Sterility and testicular atrophy related to cyclophosphamide therapy

Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children

BACKGROUND

About 80% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. Of these children, half will relapse frequently, and are at risk of adverse effects from corticosteroids. While non-corticosteroid immunosuppressive medications prolong periods of remission, they have significant potential adverse effects. Currently, there is no consensus about the most appropriate second-line agent in children with frequently relapsing SSNS. In addition, these medications could be used with corticosteroids in the initial episode of SSNS to prolong the period of remission. This is the fifth update of a review first published in 2001 and updated in 2005, 2008, 2013 and 2020.

OBJECTIVES

To evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in SSNS in children with a relapsing course of SSNS and in children with their first episode of nephrotic syndrome.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to October 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs were included if they involved children with SSNS and compared non-corticosteroid immunosuppressive medications with placebo, corticosteroids or no treatment; different non-corticosteroid immunosuppressive medications, or different doses, durations or routes of administration of the same non-corticosteroid immunosuppressive medication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias and extracted data from the included studies. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We identified 58 studies (122 reports) randomising 3720 children. Half were multicentre studies, and most studies were undertaken in South and East Asia (28 studies) and Europe (20 studies). The numbers of children randomised ranged from 14 to 211. Risk of bias assessment indicated that 32 and 33 studies were at low risk of bias for sequence generation and allocation concealment, respectively. Eleven studies were at low risk of performance bias and 13 were at low risk of detection bias. Forty-eight and 36 studies were at low risk of incomplete and selective reporting, respectively. Rituximab with or without prednisone compared with placebo with or without prednisone probably reduces the number of children experiencing relapse at six months (5 studies, 182 children: RR 0.22, 95% CI 0.11 to 0.43) and 12 months (3 studies, 108 children: RR 0.38, 95% CI 0.13 to 1.09) (moderate certainty), may increase the number with severe infusion reactions (4 studies, 162 children: RR 5.21, 95% CI 1.19 to 22.89; low certainty), but not severe infection or arthropathy (low certainty). Rituximab compared with tacrolimus probably reduces the risk of relapse at 12 months (4 studies, 238 children: RR 0.64, 95% CI 0.42 to 0.96) and may reduce the risk of relapse when compared with low dose mycophenolate mofetil (MMF) (1 study, 30 children: RR 0.17, 95% CI 0.04 to 0.62). Rituximab followed by MMF for 500 days reduces the risk of relapse compared with rituximab followed by placebo for 500 days (1 study, 78 children: RR 0.29, 95% CI 0.13 to 0.63; high certainty). Rituximab probably does not differ from ofatumumab in the riisk of relapse and 12 months (1 study, 140 children: RR 1.03, 95% CI 0.75 to 1.41; moderate certainty) or in adverse events. MMF and levamisole (1 study, 149 children: RR 0.90, 95% CI 0.70 to 1.16) may have similar effects on the number of children who relapse at 12 months (low certainty). Cyclosporin compared with MMF may reduce the risk of relapse at 12 months (3 studies, 114 children: RR 1.57, 95% CI 1.08 to 2.30) (low certainty). Levamisole compared with steroids or placebo may reduce the number of children with relapse during treatment (8 studies, 474 children: RR 0.52, 95% CI 0.33 to 0.82) (low certainty). Preliminary data from single studies indicate that levamisole and prednisone compared with prednisone alone may delay the onset of relapse after the initial episode of SSNS and that levamisole compared with increasing prednisone administration from alternate day to daily at the onset of infection may reduce the risk of relapse with infection (low certainty). Cyclosporin compared with prednisone may reduce the number of children who relapse (1 study, 104 children: RR 0.33, 95% CI 0.13 to 0.83) (low certainty). Alkylating agents compared with cyclosporin may make little or no difference to the risk of relapse during cyclosporin treatment (2 studies, 95 children: RR 0.91, 95% CI 0.55 to 1.48) (low certainty evidence) but may reduce the risk of relapse at 12 to 24 months (2 studies, 95 children: RR 0.51, 95% CI 0.35 to 0.74) (low certainty). Alkylating agents (cyclophosphamide and chlorambucil) compared with prednisone probably reduce the number of children who experience relapse at six to 12 months (6 studies, 202 children: RR 0.44, 95% CI 0.32 to 0.60) and at 12 to 24 months (4 studies, 59 children: RR 0.20, 95% CI 0.09 to 0.46) (moderate certainty).

AUTHORS' CONCLUSIONS

New studies incorporated in this review update indicate that rituximab compared with prednisone, tacrolimus, or MMF is a valuable additional agent for managing children with relapsing SSNS. Comparative studies of CNIs, MMF, and levamisole suggest that CNIs may be more effective than MMF and that levamisole may be similar in efficacy to MMF. Important new studies suggest that MMF prolongs remission following rituximab, that levamisole may prevent infection-related relapse more effectively than changing from alternate-day to daily prednisone and that levamisole and prednisone compared with prednisone alone may prolong the time to first relapse. There are currently 23 ongoing studies which should improve our understanding of how to treat children with frequently relapsing SSNS.

Uncovering the link between inflammatory rheumatic diseases and male reproductive health: a perspective on male infertility and sexual dysfunction

Inflammatory rheumatic diseases (IRDs) refer to a range of persistent disorders that have a major influence on several physiological systems. Although there is much evidence connecting IRDs to sexual dysfunction and fertility problems, research specifically focusing on male infertility in relation to these diseases is sparse. This review addresses the complicated connection between IRDs and male infertility, emphasising the physiological, psychological, and pharmacological aspects that influence reproductive health outcomes in men with rheumatic conditions. We explore the effects of IRDs and their treatments on many facets of male reproductive well-being, encompassing sexual functionality, semen characteristics, and hormonal balance. Additionally, we present a comprehensive analysis of the present knowledge on the impact of several categories of anti-rheumatic drugs on male reproductive function. Although there is an increasing awareness of the need of addressing reproductive concerns in individuals IRDs, there is a noticeable lack of research especially dedicated to male infertility. Moving forward, more comprehensive research is needed to determine the prevalence, risk factors, and mechanisms driving reproductive difficulties in males with IRDs. We can better assist the reproductive health requirements of male IRD patients by expanding our understanding of male infertility in the setting of rheumatic disorders and implementing holistic methods to care.

Alkylating agents-induced gonadotoxicity in prepubertal males: Insights on the clinical and preclinical front

Rising cure rates in pediatric cancer patients warrants an increased attention toward the long-term consequences of the diagnosis and treatment in survivors. Chemotherapeutic agents can be gonadotoxic, rendering them at risk for infertility post-survival. While semen cryopreservation is an option that can be provided for most (post)pubertal boys before treatment, this is unfortunately not an option prepubertal in age, simply due to the lack of spermatogenesis. Over the last couple of years, studies have thus focused on better understanding the testis niche in response to various chemotherapeutic agents that are commonly administered and their direct and indirect impact on the germ cell populations. These are generally compounds that have a high risk of infertility and have been classified into risk categories in curated fertility guidelines. However, with it comes the lack of evidence and the challenge of using informative models and conditions most reflective of the physiological scenario, in short, the appropriate study designs for clinically relevant outcomes. Besides, the exact mechanism(s) of action for many of these "risk" compounds as well as other agents is unclear. Understanding their behavior and effect on the testis niche will pave the way for incorporating new strategies to ultimately combat infertility. Of the various drug classes, alkylating agents pose the highest risk of gonadotoxicity as per previously established studies as well as risk stratification guidelines. Therefore, this review will summarize the findings in the field of male fertility concerning gonadotoxicity of akylating agents as a result of chemotherapy exposure.

Asperosaponin VI protects against spermatogenic dysfunction in mice by regulating testicular cell proliferation and sex hormone disruption

ETHNOPHARMACOLOGICAL RELEVANCE

Studies have found that the causes of male infertility are complex, and spermatogenic dysfunction accounts for 30%-65% of male infertility causes, which is the main cause of male infertility. Asperosaponin VI (ASVI) is a saponin extracted from the traditional Chinese herb Dipsacus asperoides C.Y.Cheng & T.M.Ai. However, the precise protective impact and underlying mechanism of ASVI in the therapy of spermatogenic dysfunction remain unknown.

