Kidney transplantation in the cyclosporine era

Insulin release and suppression by tacrolimus, rapamycin and cyclosporin A are through regulation of the ATP-sensitive potassium channel

AIM

By focusing on the pancreatic beta cell response to tacrolimus, cyclosporin A (CsA) and rapamycin we hoped to identify immunophilin, calcineurin and/or novel mechanism involvement and advance the understanding of immunosuppressant regulated insulin control.

METHODS

A glucose responsive beta cell model was established in which the glucose response was blocked by immunosuppressant treatment and this model was used to further characterise this effect. Quantification of insulin release to immunosuppressants and specific inhibitors was used to identify the mechanism involved.

RESULTS

It was found that upon the addition of tacrolimus, rapamycin, or CsA, rapid and significant exocytosis of cellular insulin was seen. A dose response study of this effect revealed optimal concentration windows of 50- 80 nm for tacrolimus, 100-300 nm for rapamycin, and 7-12 mm for CsA in RIN-5F cells. Optimal insulin release for HIT-T15 cells was similar. Additional experiments demonstrate that immunosuppressant pretreatment blocked the subsequent immunosuppressant induced insulin release but not that of a thapsigargin control, suggesting that suppression and release are non-toxic, specific and in the same pathway. Further experiments showed that this insulin release was a calcium dependent process, which was blocked by inhibitors of l-type calcium channels. Continued studies showed that the specific ATP-sensitive potassium channel agonist diazoxide (150 mm) also blocked immunosuppressant-induced insulin release.

CONCLUSIONS

A model that fits this data is a novel calcineurin-independent immunophilin mediated partial closing of the ATP-sensitive potassium channel, which would lead to an initial insulin release but would reduce subsequent responses through this pathway.

Presence of cytomegalovirus genome and leucocyte subsets in renal transplant biopsies. Relationship with prognosis

The influence of immunosuppressant therapy and of the presence of CMV genome on the distribution of lymphoid subpopulations of the inflammatory infiltrate in renal graft rejection was analyzed, as was the role of both factors in the evolution and survival of the graft. The study included 22 patients treated with Cyclosporin A (CsA) and 22 patients treated with Azathioprine (AZA). Inflammatory infiltrate was studied by immunostaining with a panel of monoclonal antibodies, and CMV DNA was detected by in situ hybridization on tissue sections. In patients treated with CsA, increased cellularity was found at both glomerular and interstitial levels, consisting mainly of macrophages and T-cells, which was consistent with the higher rate of glomerulointerstitial rejection found in this group. In contrast, the vascular type of rejection predominated in AZA treated patients. However, the presence of CMV DNA did not influence the phenotype of the inflammatory infiltrate, and was not associated with any specific lesion. Furthermore, the final outcome of the renal graft was independent of the detection of CMV. Therefore, this study provides no evidence of any active role of the CMV genome in renal graft rejection, and suggests that therapy should be adapted to the type of rejection as defined on morphologic and immunophenotypic grounds.