Extracellular Vesicles, Circulating Tumor Cells, and Immune Checkpoint Inhibitors: Hints and Promises

Immune checkpoint inhibitor (ICI) therapy has revolutionized the treatment of cancer, in particular lung cancer, while the introduction of predictive biomarkers from liquid biopsies has emerged as a promising tool to achieve an effective and personalized therapy response. Important progress has also been made in the molecular characterization of extracellular vesicles (EVs) and circulating tumor cells (CTCs), highlighting their tremendous potential in modulating the tumor microenvironment, acting on immunomodulatory pathways, and setting up the pre-metastatic niche. Surface antigens on EVs and CTCs have proved to be particularly useful in the case of the characterization of potential immune escape mechanisms through the expression of immunosuppressive ligands or the transport of cargos that may mitigate the antitumor immune function. On the other hand, novel approaches, to increase the expression of immunostimulatory molecules or cargo contents that can enhance the immune response, offer premium options in combinatorial clinical strategies for precision immunotherapy. In this review, we discuss recent advances in the identification of immune checkpoints using EVs and CTCs, their potential applications as predictive biomarkers for ICI therapy, and their prospective use as innovative clinical tools, considering that CTCs have already been approved by the Food and Drug Administration (FDA) for clinical use, but providing good reasons to intensify the research on both.

Circulating Tumour Cells: Detection and Application in Advanced Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is one of the deadliest diseases worldwide. Tissue biopsy is the current gold standard for the diagnosis and molecular profiling of NSCLC. However, this approach presents some limitations due to inadequate tissue sampling, and intra- and intertumour heterogenicity. Liquid biopsy is a noninvasive method to determine cancer-related biomarkers in peripheral blood, and can be repeated at multiple timepoints. One of the most studied approaches to liquid biopsies is represented by circulating tumour cells (CTCs). Several studies have evaluated the prognostic and predictive role of CTCs in advanced NSCLC. Despite the limitations of these studies, the results of the majority of studies seem to be concordant regarding the correlation between high CTC count and poor prognosis in patients with NSCLC. Similarly, the decrease of CTC count during treatment may represent an important predictive marker of sensitivity to therapy in advanced NSCLC. Furthermore, molecular characterization of CTCs can be used to provide information on tumour biology, and on the mechanisms involved in resistance to targeted treatment. This review will discuss the current status of the clinical utility of CTCs in patients with advanced NSCLC, highlighting their potential application to prognosis and to treatment decision making.

Analysis of EVs from patients with advanced pancreatic cancer identifies antigens and miRNAs with predictive value

The identification of predictive factors for treatment of pancreatic cancer (PC) is an unmet clinical need. In the present work, we analyzed blood-derived extracellular vesicles (EVs) from patients with advanced PC in order to find a molecular signature predictive of response to therapy. We analyzed samples from 21 patients with advanced PC, all receiving first-line treatment with gemcitabine + nab-paclitaxel. Isolated EVs have been analyzed, and the results of laboratory have been matched with clinical data in order to investigate possible predictive factors. EV concentration and size were similar between responder and non-responder patients. Analysis of 37 EV surface epitopes showed a decreased expression of SSEA4 and CD81 in responder patients. We detected more than 450 expressed miRNAs in EVs. A comparative survey between responder and non-responder patients showed that at least 44 miRNAs were differently expressed. Some of these miRNAs have already been observed in relation to the survival and gemcitabine sensitivity of tumor cells. In conclusion, we showed the ability of our approach to identify EV-derived biomarkers with predictive value for therapy response in PC. Our findings are worthy of further investigation, including the analysis of samples from patients treated with different schedules and in different settings.

Factors affecting dropout in outpatient eating disorder treatment

OBJECTIVE

To evaluate the incidence and effects of factors potentially influencing eating disordered patients' dropping out of outpatient cognitive-behavioural therapy (CBT).

METHOD

Sixty-seven (64 female, 3 male) patients with eating disorders participated in the study. All patients followed a multidisciplinary team approach for a median period of 9 months. Several factors potentially affecting dropout were retrospectively assessed prior to treatment.

RESULTS

The dropout rate was significantly higher in patients with purging anorexia nervosa (AN) compared to those with restrictive AN, bulimia nervosa and eating disorder not otherwise specified (33% vs. 27%, 25% or 21%, respectively, p<0.05). Among several factors influencing dropout, there was a significant association of patient low cooperativeness, purging episodes, restrictive eating, use of several weight control practices and psychiatric co-morbidity in patients who dropped out compared to completers (all p<0.05).