AIM OF THE STUDY

To investigate the impact of ASVI on the spermatogenic dysfunction induced by cytoxan (CTX) in mice, as well as explore any potential mechanisms.

MATERIALS AND METHODS

Potential ASVI targets were screened using the Pharmapper and Uniprot databases, while genes related to spermatogenic dysfunction were collected from the GeneCards database. The String and Cytoscape databases were then used for PPI analysis for the common targets of ASVI and spermatogenic dysfunction. Meanwhile, the Metascape database was used for KEGG and GO analysis. In vivo experiments, spermatogenic dysfunction was induced in male mice by intraperitoneal administration of CTX (80 mg/kg). To demonstrate the possible protective effects of ASVI on reproductive organs, CTX-induced spermatogenic dysfunction mice with different dosages of ASVI (0.8, 4, 20 mg/kg per day) treatment were collected and gonad weight was detected. The testis and epididymis were detected again by H&E. To assess the impact of ASVI on fertility in male mice, we analyzed sperm quality, serum hormones, sexual behavior, and fertility. The mechanism was investigated using WB, IF, IHC, and Co-IP technology.

RESULTS

The ASVI exhibited interactions with 239 associated targets. Furthermore, 1555 targets associated with spermatogenic dysfunction were predicted, and further PPI analysis identified 6 key targets. Among them, the EGFR gene exhibited the highest degree of connection and was at the core of the network. Based on the GO and KEGG enrichment analysis, ASVI may affect spermatogenic dysfunction through the EGFR pathway. In vivo experiments, ASVI significantly improved CTX-induced damage to male fertility and reproductive organs, increasing sperm quality. At the same time, ASVI can resist CTX-induced testicular cell damage by increasing p-EGFR, p-ERK, PCNA, and p-Rb in the testis and by promoting the interaction of CyclinD1 with CDK4. In addition, ASVI can also regulate sex hormone disorders and protect male fertility.

CONCLUSIONS

ASVI improves CTX-induced spermatogenesis dysfunction by activating the EGFR signaling pathway and regulating sex hormone homeostasis, which may be a new potential protective agent for male spermatogenic dysfunction.

Rheumatology-led pregnancy clinic: men perspective

The birth of reproductive rheumatology as a subject of interest in rheumatology has led to improvement of clinical care for patients living with autoimmune rheumatic diseases and paved the way towards setting a specialized pregnancy service within the standard rheumatology practice. In contrast to women, where there has been wealth of literature regarding pregnancy, lactation, and birth outcomes, there is not as much focusing on male sexual health and outcomes among inflammatory arthritis patients. Challenges such as decrease ability to conceive, impaired fertility, erectile dysfunction, and other sexual problems have been raised by male patients living with autoimmune rheumatic diseases. This broad scope gives the reproductive health concept in men another expansion with views to include sexual health problems screening among men attending the standard outpatient rheumatology clinics. This article adds to the paucity of real-life experience and aims at discussing the sexual health from the men perspective and provides a practical approach towards screening, and assessment of men living with autoimmune diseases in standard day to day practice.

Adult survivors of idiopathic childhood onset nephrotic syndrome

Like many pediatric chronic health conditions, idiopathic childhood onset nephrotic syndrome (iCONS) and late effects of iCONS medical management may continue to impact the affected population in adulthood. Approximately 15% of adult survivors of steroid-sensitive iCONS continue to relapse. Long-term kidney health is associated with steroid response patterns as well as pathology findings of FSGS, tubulointerstitial fibrosis, tubular atrophy, and global glomerulosclerosis. Long-term cardiovascular disease burden is largely unknown in adult survivors, but risk factors starting in childhood, including hypertension, dyslipidemia, and obesity, are common in iCONS. Reproductive health concerns, including azo-/oligospermia and successful pregnancies, are largely related to prior exposure to cytotoxic therapies. Additional investigations are needed to complete the assessment and initiate the mitigation of the late effects of treatment-sensitive and treatment-resistant iCONS.

The effect of paternal exposure to immunosuppressive drugs on sexual function, reproductive hormones, fertility, pregnancy and offspring outcomes: a systematic review

BACKGROUND

Information regarding the possible influence of immunosuppressive drugs on male sexual function and reproductive outcomes is scarce. Men diagnosed with immune-mediated diseases and a wish to become a father represent an important neglected population since they lack vital information to make balanced decisions about their treatment.

OBJECTIVE AND RATIONALE

The aim of this research was to systematically review the literature for the influence of paternal immunosuppressive drug use on many aspects of male sexual health, such as sexual function, fertility, pregnancy outcomes and offspring health outcomes.

SEARCH METHODS

A systematic literature search was performed in the bibliographic databases: Embase (via Elsevier embase.com), MEDLINE ALL via Ovid, Cochrane Central Register of Trials (via Wiley) and Web of Science Core Collection. Additionally, Google Scholar and the Clinical trial registries of Europe and the USA were searched. The databases were searched from inception until 31 August 2019. The searches combined keywords regarding male sexual function and fertility, pregnancy outcomes and offspring health with a list of immunosuppressive drugs. Studies were included if they were published in English and if they included original data on male human exposure to immunosuppressive drugs. A meta-analysis was not possible to perform due to the heterogeneity of the data.

OUTCOMES

A total of 5867 references were identified, amongst which we identified 161 articles fulfilling the eligibility criteria. Amongst these articles, 50 included pregnancy and offspring outcomes and 130 included sexual health outcomes. Except for large Scandinavian cohorts, most of the identified articles included a small number of participants. While a clear negative effect on sperm quality was evident for sulfasalazine and cyclophosphamide, a dubious effect was identified for colchicine, methotrexate and sirolimus. In three articles, exposure to tumour necrosis factor-α inhibitors in patients diagnosed with ankylosing spondylitis resulted in improved sperm quality. The information regarding pregnancy and offspring outcomes was scant but no large negative effect associated with paternal immunosuppressive drug exposure was reported.

WIDER IMPLICATIONS

Evidence regarding the safety of immunosuppressive drugs in men with a wish to become a father is inconclusive. The lack of standardisation on how to evaluate and report male sexual function, fertility and reproduction as study outcomes in men exposed to immunosuppressive drugs is an important contributor to this result. Future research on this topic is needed and should be preferably done using standardised methods.

New therapies in development for the management of non-infectious uveitis: A review

Uveitis is a spectrum of inflammatory disorders characterized by ocular inflammation and is one of the leading causes of preventable visual loss. The main aim of the treatment of uveitis is to control the inflammation, prevent recurrences of the disease and preserve vision while minimizing the adverse effects associated with the therapeutic agents. Initial management of uveitis relies heavily on the use of corticosteroids. However, monotherapy with high-dose corticosteroids is associated with side effects and cannot be maintained long term. Therefore, steroid-sparing agents are needed to decrease the burden of steroid therapy. Currently, the therapeutic approach for non-infectious uveitis (NIU) consists of a step-ladder strategy with the first-line option being corticosteroids in various formulations followed by the use of first-, second- and third-line agents in cases with suboptimal steroid response. Unfortunately, the agents currently at our disposal have limitations such as having a narrow therapeutic window along with their own individual potential side-effect profiles. Therefore, research has been targeted to identify newer drugs as well as new uses for older drugs that target specific pathways in the inflammatory response. Such efforts are made in order to provide targeted and safer therapy with reduced side effects and greater efficacy. Several specially designed molecular antibodies are currently in various phases of investigations that can potentially halt the inflammation in patients with NIU. In the review, we have provided a comprehensive overview of the current and upcoming therapeutic options for patients with NIU.

Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children

BACKGROUND

About 80% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. Of these children, half relapse frequently, and are at risk of adverse effects from corticosteroids. While non-corticosteroid immunosuppressive medications prolong periods of remission, they have significant potential adverse effects. Currently, there is no consensus about the most appropriate second-line agent in children who are steroid sensitive, but who continue to relapse. In addition, these medications could be used with corticosteroids in the initial episode of SSNS to prolong the period of remission. This is the fourth update of a review first published in 2001 and updated in 2005, 2008 and 2013.

