI documented in 38.3% of patients and smoking history in 46%. Fifty percent and 41% of patients with HbA1c > 7.5% were referred to diabetes educator and dietitian respectively. For outcome measures, 26% of patients achieved HbA1c < or = 7%, 33% achieved BP < or = 130/80 while 56% achieved LDL < or = 2.6 mmol/L. Aspirin was prescribed in 78% and ACE inhibitor or angiotensin receptor blocker in 91.8% of patients. Lifestyle intervention and complication screening are the two major areas of deficiencies in the care of type 2 diabetic patients in our hospital general medical clinic.

Phase 1 dose-escalation study of CP-690 550 in stable renal allograft recipients: preliminary findings of safety, tolerability, effects on lymphocyte subsets and pharmacokinetics

CP-690 550 inhibits Janus kinase 3 with nanomolar potency. In this dose-escalation study, we assessed the safety, tolerability, effects on lymphocyte subsets, and pharmacokinetics of CP-690 550 when coadministered with mycophenolate mofetil in stable renal allograft recipients for 28 days. Twenty-eight patients were enrolled. Six patients received CP-690 550 5 mg twice daily (BID), 6 patients received 15 mg BID, 10 patients received 30 mg BID, and 6 patients received placebo. The most frequent adverse events were infections and gastrointestinal (abdominal pain, diarrhea, dyspepsia, and vomiting). CP-690 550 15 mg BID and 30 mg BID were associated with a mean decrease in hemoglobin from baseline of 11% and a mean decrease in absolute natural killer cell counts of 50%. CP-690 550 30 mg BID was also associated with a mean increase in absolute CD19(+) B-lymphocytes of 130%. There were no changes in the number of neutrophils, total lymphocytes, platelets, or CD4(+) or CD8(+) T cells; clinical chemistry; vital signs; or electrocardiograms from the pretreatment baseline. Administration of CP-690 550 without a concomitant calcineurin inhibitor resulted in CP-690 550 exposures consistent with previous studies in nontransplant subjects. Additional dose-ranging studies are warranted to evaluate the safety and efficacy of CP-690 550 in renal transplant recipients over longer treatment duration.

MicroRNAs that underlie response to salvage chemotherapy in ovarian cancer

10542

Background: MicroRNAs (miRNAs) are non-protein coding, endogenous, small RNAs that can bind complementary mRNA to modulate gene expression and protein translation. Recent studies indicate that miRNAs may be mechanistically involved in ovarian cancer chemosensitivity and may play an important role in the development of chemoresistance. The objective of the current study was to explore the role of miRNAs in the response of platinum-resistant recurrent or persistent ovarian cancer to salvage chemotherapy. Methods: MicroRNA was extracted from 16 ovarian cancer cell lines. All samples were hybridized to a miRNA array that contained Ambion and Invitrogen probe sets. In parallel, the 16 ovarian cancer cell lines were treated with Doxorubicin, Topotecan, Paclitaxel, Docetaxel, and Gemcitabine, and their response to treatment evaluated using proliferation assays. Logistic regression analysis was used to identify miRNAs associated with responsiveness to individual chemotherapeutic agents. Results: Linear regression analysis identified a total of 39 miRNAs significantly associated with salvage chemotherapy responsiveness. Sixteen miRNAs were associated with response to Doxorubicin, 18 associated with response to Topotecan, 2 associated with response to Docetaxel, 9 associated with response to Paclitaxel, and 11 associated with response to Gemcitabine (p<0.05). Ten miRNAs were associated with more than one chemotherapy (miR-126, miR-199a, miR-202 [Doxorubicin, Topotecan, Gemcitabine], miR-26a, miR-320 [Doxorubicin, Topotecan], miR-181b [Doxorubicin, Topotecan, Paclitaxel], 181a [Topotecan, Gemcitabine, Adriamycin, Paclitaxel], miR-99b [Doxorubicin, Paclitaxel, Docetaxel], miR-31 [Docetaxel, Paclitaxel], miR-339 [Doxorubicin, Gemcitabine]). Conclusion: We have identified miRNAs that may influence ovarian cancer responsiveness to salvage chemotherapy. Ten of the miRNAs were associated with chemosensitivity to more than one drug. These miRNAs may regulate common determinants of chemoresistance and may also serve as novel therapeutic targets for patients with chemoresistant ovarian cancer. Further studies are warranted to validate these results.

No significant financial relationships to disclose.

Ultraviolet-inactivated human cytomegalovirus induces placental syncytiotrophoblast apoptosis in a Toll-like receptor-2 and tumour necrosis factor-alpha dependent manner

Placentae obtained from newborns with congenital human cytomegalovirus (HCMV) infection often display chronic villitis and disruptions of the syncytiotrophoblast (ST). Little is known about how HCMV infection induces inflammation in the villous placenta and loss of the trophoblast. We propose that the inflammation is initiated with innate defence responses of the ST to maternal blood-borne virus. In this paper we show with a culture model (ST derived from primary cytotrophoblasts) that UV-inactivated HCMV (UV-HCMV) doubled the frequency of ST apoptosis. ST cultures challenged with UV-HCMV increased transcription and secretion of the inflammatory cytokines tumour necrosis factor alpha (TNFalpha) and interleukin-8, and antibody to TNFalpha inhibited UV-HCMV-induced apoptosis. Treatment with cycloheximide, an inhibitor of protein translation, did not reduce UV-HCMV-induced TNFalpha gene transcription, indicating that upregulation was independent of de novo protein synthesis. Neutralizing antibody to Toll-like receptor (TLR)2 inhibited UV-HCMV-induced transcription and translation of TNFalpha, and consequently inhibited the increase in ST apoptosis. Our results show that even transcriptionally inactive HCMV binding to TLR2 on ST can initiate inflammation, including secretion of TNFalpha, which leads to trophoblast death.

A problem encapsulated: the rare peritoneal encapsulation syndrome

Peritoneal encapsulation (PE) is a rare condition that has been described interchangeably with sclerosing encapsulated peritonitis as well as abdominal cocoon. We report an otherwise well 38-year-old man who presented with two episodes of intestinal obstruction about two months apart. Computed tomography (CT) of the abdomen showed characteristic features of the PE syndrome. Exploratory laparotomy was performed and small bowel was freed of adhesions and the encapsulation. Post-operative recovery was uneventful. PE is an extremely rare congenital condition in which there is abnormal return of the midgut loop to the abdominal cavity in the early stages of development. The small intestine is thus covered by the original dorsal mesentery, forming the characteristic accessory peritoneal sac. Management of cases is difficult as CT findings may not be characteristic and may only be diagnosed at laparotomy.