CONCLUSIONS

In outpatient eating disorder treatment, non-compliance and premature interruption of therapy are affected primarily by factors which are related to patients' attitude and behaviour. These factors should be carefully addressed in patients with eating disorders to improve outcome.

Immunosuppression in renal transplantation: viral diseases and chronic allograft nephropathy

Chronic allograft dysfunction after renal transplantation can be ascribed to different causes, among which are viral infections. The aim of this work was to show the various ways by which different kinds of viruses affect transplant structure and function. Polyoma virus is an example of viruses directly affecting the kidney because of a specific tropism to the uroepitelial cells. Cytomegalovirus (CMV) has been chosen both because of the frequency of this infection and because CMV (as other viruses) can produce transplant vascular sclerosis. Finally, we describe hepatitis C virus (HCV) because of its capacity to induce renal lesions independently from chronic allograft nephropathy. Indeed HCV is likely to determine immunologically mediated nephritis in the transplanted kidney as well in the native one.

Donor characteristics can influence transplant activities and the access to transplant for some age groups

In recent years Italy has experienced a remarkable increase in organ donation and transplant rates for kidney transplantation. The organ donation rate has placed Italy among the European leaders, but a careful comparative evaluation of Italian and international registries data demonstrates that renal transplantations have not shared the same significant growth. In a decisive way donor characteristics have influenced not only the number of renal transplantations, but also the access to transplant for some age groups. We investigated the probability of transplantation from different age groups using the Kaplan-Meier method and the log-rank test. The 7-year probability of transplant was 72% for the 15 to 45 age group, 85.7% for the 46 to 55 age group, and 88.5% for the over 55 years group (P = .0029). Ethical considerations suggest new approaches of innovative promotion of living donor transplants and a revision of organ allocation criteria.

Efficacy and safety of Palmaz stent implantation in the treatment of renal artery stenosis in renal transplantation

To verify the long-term efficacy and safety of Palmaz stent implantation in the treatment of transplant renal artery stenosis (TRAS), we reviewed the charts of 26 patients affected by TRAS and treated by percutaneous transluminal angioplasty (PTA) followed by permanent insertion of a Palmaz stent. The mean follow-up period was 43.31 +/- 33.6 months. The mean blood pressure fell significantly at 1 month after stenting (118 +/- 8.1 vs 101 +/- 7.8 mmHg; P < .0001); then remained stable. Renal artery blood flow, as determined by Doppler ultrasonography, was reduced from 352.5 +/- 56.5 to 157.3 +/- 53.7 cm/sec at 1 month after stenting (P < .0001). Renal function improved after stenting (serum creatinine 2.2 +/- 1.4 mg/dL preinsertion versus 1.72 +/- 1.05 at 3 years). In conclusion, in cases of severe or recurrent TRAS, stenting of the renal artery has proved to be an effective therapeutic tool. This method, which has low procedure costs and an extremely low complication rate has proved to be safe and to offer the potential of preserving luminal patency, improving the long-term efficacy of percutaneous angioplasty.

Cardiovascular risk factors in severe chronic renal failure: the role of dietary treatment

BACKGROUND

Lipoprotein abnormalities and increased oxidized LDL (OxLDL) are often observed in uremia and are reported to play a central role in the development of cardiovascular disease (CVD). Vegan diet, known for its better lipoprotein profile and antioxidant vitamins content, could protect against CVD. Aim of this study was to investigate the influence of vegan diet supplemented with essential amino acids (EAA) and ketoanalogues (VSD) on both traditional and non-traditional cardiovascular risk factors (CVRF).

METHODS

Twenty-nine patients (18 M, 11 F) aged 55 years (range 29-79 years) with advanced chronic renal failure (median sCr: 5.6 mg/dl) on very low protein vegetarian diet (0.3 g/kg/day) supplemented with a mixture of EAA and ketoacids (VSD) and 31 patients (20 M, 11 F) aged 65 years (range 29 - 82 years) on conventional low-protein diet (CD: 0.6 g/kg/day) with a similar renal function (median sCr: 5.2 mg/dl), were investigated for lipids and apolipoprotein parameters (traditional CVRF) as well as for oxidative stress (oxidized LDL, antibodies against OxLDL and thiobarbituric acid-reactive substances (TBARS)), total homocysteine (tHcy), lipoprotein(a) (Lp(a)), albumin and c-reactive protein (CRP) (non-traditional CVRF) including vitamins A, E, B12 and folic acid.