OBJECTIVES

To evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in SSNS in children with a relapsing course of SSNS and in children with their first episode of nephrotic syndrome.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 10 March 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs were included if they involved children with SSNS and compared non-corticosteroid immunosuppressive medications with placebo, corticosteroids (prednisone or prednisolone) or no treatment; compared different non-corticosteroid immunosuppressive medications or different doses, durations or routes of administration of the same non-corticosteroid immunosuppressive medication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias of the included studies and extracted data. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

We identified 43 studies (91 reports) and included data from 2428 children. Risk of bias assessment indicated that 21 and 24 studies were at low risk of bias for sequence generation and allocation concealment respectively. Nine studies were at low risk of performance bias and 10 were at low risk of detection bias. Thirty-seven and 27 studies were at low risk of incomplete and selective reporting respectively. Rituximab (in combination with calcineurin inhibitors (CNI) and prednisolone) versus CNI and prednisolone probably reduces the number of children who relapse at six months (5 studies, 269 children: RR 0.23, 95% CI 0.12 to 0.43) and 12 months (3 studies, 198 children: RR 0.63, 95% CI 0.42 to 0.93) (moderate certainty evidence). At six months, rituximab resulted in 126 children/1000 relapsing compared with 548 children/1000 treated with conservative treatments. Rituximab may result in infusion reactions (4 studies, 252 children: RR 5.83, 95% CI 1.34 to 25.29). Mycophenolate mofetil (MMF) and levamisole may have similar effects on the number of children who relapse at 12 months (1 study, 149 children: RR 0.90, 95% CI 0.70 to 1.16). MMF may have a similar effect on the number of children relapsing compared to cyclosporin (2 studies, 82 children: RR 1.90, 95% CI 0.66 to 5.46) (low certainty evidence). MMF compared to cyclosporin is probably less likely to result in hypertrichosis (3 studies, 140 children: RR 0.23, 95% CI 0.10 to 0.50) and gum hypertrophy (3 studies, 144 children: RR 0.09, 95% CI 0.07 to 0.42) (low certainty evidence). Levamisole compared with steroids or placebo may reduce the number of children with relapse during treatment (8 studies, 474 children: RR 0.52, 95% CI 0.33 to 0.82) (low certainty evidence). Levamisole compared to cyclophosphamide may make little or no difference to the risk for relapse after 6 to 9 months (2 studies, 97 children: RR 1.17, 95% CI 0.76 to 1.81) (low certainty evidence). Cyclosporin compared with prednisolone may reduce the number of children who relapse (1 study, 104 children: RR 0.33, 95% CI 0.13 to 0.83) (low certainty evidence). Alkylating agents compared with cyclosporin may make little or no difference to the risk of relapse during cyclosporin treatment (2 studies, 95 children: RR 0.91, 95% CI 0.55 to 1.48) (low certainty evidence) but may reduce the risk of relapse at 12 to 24 months (2 studies, 95 children: RR 0.51, 95% CI 0.35 to 0.74), suggesting that the benefit of the alkylating agents may be sustained beyond the on-treatment period (low certainty evidence). Alkylating agents (cyclophosphamide and chlorambucil) compared with prednisone probably reduce the number of children, who experience relapse at six to 12 months (6 studies, 202 children: RR 0.44, 95% CI 0.32 to 0.60) and at 12 to 24 months (4 studies, 59 children: RR 0.20, 95% CI 0.09 to 0.46) (moderate certainty evidence). IV cyclophosphamide may reduce the number of children with relapse compared with oral cyclophosphamide at 6 months (2 studies, 83 children: RR 0.54, 95% CI 0.34 to 0.88), but not at 12 to 24 months (2 studies, 83 children: RR 0.99, 95% CI 0.76 to 1.29) and may result in fewer infections (2 studies, 83 children: RR 0.14, 95% CI 0.03 to 0.72) (low certainty evidence). Cyclophosphamide compared to chlorambucil may make little or no difference in the risk of relapse after 12 months (1 study, 50 children: RR 1.31, 95% CI 0.80 to 2.13) (low certainty evidence).

AUTHORS' CONCLUSIONS

New studies incorporated in this review indicate that rituximab is a valuable additional agent for managing children with steroid-dependent nephrotic syndrome. However, the treatment effect is temporary, and many children will require additional courses of rituximab. The long-term adverse effects of this treatment are not known. Comparative studies of CNIs, MMF, levamisole and alkylating agents have demonstrated little or no differences in efficacy but, because of insufficient power; clinically important differences in treatment effects have not been completely excluded.

Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review

The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.

Molecular Mechanisms and Signaling Pathways Involved in Sertoli Cell Proliferation

Sertoli cells are somatic cells present in seminiferous tubules which have essential roles in regulating spermatogenesis. Considering that each Sertoli cell is able to support a limited number of germ cells, the final number of Sertoli cells reached during the proliferative period determines sperm production capacity. Only immature Sertoli cells, which have not established the blood-testis barrier, proliferate. A number of hormonal cues regulate Sertoli cell proliferation. Among them, FSH, the insulin family of growth factors, activin, and cytokines action must be highlighted. It has been demonstrated that cAMP/PKA, ERK1/2, PI3K/Akt, and mTORC1/p70SK6 pathways are the main signal transduction pathways involved in Sertoli cell proliferation. Additionally, c-Myc and hypoxia inducible factor are transcription factors which participate in the induction by FSH of various genes of relevance in cell cycle progression. Cessation of proliferation is a pre-requisite to Sertoli cell maturation accompanied by the establishment of the blood-testis barrier. With respect to this barrier, the participation of androgens, estrogens, thyroid hormones, retinoic acid and opioids has been reported. Additionally, two central enzymes that are involved in sensing cell energy status have been associated with the suppression of Sertoli cell proliferation, namely AMPK and Sirtuin 1 (SIRT1). Among the molecular mechanisms involved in the cessation of proliferation and in the maturation of Sertoli cells, it is worth mentioning the up-regulation of the cell cycle inhibitors p21Cip1, p27Kip, and p19INK4, and of the gap junction protein connexin 43. A decrease in Sertoli cell proliferation due to administration of certain therapeutic drugs and exposure to xenobiotic agents before puberty has been experimentally demonstrated. This review focuses on the hormones, locally produced factors, signal transduction pathways, and molecular mechanisms controlling Sertoli cell proliferation and maturation. The comprehension of how the final number of Sertoli cells in adulthood is established constitutes a pre-requisite to understand the underlying causes responsible for the progressive decrease in sperm production that has been observed during the last 50 years in humans.

Infertility and teratogenicity after paternal exposure to systemic dermatologic medications: A systematic review

BACKGROUND

This systematic review assesses effects of paternal exposure to dermatologic medications by using the former US Food and Drug Administration (FDA) pregnancy categories as a benchmark.

OBJECTIVE

To assess whether systemic dermatologic medications can cause infertility and teratogenicity when taken by men.

METHODS

Categories D and X dermatologic medications were identified; a systematic review of the literature and reviews of the FDA Adverse Events Reporting System and prescribing information were performed to identify the effects of these medications on male fertility and teratogenicity. A secondary search was performed to assess for other systemic dermatologic medications causing teratogenicity or infertility following paternal exposure.

RESULTS

A total of 13 medications met the inclusion criteria. Of 1,032 studies identified, 19 were included after a systematic review of the literature. Studies evaluating medication effects with paternal exposure were identified for 10 of the 13 evaluated medications, and evidence of a negative effect was identified for 6 medications.

LIMITATIONS

We did not encounter any studies for 3 medications that met the inclusion criteria. Information submitted to the FDA Adverse Events Reporting System may not reflect the incidence of side effects.

CONCLUSIONS

Many former pregnancy category D and X systemic dermatologic medications also have effects on male fertility. More research and better-quality studies are required in this area, particularly studies assessing potential teratogenicity.

Fertility Preservation in Pediatric Subspecialties: A Pilot Needs Assessment Beyond Oncology

Physicians from 6 non-oncology pediatric subspecialties were surveyed about fertility preservation (FP) to assess education/service needs. Almost all (96%; 25 of 26) reported having patients at risk of infertility; however, only 58% (15 of 26) had discussed FP with patients' families. Most subspecialists (92%; 23 of 25) would like access to an FP program. Our data support exploring the expansion of FP programs beyond oncology.

FDA-approved drugs that are spermatotoxic in animals and the utility of animal testing for human risk prediction

PURPOSE

This study reviews FDA-approved drugs that negatively impact spermatozoa in animals, as well as how these findings reflect on observations in human male gametes.

METHODS

The FDA drug warning labels included in the DailyMed database and the peer-reviewed literature in the PubMed database were searched for information to identify single-ingredient, FDA-approved prescription drugs with spermatotoxic effects.

RESULTS

A total of 235 unique, single-ingredient, FDA-approved drugs reported to be spermatotoxic in animals were identified in the drug labels. Forty-nine of these had documented negative effects on humans in either the drug label or literature, while 31 had no effect or a positive impact on human sperm. For the other 155 drugs that were spermatotoxic in animals, no human data was available.

CONCLUSION

The current animal models are not very effective for predicting human spermatotoxicity, and there is limited information available about the impact of many drugs on human spermatozoa. New approaches should be designed that more accurately reflect the findings in men, including more studies on human sperm in vitro and studies using other systems (ex vivo tissue culture, xenograft models, in silico studies, etc.). In addition, the present data is often incomplete or reported in a manner that prevents interpretation of their clinical relevance. Changes should be made to the requirements for pre-clinical testing, drug surveillance, and the warning labels of drugs to ensure that the potential risks to human fertility are clearly indicated.

Immunosuppressants and Male Reproduction

Prolonged use of immunosuppressant medications is occasionally seen in infertile men with chronic inflammatory conditions; autoimmune disorders; or an organ or hematopoietic stem cell transplant. Chronic inflammation impacts negatively on male reproductive endpoints, so immunosuppressant therapy can produce improvements. Corticosteroids have been used to treat antisperm antibodies and even as an empirical treatment for male infertility in general. Trials of these methods have provided mixed results on semen quality and fertility, with improvement, no change and negative effects reported by different investigators. In a substantial number of observational studies, patients on long-term therapy with prednisone for chronic inflammatory disease, testosterone levels were lower compared to untreated controls, though randomized controlled trials have not been conducted. Similarly decreases in testosterone have been reported in men receiving corticosteroids to minimize transplant rejection; however, most were treated with multiple immunosuppressive medications that may have contributed to this effect. A large number of trials of healthy men treated with corticosteroids have shown some disruption in reproductive hormone levels, but other studies reported no effect. Studies in monkeys, rats (at human equivalent dose), cattle, sheep, and horses have shown endocrine disruption, including low testosterone with dexamethasone treatment. Of the cytostatic immunosuppressives, which have high potential for cellular damage, cyclophosphamide has received the most attention, sometimes lowering sperm counts significantly. Methotrexate may decrease sperm numbers in humans and has significant negative impacts in rodents. Other chemotherapeutic drugs used as immunosuppressants are likely to impact negatively on male fertility endpoints, but few data have been collected. The TNF-α Inhibitors have also received little experimental attention. There is some evidence that the immunophilin modulators: cyclosporine, sirolimus, and everolimus cause endocrine disruption and semen quality impairment. As we review in this chapter, results in experimental species are concerning, and well-designed studies are lacking for the effects of these medications on reproductive endpoints in men.

Critical review of the current recommendations for the treatment of systemic inflammatory rheumatic diseases during pregnancy and lactation

The crucial issue for a better pregnancy outcome in women with autoimmune rheumatic diseases is appropriate planning, with counseling of the ideal timing and treatment adaptation. Drugs used to treat rheumatic diseases may interfere with fertility or increase the risk of miscarriages and congenital abnormalities. MTX use post-conception is clearly linked to abortions as well as major birth defects, so it should be stopped 3months before conception. Leflunomide causes abnormalities in animals even in low doses. Although in humans, it does not seem to be as harmful as MTX, when pregnancy is detected in a patient on leflunomide, cholestyramine is given for washout. Sulfasalazine can be used safely and is an option for those patients who were on MTX or leflunomide. Azathioprine is generally the immunosuppressive of choice in many high-risk pregnancy centers because of the safety profile and its steroid-sparing property. Cyclosporine and tacrolimus can also be used as steroid-sparing agents, but experience is smaller. Although prednisone and prednisolone are inactivated in the placenta, we try to limit the dose to the minimal effective one, to prevent side effects. Antimalarials have been broadly studied and are safe during pregnancy and breastfeeding. Among biologic disease modifying anti-rheumatic agents (bDMARD), the anti-TNFs that have been used for longer are the ones with greater experience. The large monoclonal antibodies do not cross the placenta in the first trimester, and after conception, the decision to continue medication should be taken individually. The experience is larger in women with inflammatory bowel diseases, where anti-TNF is generally maintained at least until 30weeks to reduce fetal exposure. Live vaccines should not be administrated to the infant in the first 6months of life. Pregnancy data for rituximab, abatacept, anakinra, tocilizumab, ustekinumab, belimumab, and tofacitinib are limited and their use in pregnancy cannot currently be recommended.

Review : Infertility after chemotherapy: A review of the risks and strategies for prevention

Purpose. Infertility as a late complication of cancer chemotherapy, focusing on specific drug-related ef fects, effects observed in the treatment of certain malignancies, and strategies for prevention is re viewed.

Data Sources. A MEDLINE search of articles from 1966 to present was conducted using the terms infertility, antineoplastics, amenorrhea, azospermia, oogenesis, and spermatogenesis. Additional refer ences were identified using review articles and phar macology textbooks.

Study Selection. All human studies reported in English language were included. Animal studies were included when human data were insufficient or un available.

Data Synthesis. Data on the infertility effects of individual antineoplastic agents are difficult to inter pret for several reasons, including small sample sizes, lack of prechemotherapy fertility assessment, inade quate long-term follow-up, and use of regimens in cluding multiple agents. In general, the incidence and severity of antifertility effects are dependent on the total dosage delivered, duration of therapy, and age at exposure. The alkylating agents have the most signif icant effects on fertility. Fertility outcomes have been reported for several different malignancies, especially in patients cured of Hodgkin's disease and testicular cancer. Information on specific antineoplastic agents and cancers are reviewed. Several methods have been employed to decrease gonadotoxic effects, but none have been effective.

Conclusions. Infertility is a common late com plication of cancer chemotherapy that is receiving increasing attention as the number of cancer survi vors increases. Health care professionals should be aware of infertility risks associated with antineoplastic agents and certain malignancies, and patients should be informed of these risks as treatment decisions are made.

Fertility preservation in patients receiving cyclophosphamide therapy for renal disease

Cyclophosphamide continues to have an important role in the treatment of renal disease, including nephrotic syndrome and lupus nephritis, despite known complications of gonadotoxicity and potential infertility in both male and female patients. It is important that the physician recommending this therapy mitigates the effect of the drug on fertility by adhering to recommendations on dosing limits and offering fertility-preserving strategies. In addition to well-established methods, such as sperm banking and embryo cryopreservation, advances in reproductive technology have yielded strategies such as oocyte cryopreservation, resulting in more fertility-preserving options for the pediatric patient. Despite these advances, there continues to be a significant barrier to referral and access to sperm banks and fertility specialists. These issues are further complicated by ethical issues associated with the treatment of pediatric patients. In this review we explore the development of recommended dosing limits and include a discussion of the available fertility-preserving methods, strategies for increasing access to fertility specialists, and the ethical considerations facing the pediatric healthcare provider.