RESULTS

Compared to patients on CD, those on VSD showed increased HDL cholesterol levels (p < 0.005) with a reduction of LDL cholesterol (p < 0.01) and an increase of apoA1/apoB ratio (p < 0.02). Among non-traditional CVRF, a mild but significant reduction of OxLDL (p < 0.05) with lower TBARS concentrations (p < 0.01) and a significant reduction of total homocysteine (p < 0.002), Lp(a) (p < 0.002) and CRP levels (p < 0.05) were also observed in these patients. Concentrations of vitamin E and A were not different between the two groups while vitamin B12 and folic acid resulted markedly increased in patients on VSD. OxLDL significantly correlated with total and LDL cholesterol, triglycerides and Apo B in CD but not in VSD patients. Patients on CD also showed a significant correlation between urea and CRP. After a multivariate analysis, only urea (p < 0.001) and OxLDL (p < 0.006) were associated to a risk of CRP > 0.3 mg/dl.

CONCLUSIONS

These results indicate a better lipoprotein profile in patients on vegan diet including non-traditional CVRF. In particular, these patients show a reduced oxidative stress with a reduced acute-phase response (CRP) as compared to patients on conventional diet. We hypothesize that urea, significantly lower in patients on VSD, may account, possibly together with the reduction of other protein breakdown products, for the decreased acute-phase response observed in these patients. Our findings suggest that low-protein diets, and vegan in particular, may exert a beneficial effect on the development of cardiovascular disease in patients with end-stage renal disease (ESRD).

Nodular macroglossia with combined light chain and beta-2 microglobulin deposition in a long-term dialysis patient

We describe a case in which nodular macroglossia, a very rare type of tongue involvement, was associated with the co-deposition of lambda light chain and beta-2 microglobulin fibrils in the tongue. The combined presence of two different amyloid fibrils did not lead to a more unfavourable clinical outcome. We believe that both these features often remain underdiagnosed and are in fact more frequent than reported. A careful clinical examination of the tongue together with serum immunofixation should be routine in all patients with dialysis-related amyloidosis in order to investigate the prevalence and type of tongue involvement and to rule out other types of amyloidosis. In all cases of suspected mixed amyloidosis, immunohistochemical characterization of fibrils should be carried out by electron microscopy.

Cationic membranes for phenols production

Ionic Substitution by Electrodialysis is a good alternative to the industrial conversion of sodium salts of phenols into undissociated phenols, conventionally performed through acidification by strong acids. The acidification through electromembranes combines the possibility to achieve high conversion values with the advantage of keeping the process stream separated from the acid stream. The process is performed through cationic membranes; conversion can be obtained also in the absence of electric current, even if slightly better performances can be achieved by applying an electric field. Process feasibility as well as membrane resistance is tested, for the case of model solutions reproducing the main features of the real process streams. Maximum conversion and process rate are greatly affected by the ratio between protons in the acid solution and sodium ions in the process solution. Phenol losses into the acid stream and chloride contamination of the process stream can be reduced by working with diluted process and acid streams.

Mycophenolate mofetil (MMF) in the treatment of chronic renal rejection

BACKGROUND

Experimental studies suggest the efficacy of MMF in the treatment of chronic renal rejection in rats. Studies on the efficacy of MMF in chronic renal rejection in man are scarce and controversial.

AIM

The aim of this study was to verify in a prospective non-randomized study the efficacy of MMF given at the dose of 2 g/day in substitution of azathioprine (AZA) in the chronic rejection of cadaveric kidney transplantation.

PATIENTS AND METHODS

Twelve patients with histologically proven chronic renal rejection were enrolled. The patients were 5 males and 7 females. Mean age 38.3 +/- 13.8 years, with a mean duration of transplant of 39 +/- 19 months. Mean serum creatinine values at -6, -3, 0, +3, +6, +12 months were respectively 1.72 +/- 0.33, 1.84 +/- 0.36, 2.15 +/- 0.50, 1.88 +/- 0.54, 1.81 +/- 0.71, 1.73 +/- 0.58 mg/dl. Mean creatinine clearance values were 58.85 +/- 10.06,48.8 +/- 13.3,45.8 +/- 10.2, 54.7 +/- 13.3, 51 +/- 12.7, 57.7 +/- 18.5 ml/min. Mean deltaGFR before MMF was -2.15 ml/month.