Side-effects of anti-inflammatory therapy in uveitis

Uveitis is a group of inflammatory ocular conditions that cause significant visual morbidity around the world. Many of the cases of blindness secondary to uveitis can be avoided with adequate and aggressive management of the intraocular inflammation. Steroids have been utilized in the treatment of noninfectious uveitis for more than 60 years, but their chronic use is associated with severe ocular and systemic side-effects. Ophthalmologists are often not familiar with the systemic steroid-sparing agents available for the management of ocular inflammation and depend primarily on the use of corticosteroids. In this article, we review the most common agents utilized in the treatment of uveitis and their side-effect profiles.

Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children

BACKGROUND

About 80% to 90% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. Of these children, around half relapse frequently, and are at risk of adverse effects from corticosteroids. Non-corticosteroid immunosuppressive medications are used to prolong periods of remission in these children; however, these medications have significant potential adverse effects. Currently, there is no consensus about the most appropriate second line agent in children who are steroid sensitive, but who continue to relapse. This is the third update of a review first published in 2001 and updated in 2005 and 2008.

OBJECTIVES

To evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in relapsing SSNS in children.

SEARCH METHODS

For this update we searched the Cochrane Renal Group's Specialised Register to June 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs were included if they compared non-corticosteroid immunosuppressive medications with placebo, prednisone or no treatment, different non-corticosteroid immunosuppressive medications and different doses, durations or routes of administration of the same non-corticosteroid immunosuppressive medication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias of the included studies and extracted data. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

We identified 32 studies (1443 children) of which one study is still ongoing. In the 31 studies with data, risk of bias assessment indicated that 11 (37%) and 16 (53%) studies were at low risk of bias for sequence generation and allocation concealment respectively. Six (29%) studies were at low risk of performance and detection bias. Twenty seven (87%) and 19 (60%) studies were at low risk of incomplete and selective reporting respectively. Alkylating agents (cyclophosphamide and chlorambucil) significantly reduced the risk of relapse at six to 12 months (RR 0.43, 95% CI 0.31 to 0.60) and 12 to 24 months (RR 0.20, 95% CI 0.09 to 0.46) compared with prednisone alone. There was no significant difference in relapse risk at two years between chlorambucil and cyclophosphamide (RR 1.31, 95% CI 0.80 to 2.13). There was no significant difference at one year between intravenous and oral cyclophosphamide (RR 0.99, 95% CI 0.76 to 1.29). Cyclosporin was as effective as cyclophosphamide (RR 1.07, 95% CI 0.48 to 2.35) and chlorambucil (RR 0.82, 95% CI 0.44 to 1.53) at the end of therapy while levamisole (RR 0.47, 95% CI 0.24 to 0.89) was more effective than steroids alone. However the effects of cyclosporin and levamisole were not sustained once treatment was stopped. In one small study cyclosporin significantly reduced the relapse rate compared with mycophenolate mofetil (MD 0.75, 95% CI 0.01 to 1.49). Limited data from a cross-over study suggested that cyclosporin was more effective than mycophenolate mofetil in maintaining remission. In steroid- and cyclosporin-dependent disease, rituximab significantly reduced the risk of relapse at three months compared with conventional therapy. Mizoribine and azathioprine were no more effective than placebo or prednisone alone in maintaining remission.

AUTHORS' CONCLUSIONS

Eight-week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Limited data indicate that mycophenolate mofetil and rituximab are valuable additional medications for relapsing SSNS. However clinically important differences in efficacy are possible and further comparative studies are still needed.

Using cyclophosphamide in inflammatory rheumatic diseases

Cyclophosphamide (CYC), primarily introduced into clinical practice as an anti-cancer substance, is a potent immunosuppressive drug. Today, it is used in a number of organ- or life -threatening autoimmune diseases such as systemic vasculitides or connective tissue diseases. While being effective, CYC has a small therapeutic index and is associated with significant toxicity. CYC has been used in oncology in a variety of diseases and a lot of data has been derived from this area. This knowledge is often extrapolated to the rheumatologic settings. However, besides some similarities substantial differences between these two specialties considering the underlying diseases as well as the kind of application of the drug exist. The aim of the present review is to describe the general characteristics of the use of CYC from the rheumatologist's point of view, including pharmacologic and pharmacokinetic properties, drug interactions, toxicity and possible preventive and/or therapeutic measures; all of which are important to consider when using this particular drug in the treatment of inflammatory rheumatic diseases.

Cistanches herba induces testis cytotoxicity in male mice

We investigated the effects of Cistanches herba (CH) on the male reproductive system in mice, assessing CREM gene expression and spermatogenesis. Our results demonstrate that CH treatment lead to a significant decrease in sperm count dose-dependently, 298.3 ± 48.9 vs. 296.6 ± 102.4 (250 mg/kg), 236.7 ± 75.1 (500 mg/kg), 223.0 ± 48.7 × 10(6) (1000 mg/kg), respectively. Additionally, serum testosterone levels decreased following CH treatment to as low as ~57% compared with the vehicle-treated group. CREM gene expression was also down-regulated following CH treatment and histological examination of the testicular seminiferous tubules showed severe damage on CH treatment. These results suggest that CH induces cytotoxicity in the male reproductive system, through the inhibition of spermatogenesis, testicular damage, and limited hormonal function.

Hyperprolactinemia associated with psychotropics--a review

INTRODUCTION

Different classes of psychotropics can cause hyperprolactinemia to varying degrees. Among antipsychotics, typical agents and risperidone are the most frequent and significant offenders. In this review we discuss the pathophysiology, offending medications, assessment and management of hyperprolactinemia.

METHODS

We did a literature review between 1976 and 2008 using PubMed, MEDLINE, PsychINFO and Cochrane database. Search terms used were prolactin, hyperprolactinemia, psychotropics, antipsychotics, typical antipsychotics, atypical antipsychotics, antidepressants and SSRIs.

RESULTS

Prolactin elevation is more common with antipsychotics than with other classes of drugs. Typical antipsychotics are more prone to cause hyperprolactinemia than atypical agents. Management options include discontinuation of offending medication, switching to another psychotropic, supplementing concurrent hormonal deficiencies and adding a dopamine agonist or aripiprazole.

CONCLUSION

Clinicians need to be alert about the potential for hyperprolactinemia and its manifestations with these medications. Prolactin levels need to be monitored and other causes of hyperprolactinemia ruled out in suspected cases.

Cyclophosphamide for ocular inflammatory diseases

PURPOSE

To evaluate the outcomes of cyclophosphamide therapy for noninfectious ocular inflammation.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Two hundred fifteen patients with noninfectious ocular inflammation observed from initiation of cyclophosphamide.

METHODS

Patients initiating cyclophosphamide, without other immunosuppressive drugs (other than corticosteroids), were identified at 4 centers. Dose of cyclophosphamide, response to therapy, corticosteroid-sparing effects, frequency of discontinuation, and reasons for discontinuation were obtained by medical record review of every visit.

MAIN OUTCOME MEASURES

Control of inflammation, corticosteroid-sparing effects, and discontinuation of therapy.

RESULTS

The 215 patients (381 involved eyes) meeting eligibility criteria carried diagnoses of uveitis (20.4%), scleritis (22.3%), ocular mucous membrane pemphigoid (45.6%), or other forms of ocular inflammation (11.6%). Overall, approximately 49.2% (95% confidence interval [CI], 41.7%-57.2%) gained sustained control of inflammation (for at least 28 days) within 6 months, and 76% (95% CI, 68.3%-83.7%) gained sustained control of inflammation within 12 months. Corticosteroid-sparing success (sustained control of inflammation while tapering prednisone to 10 mg or less among those not meeting success criteria initially) was gained by 30.0% and 61.2% by 6 and 12 months, respectively. Disease remission leading to discontinuation of cyclophosphamide occurred at the rate of 0.32/person-year (95% CI, 0.24-0.41), and the estimated proportion with remission at or before 2 years was 63.1% (95% CI, 51.5%-74.8%). Cyclophosphamide was discontinued by 33.5% of patients within 1 year because of side effects, usually of a reversible nature.