RESULTS

After MMF introduction, the overall GFR decrease attenuated. In particular in seven patients after MMF administration, we obtained a significant reduction of mean serum creatinine value (1.84 +/- 0.55 vs. 1.38 +/- 0.41mg/dl; p = 0.004). In three patients, we obtained a stabilization in GFR. Two patients were slowly progressing even after MMF introduction. After a switch to MMF in almost all patients, we obtained an improvement of renal function. In three patients, we obtained a stabilization of renal function without regression. In particular, seven patients showed a remarkable improvement of renal function.

CONCLUSIONS

In conclusion our data even if concerning a small number of patients, confirm the efficacy of MMF in the treatment of renal allograft chronic dysfunction.

[Arteriovenous fistulas for hemodialysis: transposition of the cephalic veins, a personal experience]

BACKGROUND

Vascular access for hemodialysis has remarkably developed during these years. Since 1966 we have the Brescia-Cimino fistula which is considered nowadays the best choice for angioaccess. The transposed cephalic vein is the "variant" which has been evaluated in a single stage surgical technique.

METHODS

A prospective and randomized study regarding 23 patients submitted to operation for first fistula during 1998. With a median follow-up of 10 months, these fistulas have been studied with echocolordoppler in order to verify their primary patency, diameter and blood flow in artery, in vein and anastomosis.

RESULTS

Fistulas have been patented in all cases (15 males e 8 females) and used for dialysis after 3 weeks. No early or late complications have been observed. Mean diameter has been 1.2 cm with mean velocity of 1.8 m/sec, in artery mean velocity 2.3 m/sec and in vein 1.1 m/sec.

CONCLUSIONS

Increasing length of life even for high critical patients like these with chronic renal failure underlines the need of surgical strategies which may improve the quality to life. This technique of transposed cephalic vein has the same advantages of direct fistulas also for those patients in which we should have used prosthetic grafts.

Regional vs. national renal sharing organizations: pros and cons

Delayed graft function, defined as the need of dialysis in the first week after transplantation, neither due to immunological nor technical causes, determines a poor outcome of renal grafts. Delayed graft function is related to the cold ischemia time, which is shorter in local allocation programs. These, however, do not assure an optimal HLA-A,B,DR matching that can be provided by national allocation organizations. We reviewed 160 cadaveric kidney grafts performed in our local transplant network. Owing to the long waiting list caused by organ shortage, we were able to ensure both a high-grade histocompatibility and short cold ischemia times. The mean HLA-B,DR mismatch was 1.17. Cold ischemia time was < 24 h in 85% of cases. The incidence of DGF was 23.1%. In our experience a regional sharing program in the case of organ shortage provides good graft outcome (86.9% graft survival at 1 yr) with low incidence of delayed graft function.

Lipoprotein abnormalities in chronic renal failure and dialysis patients

Lipoprotein abnormalities are common in patients with chronic renal failure (CRF) on either dialysis or conservative therapy. In order to investigate the changes in lipid and apolipoprotein pattern from early CRF to dialysis treatment, plasma lipids with apoproteins AI, B, E, CII, CIII, CII/CIII ratio, E/CIII ratio, parathyroid hormone (PTH) and insulin levels were examined in 72 patients with different degrees of CRF and 31 patients on hemodialysis (HD), and compared the values of 28 controls. A significant decrease in the Apo CII/CIII ratio was the earliest lipoprotein abnormality to occur in CRF. Hypertriglyceridemia (HTG) with reduced high-density lipoprotein cholesterol levels, increased Apo CIII and decreased Apo E/Apo CIII ratio only occurred in more advanced renal failure (creatinine clearance < 31 ml/min). HD patients showed a general worsening of the lipoprotein profile with elevated Apo E levels and indirect evidence of remnant accumulation. While PTH did not have any significant influence on lipoprotein pattern, increased insulin levels during HD might partly account for the HTG of these patients. Our results point to elevated Apo CIII, reduced Apo CII/Apo CIII and Apo E/ Apo CIII ratios as typical features of uremic hyperlipidemia and show that a defective triglyceride removal is the major pathogenetic mechanism of uremic HTG. HD treatment seems generally to worsen the lipid and apolipoprotein pattern observed in the predialytic stage of CRF.

Oral activated charcoal in patients with uremic pruritus

Twenty-three chronic uremic patients on maintenance hemodialysis and suffering from severe pruritus were treated with activated powdered charcoal (6 g daily p.o.). In 10 patients pruritus disappeared completely, and in 10 other patients a partial effect was observed. The favorable results persisted for several weeks after discontinuation of the treatment. Only 3 cases were totally unresponsive. No relevant undesirable side effects were observed with the exception of 1 case who showed treatment intolerance. It is concluded that activated charcoal per os is a safe, effective, and low-cost therapy for patients with uremic pruritus, but its mechanism of action is unknown.