CONCLUSIONS

The data suggest that cyclophosphamide is effective for most patients for controlling inflammation and allowing tapering of systemic corticosteroids to 10 mg prednisone or less, although 1 year of therapy may be needed to achieve these goals. Unlike with most other immunosuppressive drugs, disease remission was induced by treatment in most patients who were able to tolerate therapy. To titrate therapy properly and to minimize the risk of serious potential side effects, a systematic program of laboratory monitoring is required. Judicious use of cyclophosphamide seems to be beneficial for severe ocular inflammation cases where the potentially vision-saving benefits outweigh the substantial potential side effects of therapy, or when indicated for associated systemic inflammatory diseases.

Toxic effects of different doses of cyclophosphamide on the reproductive parameters of male mice

The cyclophosphamide is used in cancer treatment. The aim of this study was evaluating the effect of different doses of this drug on male mice reproductive parameters. The cyclophosphamide was administered in the doses 100, 150, 200 e 250 mg.kg-1, intraperitoneal route, for six weeks. As a result, it was observed a decrease in body mass and a decrease in testicles and kidney's weight, in all animals treated with cyclophosphamide. Only the groups that received the doses 100, 150 mg.kg-1 of cyclophosphamide were able to fertilize their females. There was higher incidence of post- implantation losses, reabsorptions and decrease in fetal viability in the group that received the dose of 150 mg.kg-1. It was observed a reduction in epididymis and liver's weight of the animals treated with the doses 150, 200 e 250 mg.kg-1. Abnormal spermatozoa were found in the doses 200 e 250 mg.kg-1. Based on the methodology used and results obtained, it was concluded that the cyclophosphamide was toxic, considering the decrease in animal's body mass and testicle's weight; promoted hepatotoxicity and nephrotoxic effect; influenced in the animals spermatogenesis taking them to infertility and/or subfertility; decreased fetal viability, despite it didn't cause significant malformations in the offspring.

On the morphology of the human Sertoli cells under normal conditions and in patients with impaired fertility

Sertoli cells in testicular biopsies from 7 patients with Sertoli-cell only syndrome, 8 patients who had been treated with cyclophosphamide for testicular neoplasia, 8 patients with oligozoospermia, 7 patients with cryptorchidism, and 8 patients with seminoma were examined under the electron microscope and compared with Sertoli cells of normal tissues. The investigations reveal that each of these conditions of impaired fertility is characterized of a special type of Sertoli cell. The cell pattern is either restricted to one or two of the normally occurring cell types, or modified cells predominate that might be typical of the underlying disturbances of spermatogenesis. It is suggested that the cell type which prevails in the Sertoli-cell only syndrome is capable of maintaining a basic production of a substance that inhibits FSH secretion.

The impact of commonly prescribed drugs on male fertility

To analyze the impact of commonly used drugs on male fertility, we assessed the clinical characteristics of patients with impaired semen quality while they were taking medication for chronic diseases and after switching therapies. Of 1768 infertile males, 201 patients were taking medications and had impaired semen quality without any seminal tract obstruction, spermatogenic abnormalities or hypogonadotropic hypogonadism. Of these 201 men, a total of 165 had no history of testicular diseases nor abnormalities in any examinations. Amongst them, H1 receptor antagonists were the most common medication taken, followed by antiepileptics and antibiotics. They were divided into two groups: an intervention group (73 patients), who could stop or switch their medications, and a control group (92 patients), who could not. In the intervention group, semen quality improvement rate and conception rate (93% and 85%, respectively) were much higher than those of the control group (12% and 10%, respectively). After switching therapies, the time interval before conception was 7.3 months, which was significantly shorter in asthenozoospermia than oligozoospermia. Our results confirm the potential fertility hazards of commonly used drugs and their reversibility. Moreover, after switching medication, drug-induced asthenozoospermia was cured more rapidly than oligozoospermia, suggesting that further delineation of such differences may help to elucidate mechanisms of spermatogenesis and might facilitate the development of non-hormonal male contraceptive agents.

Non-corticosteroid treatment for nephrotic syndrome in children

BACKGROUND

Eighty to 90% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. About half relapse frequently and are at risk of the adverse effects of corticosteroids. Non-corticosteroid immunosuppressive agents are used to prolong periods of remission in these children, however these agents have significant potential adverse effects. Currently there is no consensus as to the most appropriate second line agent in children who are steroid sensitive, but who continue to relapse.

OBJECTIVES

To evaluate the benefits and harms of non-corticosteroid immunosuppressive agents in relapsing SSNS in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, reference lists, conference abstracts and contact with known investigators. Search date: September 2007

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs were included if they compared non-corticosteroid agents with placebo, prednisone or no treatment, different doses and/or durations of the same non-corticosteroid agent, different non-corticosteroid agents.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI).

MAIN RESULTS

We identified 26 studies (1173 children). Cyclophosphamide (RR 0.44, 95% CI 0.26 to 0.73) and chlorambucil (RR 0.15, 95% CI 0.02 to 0.95) significantly reduced the relapse risk at six to twelve months compared with prednisone alone. There was no difference in relapse risk at two years between chlorambucil and cyclophosphamide (RR 1.31, 95% CI 0.80 to 2.13). There was no difference at one year between intravenous and oral cyclophosphamide (RR 0.99, 95% CI 0.76 to 1.29). Cyclosporin was as effective as cyclophosphamide (RR 1.07, 95% CI 0.48 to 2.35) and chlorambucil (RR 0.82, 95% CI 0.44 to 1.53) and levamisole (RR 0.43, 95% CI 0.27 to 0.68) was more effective than steroids alone but the effects were not sustained once treatment was stopped. There was no difference in the risk for relapse between mycophenolate mofetil and cyclosporin (RR 5.00, 95% CI 0.68 to 36.66) but CI were large. Mizoribine and azathioprine were no more effective than placebo or prednisone alone in maintaining remission.

AUTHORS' CONCLUSIONS

Eight week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Clinically important differences in efficacy are possible and further comparative studies are still needed.

Children with sickle cell disease: growth and gonadal function after hematopoietic stem cell transplantation

The aim of this study is to describe the growth, pubertal development, and gonadal function of a cohort of 30 sickle cell disease children who underwent bone marrow transplantation. They all received the standard pretransplant conditioning regimen of busulfan (14 or 16 mg/kg) and cyclophosphamide (200 mg/kg). Growth was normal both before and after transplant. Seven out of 10 girls had severe ovarian failure and requirement for estrogen replacement. Three out of 10 girls recovered some ovarian function posttransplant, with spontaneous pubertal development, menses, and 1 successful normal pregnancy. Follicle-stimulating hormone (FSH) serum levels were very high during spontaneous puberty and slowly normalized thereafter in these 3 patients. The 3 girls with ovarian function recovery differed from the 7 others by the lower busulphan dose of the conditioning regimen they received (14 rather than 16 mg/kg). All boys showed spontaneous pubertal development. However, most of them had small testis and elevated serum FSH levels, reflecting germinal epithelium damage. Testosterone level was low normal and luteinizing hormone elevated, reflecting Leydig cell insufficiency. In conclusion, 7/10 girls had complete gonadal failure and most of the boys had spontaneous puberty but germinal epithelial failure. Serum FSH levels showed important variations over time in the same patient.

Children with steroid-sensitive nephrotic syndrome come of age: long-term outcome

OBJECTIVE

Long-term outcome of steroid-sensitive idiopathic nephrotic syndrome (SSNS) in children is usually considered benign, although data on follow-up into adulthood are scarce. The aim of this study was to investigate adults who had childhood SSNS regarding their relapse rate, growth, and renal and extrarenal morbidity.

STUDY DESIGN

Adult patients (n=42, 26 males) were evaluated at a median age of 28.0 (18.1 to 46.9) years and a median follow-up of 22.0 (2.9 to 39.0) years since diagnosis.

RESULTS

Fourteen of 42 (33%) patients relapsed in adulthood. The number of relapses during childhood and adolescence and a complicated course-administration of steroid-sparing medication such as cyclophosphamide, chlorambucil, and cyclosporin A-were identified as risk factors. Final adult height (median SD score -0.4, range -3.3 to +1.3) and body mass index (BMI) were normal. Renal function was normal in all patients, and overall morbidity was low. Only eight patients (three males) had children. Cytotoxic therapy was identified as a major factor contributing to childlessness.

CONCLUSION

Relapses in adulthood were common in pediatric patients with SSNS. Growth and renal function were normal, and overall morbidity was low. Yet, transition to an adult nephrologist is recommended for all children with relapsing SSNS.

Non-corticosteroid treatment for nephrotic syndrome in children

BACKGROUND

Eighty to ninety per cent of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. About half relapse frequently and are at risk of the adverse effects of corticosteroids. Non-corticosteroid immunosuppressive agents are used to prolong periods of remission in children who relapse frequently. However these non-corticosteroid agents also have significant potential adverse effects. Currently there is no consensus as to the most appropriate second line agent in children who are steroid sensitive, but who continue to relapse.

OBJECTIVES

To evaluate the benefits and harms of non-corticosteroid immunosuppressive agents in relapsing SSNS in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, reference lists of articles, abstracts from proceedings and contact with known investigators. Search date: August 2004

SELECTION CRITERIA

RCTs or quasi-RCTs were included if they were undertaken in children with relapsing SSNS, if they compared non-corticosteroid agents with placebo, prednisone or no treatment, different doses and/or durations of the same non-corticosteroid agent, different non-corticosteroid agents and outcome data at six months.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Twenty trials involving 923 children were identified. Cyclophosphamide (three trials: RR 0.44, 95% CI 0.26 to 0.73) and chlorambucil (two trials: RR 0.13, 95% CI 0.03 to 0.57) significantly reduced the relapse risk at six to twelve months compared with prednisone alone. In the single chlorambucil versus cyclophosphamide trial, there was no observed difference in relapse risk at two years (RR 1.31, 95% CI 0.80 to 2.13). Cyclosporin was as effective as cyclophosphamide (one trial: RR 1.07, 95% CI 0.48 to 2.35) and chlorambucil (one trial: RR 0.82, 95% CI 0.44 to 1.53) but the effect was not sustained when cyclosporin was ceased. During treatment, levamisole (three trials: RR 0.60, 95% CI 0.45 to 0.79) was more effective than steroids alone but the effect was not sustained. Mizoribine (one trial) and azathioprine (two trials) were no more effective than placebo or prednisone alone in maintaining remission.

AUTHORS' CONCLUSIONS

Eight week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Clinically important differences in efficacy among these agents are possible and further comparative trials are still needed.

Chemotherapy for bone sarcoma does not affect fertility rates or childbirth

There have been unprecedented improvements in the survival of patients with bone sarcomas because of advances in chemotherapy during the past two decades. However, along with improved survival, there have been concerns of gonadal toxicity and fertility. These problems with chemotherapy are well documented for conditions like lymphomas and testicular cancers. There are few reports on fertility outcomes with chemotherapy for bone sarcomas. The purpose of this study was to review the rate of successful conceptions, pregnancy outcomes, incidence of birth defects, and fertility rates in young adults who had chemotherapy for high-grade bone sarcomas. A retrospective chart review of all eligible patients was done. No laboratory assessment of fertility was done. Fifteen of the 36 patients attempted conceptions, and all were successful [corrected] One miscarriage occurred and one medical termination of pregnancy was done because of a spinal metastasis. There were 13 successful full-term pregnancies with no birth defects. The conception rate was 1.6. Despite the common misconception of probable infertility, these patients can have high expectations to conceive, with uneventful childbirth and no birth defects in the newborns. Although counseling should include the possibility of infertility, patients also should be reminded of the high rate of success of having a normal conception and childbirth.

Endocrine complications of high-dose therapy with stem cell transplantation

Evaluations of endocrine function following hematopoietic cell transplantation demonstrate that the endocrine function abnormalities observed are related to the type of transplant preparative regimen received. Children given high dose cyclophosphamide (CY) only have normal thyroid function, normal growth and development. Children who received a busulfan (BU) plus CY preparative regimen usually have normal thyroid function, normal prepubertal growth, delayed or absent pubertal development, and blunted post-pubertal growth. Recipients of preparative regimens containing total body irradiation may be anticipated to have some thyroid dysfunction, impaired growth rates and delayed or absent pubertal development. Post-pubertal teens and young adults are likely to have gonadal function recover if they received a preparative regimen with CY only but are likely to have primary gonadal failure if they received a preparative regimen with BU or total body irradiation. Individuals whose gonadal function becomes normal have become parents of normal children. All patients who receive a marrow transplant should be followed long-term for development of endocrine function abnormalities.

Some aspects relating to the evaluation of the effects of chemicals on male fertility

Reviews and studies on individual compounds were analyzed as to the suitability of different study designs and endpoints for detecting adverse effects of chemicals on male reproduction in animal species. Of the endpoints investigated, the most sensitive proved to be histopathology of the testes. Using refined histopathology, effects could be detected with a high degree of sensitivity as early as 4 weeks after treatment. Other sensitive endpoints were the weights of reproductive organs, including accessory glands, i.e., testis, epididymis, prostate, and of the seminal vesicle, as well as sperm parameters such as sperm count, sperm morphology, and sperm motility. Sperm motility was found to be in some cases more sensitive than histopathology. The above parameters showed a higher sensitivity than fertility parameters. In fact, in most cases, not only one but several endpoints were affected. Continuous breeding studies and 90-day studies with additional measurements of sperm parameters were similarly effective in detecting compounds which affect male fertility. Interspecies extrapolation factors (IEFs) have been derived for the most sensitive endpoints in laboratory animals. If the calculation is based on caloric demand and a sensitive endpoint of reproductive toxicity, many IEFs tend to be about 1, indicating that humans are generally not more susceptible to reproductive toxicants than laboratory animals. With respect to hazard identification, it is possible to detect adverse effects on male reproduction in a standard subacute study with concentrations that produce significant general toxicity. If effects are found, for the risk assessment the NOAEL has to be determined by testing specific sensitive parameters as specified above.

Effects of growth hormone on testicular dysfunction induced by cyclophosphamide (CP) in GH-deficient rats

Growth hormone (GH) is known to accelerate spermatogenesis and maintain gonadal function. In this study, we evaluated the effect of GH on recovery from testicular damage induced by cyclophosphamide (CP). Eleven- to fourteen-week-old GH-deficient Lewis rats (dw/dw) were divided into 4 groups (n = 10 each), with one group serving as controls. In the CP group, CP was intravenously administered in daily doses of 50 mg/kg for 2 days, followed by daily doses of 10 mg/kg for the next 3 days. In the GH group, rat GH was subcutaneously administered at a daily dose of 0.3 mg/kg until the rats were sacrificed. In the CP/GH group, GH and CP administration were started simultaneously. In the CP/preGH group, GH administration was started 14 days before CP administration. Five rats from each group were sacrificed at days 14 and 28 after administration of CP. Spermatogenesis was then evaluated morphometrically by counting numbers of cells at several stages of the spermatogenic cycle. On day 14, there were no significant differences in the numbers of the spermatocytes between CP and CP/GH group. On day 28, the numbers of spermatocytes and motility of spermatozoa in CP/GH group were greater than those of CP group were. In the CP/preGH group, these effects of GH administration were not observed. These results suggested that administration of GH improved testicular function damaged by CP under GH-deficient condition, when GH and CP administration are started simultaneously.