Progression of uremic hyperparathyroidism involves allelic loss on chromosome 11

In occasional cases of secondary hyperparathyroidism, long term stimulation of the parathyroid glands leads from compensatory to autonomous hyperfunction, and thus, hypercalcemia develops. This clinical entity, named tertiary hyperparathyroidism, is possibly due to the formation of an adenoma in one of the hyperplastic glands. Previous studies have shown that parathyroid adenomas may arise with allelic loss on chromosome 11. We tested for allelic loss at several loci on chromosome 11 in 12 enlarged parathyroid glands from 6 uremic patients and found loss of heterozygosity in 2 of the glands from 2 different patients with higher serum calcium levels (11.3 +/- 0.29 vs. 9.8 +/- 0.28 mg/dL; P < 0.004) and, therefore, ascribable to the so-called tertiary hyperparathyroidism. The 2 glands with allelic loss were significantly greater in mass than those without loss (3.42 +/- 0.37 vs. 1.60 +/- 0.54 g; P < 0.001). These data offer new evidence that autonomous parathyroid proliferation in uremic patients can develop through overgrowth by a monoclonal tumor, presumably with inactivation of a tumor suppressor gene(s) on chromosome 11.

Aging on the waiting list: should it be a further criterion for cadaver kidney allocation?

Transplant recipients have been selected from our dialysis patients mainly according to the criteria of the best HLA match and the best clinical condition. We have observed that, in using these criteria, most of the patients who receive transplants in the first 2 years on the waiting list. The other patients remain on the waiting list with progressively less chance of transplantation due to a deterioration of their clinical condition and the related increase in risk factors.

[Diagnosis and therapy of lymphocele as a complication of renal transplantation]

Of 165 renal transplanted patients, three (1.8%) developed a pelvic lymphocele. Decreased renal function, leg edema, a lower quadrant abdominal mass and fluid retention represented suspicion as the possibility of lymph collection in the perirenal space. Excretory urography associated with pelvic tomography, Computerized Tomography and B scan ultrasound confirmed diagnosis and were helpful in the post-operative follow-up. Drainage procedure restored normal renal function and morphology. External drainage and marsupialization into the peritoneum have been used successfully.

[Aseptic osseous necrosis after renal transplantation]

Of 165 renal Transplantated patients, 12 developed aseptic bone necrosis in the femoral head (6 patients), in the femoral condyle (5 patients), in the astragalus (1 patient). The onset of symptoms was 6 to 23 months after transplantation. 99mTc-O4-MDP bone scintigraphy and radiological examination associated with clinical signs confirmed the diagnosis. Unresolved hyperparathyroidism, phosforus depletion, ponderal increase, total i.v. prednisolone-boluses and trauma represented conditions which might predispose to the development of lesion. 8 patients were managed with conservative treatment. 4 patients required a total of 8 operations: head replacement arthroplasty and articular cartilage reimplant in two patients with disease involving femoral head; articular cartilage reimplant and condyle replacement arthroplasty in two patients with disease involving femoral condyle.

Coagulation Disorders in Fulminant Hepatitis Treated by Dialysis

A young man, 28 years old, was admitted to Infectious Division with transaminases over 2500 U/ml, reduced cortical activity and decerebrate posturing. A prolonged APTT, Prothrombin below 15%, very low levels of Factor II, V, VII (5-20%). At III by S-2238 (17%), Antiplasmin (20%) and Plasminogen(5%) by S-2251, Preltallikrein by S-2302 (5%). Fibrinogen (70mg%) but very high VIII AHF(4.5U/ml}, VIII AGN (4.0U/ml) and VIII VWF (3.8U/ml) were recorded. After 3 daily dialysis sessions with polyacrilonitrile membrane (RP 6) a marked improvement was observed. The patient awoke while prothrombin and platelet recovery took place, fibrinogen,VIII AHF and Factor V rose over normal value to 600mg%, 7.5U/ml and 3U/ml rispectively. Antiplasmin, Plasminogen, PKK showed a slow but costant improvement. Unfortunatly a venous thrombosis and sepsis set in during the 2nd day after dialysis, with a rapid decrease of platelets. Heparin infusion 1 mg/kg b.w. was infused every 6 hrs. After 15days platelet returned to normal value and VIII AHF to initial level but it was still higher (4U/ml) than normal value after 2 mounths from recovery.