Chronic graft-versus-host disease and late effects after hematopoietic stem cell transplantation

Late effects following HSCT are related to either the transplant process or to the transplant preparative regimen. Problems related to the transplant process include delayed recovery of the immune system and chronic GVHD. Chronic GVHD presents between 3-14 months post-HSCT in approximately 20% of matched sibling transplants and 40% of matched unrelated donor recipients. Most commonly involved sites are skin, mouth, liver, gastrointestinal tract, and eye. Patients with platelet count < 100,000/ml and receiving cortocosteroid therapy at day 80 with any clinical manifestations of chronic GVHD require prolonged immune suppressive therapy with prednisone, cyclosporine +/- other agents. Treatment should be administered until all clinical and pathological signs and symptoms of chronic GVHD have resolved which may take one to several years. Problems related to the transplant preparative regimen include those involving the endocrine system, eyes, lungs, bone, and development of secondary malignancies. Endocrine deficiencies include growth failure with growth hormone (GH) deficiency, overt hypothyroidism, primary gonadal failure, Type 1 or Type 2 diabetes, and exocrine pancreatic insufficiency. These problems develop at any time post-HSCT, but usually occur within the first few years and should be treated with appropriate hormone supplementation. Eye problems are primarily related to development of cateracts secondary to total body irradiation (TBI) or prolonged corticosteroid use. Cateracts developing after fractionated frequently do not require removal. Pulmonary problems may be due to bronchiolitis obliterans (BO) or to restrictive lung disease. BO may be associated with chronic GVHD and may respond to chronic GVHD therapy. Restrictive lung disease does not occur for many years after HSCT. There is not therapy for this problem. Development of decreased bone mineral density (BMD) is related to GH deficiency and/or corticosteroid therapy. Treatment includes withdrawal of corticosteroids, administration of GH and calcium, Vitamin D and antiresorptive agents. All malignant disease survivors are at risk for development of secondary malignancies, including survivors of HSCT. Recipients of TBI are at highest risk as are children. All pediatric and adult survivors of HSCT should be followed for their life-time for development of delayed effects of transplantation.

Effect of tamoxifen on sperm fertilising ability and preimplantation embryo development

Recent evidences point to a role of estrogens in males. We have earlier reported that tamoxifen, a synthetic non-steroidal antiestrogen, when administered to adult male rats, in the dose range of 0.04-0.4 mg/kg per day, reduced fertility. The reduced fertility was measured in terms of fertility index (a measure of the efficiency of the ovulated ovas to fertilise and implant), fecundity (siring ability) and litter size. The present study was done to investigate whether the reduction in fertility index was due to reduction in fertilising ability or increase in pre-implantation embryo loss. Also a dose related effect of tamoxifen from 0.02 mg to 2 mg/kg per day on the fertility of the male rats was studied. To study the fertilising ability, control and tamoxifen (0.4 mg/kg per day, the most effective dose) treated adult male rats were mated with normal cycling females and the females sacrificed at day 0-4 of gestation. Eggs fertilised/unfertilised were flushed from the oviduct/uterus and the number and types of eggs were noted. The index of fertilisation, a measure of the fertilising ability was determined. The studies demonstrate that the reduction in fertility is not due to decreased fertilising ability but because of the increased pre-implantation embryo loss as evident from an increase in number of abnormal eggs in the treated group with no change in index of fertilisation. A dose related decrease in fertility was observed. The present study suggests that tamoxifen at 0.02-2-mg dose is predominantly estrogenic in males and paternal factor/s sensitive to tamoxifen is involved in embryogenesis.

Immunosuppressive agents in childhood nephrotic syndrome: a meta-analysis of randomized controlled trials

BACKGROUND

Many children with steroid-sensitive nephrotic syndrome (SSNS) relapse frequently and receive immunosuppressive agents. In this systematic review of randomized controlled trials (RCTs), the benefits and harms of these immunosuppressive agents are evaluated.

METHODS

RCTs with outcome data at six months or more that evaluated noncorticosteroid agents in relapsing SSNS were included. A summary relative risk for relapse at 6 to 12 months was calculated using a random effects model.

RESULTS

Seventeen trials involving 631 children were identified. Cyclophosphamide [3 trials; relative risk (RR) 0.44, 95% confidence interval (CI), 0.26 to 0.73] and chlorambucil (2 trials; RR 0.13, 95% CI, 0.03 to 0.57) significantly reduced the relapse risk at 6 to 12 months compared with prednisone alone. In the single chlorambucil versus cyclophosphamide trial, there was no observed difference in relapse risk at two years (RR 1.31, 95% CI, 0.80 to 2.13). Cyclosporine was as effective as cyclophosphamide (1 trial; RR 1.07, 95% CI, 0.48 to 2.35) and chlorambucil (1 trial; RR 0.82, 95% CI, 0.44 to 1.53), but the effect was not sustained when cyclosporine was ceased. During treatment, levamisole (3 trials; RR 0.60, 95% CI, 0.45 to 0.79) was more effective than steroids alone, but the effect was not sustained.

CONCLUSIONS

Cyclophosphamide, chorambucil, cyclosporine, and levamisole reduce the risk of relapse in children with relapsing SSNS compared with prednisone alone. Clinically important differences in efficacy among these agents are possible, and further comparative trials are still needed. Meanwhile, the choice between these agents depends on physician and patient preferences related to therapy duration and complication type and frequency.

Application of computer-assisted sperm analysis system to elucidate lack of effects of cyclophosphamide on rat epididymal sperm motion

A computer-assisted sperm analysis (CASA) system was used to examine the motion of epididymal spermatozoa derived from cyclophosphamide (CP)-treated male rats. Male rats were orally dosed daily for 1 week with 20 mg/kg of CP. Males were euthanized or were mated 3 times with untreated females at 1 day, 3 weeks, and 8 weeks after the final treatment. Significant decreases in testicular and epididymal weights and epididymal sperm counts of the treated animals were noted after 8-week recovery. Histopathological morphometry of the testis revealed minimal damage to spermatogonia at 1 day after the final treatment and to spermatocytes after 3-week recovery in the CP-treated group. On Caesarian section, increased post-implantation losses were found in females mated with CP-treated males in matings starting 1 day and 3 weeks after the final treatment. On the other hand, none of the sperm motion parameters of treated males derived from the CASA system exhibited significant changes at any time points, although the spermatozoa of treated males at 1 day and 3 weeks after the final treatment were damaged at the DNA level, and the spermatozoa of males after 8-week recovery had been the target cells of CP when they were spermatogonia in the testis. It was thus found that damaged spermatozoa could exhibit no changes on their motion when the damage was confined to the nuclei, and that the effect of CP on sperm nuclei was reversible.

High risk of infertility and long term gonadal damage in males treated with high dose cyclophosphamide for sarcoma during childhood

BACKGROUND

Therapy with alkylating agents, such as cyclophosphamide, can be associated with irreversible gonadal toxicity in male survivors of adult cancer. To the authors's knowledge the effect of high dose therapy with cyclophosphamide during childhood on adult testicular reproductive and endocrine function has not been established.

METHODS

Gonadal function was studied in 17 adult male survivors of childhood sarcomas treated with high dose pulse cyclophosphamide therapy as part of a VAC (vincristine, actinomycin, and cyclophosphamide) or Adria-VAC (doxorubicin, vincristine, actinomycin, and cyclophosphamide) chemotherapy regimen. Patients answered a questionnaire concerning sexual functioning and underwent a comprehensive physical examination, semen analysis, and hormonal evaluation.

RESULTS

Of the 17 males who underwent semen analysis, 10 (58.8%) had azoospermia, 5 (29.4%) had oligospermia, and only 2 (11.8%) were found to have a normal sperm count. All patients treated prior to the onset of puberty had an abnormal semen analysis. The 2 patients with normal sperm counts received the lowest doses of cyclophosphamide (< 7.5 g/m(2)). The baseline follicle-stimulating hormone level was elevated in only 10 of 14 patients with abnormal sperm counts (71.4%). Testosterone levels were normal in 15 of 16 patients (93.8%); however, the baseline luteinizing hormone (LH) level was elevated in 6 of 15 patients with normal testosterone levels (40%). Gonadotropin-releasing hormone-stimulated LH levels were > 3 times that of baseline in 13 of /14 patients (92.9%), suggesting some degree of Leydig cell insufficiency.

CONCLUSIONS

The results of the current study show a high risk of gonadal dysfunction in men exposed to cyclophosphamide during childhood as part of a VAC/Adria-VAC chemotherapy regimen. Exposure prior to puberty was not found to be protective, and the risk of infertility appeared to increase with higher doses of therapy. To the authors' knowledge the clinical significance of impaired Leydig cell function beginning at a young age is unknown and merits further study.