Slow Progression of Aortic Calcification Is a Potential Benefit of Pre-emptive Kidney Transplantation

PURPOSE

Pre-emptive kidney transplantation (PKT) is expected to improve graft and cardiovascular event-free survival compared with standard kidney transplantation. Aortic calcification is reported to be closely associated with renal dysfunction and cardiovascular events; however, its implication in PKT recipients remains incompletely explored. This aim of this study was to evaluate whether PKT confers a protective effect on aortic calcification, renal function, graft survival, and cardiovascular event-free survival.

METHODS

One hundred adult patients who underwent renal transplantation between January 1996 and March 2016 at Hirosaki University Hospital and Oyokyo Kidney Research Institute were included. Among them, 19 underwent PKT and 81 patients underwent pretransplant dialysis. We retrospectively compared pretransplant and post-transplant aortic calcification index (ACI), renal function (estimated glomerular filtration rate [eGFR]), and graft and cardiovascular event-free survivals between the 2 groups.

RESULTS

The median age of this cohort was 45 years. Preoperative ACI was significantly lower in PKT recipients. There were no significant differences between the 2 groups regarding postoperative eGFR, graft survival, and cardiovascular event-free survival. However, the ACI progression rate (ΔACI/y) was significantly lower in PKT recipients than in those who underwent pretransplant dialysis. Higher ACI was significantly associated with poor cardiovascular event-free survival.

CONCLUSIONS

PKT is beneficial in that it contributes to the slow progression of after transplantation. Although we could not observe significant differences in graft and cardiovascular event-free survivals between the 2 groups, slow progression of aortic calcification showed a potential to decrease cardiovascular events in PKT recipients during long-term follow-up.

Partial Cystectomy of Paraganglioma of the Urinary Bladder Before Living Kidney Transplantation: Case Report

BACKGROUND

Paraganglioma (extra-adrenal pheochromocytoma) of the bladder is a very rare disease, accounting for 0.06% of all bladder tumors. Optimal management of bladder paraganglioma before kidney transplantation is unknown. We report a case of partial cystectomy for urinary bladder paraganglioma before living kidney transplantation.

CASE PRESENTATION

A 59-year-old man with a 27-year history of hemodialysis was referred to our department for further examination of a bladder tumor detected during pre-transplantation testing. Cystoscopy revealed a submucosal tumor on the right side of the bladder. The patient experienced a hypertensive crisis during transurethral resection of the bladder tumor. Endocrinologic and pathologic examinations confirmed the diagnosis of paraganglioma in the urinary bladder. A partial cystectomy was performed before kidney transplantation. Nine months after partial cystectomy, the patient underwent AB0-incompatible living kidney transplantation from his spouse. No disease recurrence or graft rejection was observed 12 months after the transplantation.

CONCLUSIONS

To our knowledge, this is the 1st report on the management of paraganglioma in the urinary bladder before living kidney transplantation. Kidney transplantation after partial cystectomy is an option that may be considered in patients with paraganglioma of the urinary bladder, with careful observations of bladder function and vesicoureteral reflux to the grafts.

Condyloma Acuminata of the Urethra in a Male Renal Transplant Recipient: A Case Report

BACKGROUND

Condyloma acuminatum (CA) is a common sexually transmitted disease associated with human papilloma virus (HPV). CA occurring in the urethra is rare and has not been reported in male renal transplant recipients. In addition, despite immunosuppressive conditions and increased risk of HPV-related malignant neoplasms in transplant recipients, HPV testing in male transplant recipients has been uncommon. Here we report a case of urethral CA in a male deceased donor renal transplantation recipient and discuss the importance of HPV testing in male transplant recipients.

CASE PRESENTATION

A 33-year-old male deceased donor renal transplant recipient presented with miction pain 5 years after the transplantation. He reported repeated urinary tract infections with no sexual contact since the renal transplantation. Multiple papillary tumors in his penile urethra were detected by cystoscopy, and a biopsy sample was pathologically diagnosed with CA. Transurethral tumor resection was performed, and the tumors were completely resected. Additional HPV risk type screening with a urethral smear sample showed the prevalence of low-risk HPV. Although tacrolimus was switched to everolimus and imiquimod cream was administered, the tumors recurred 6 months after the resection, and a second resection was performed. No further recurrence has been observed for 1 year to date.

CONCLUSION

As the urethral CA was possibly related to immunosuppressive conditions and a risk for HPV-related malignant neoplasm, the case required careful diagnosis, including HPV risk type. The methodology of sampling for HPV testing in men has not been established. This case suggests the necessity for further discussion about HPV testing in male transplant recipients.

Influence of 1 year of androgen deprivation therapy on lipid and glucose metabolism and fat accumulation in Japanese patients with prostate cancer

BACKGROUND

We prospectively examined influence of androgen deprivation therapy (ADT) on lipid and glucose metabolisms in Japanese patients with prostate cancer.

METHODS

Patients with prostate cancer who were hormone-naive and scheduled to receive long-term ADT were recruited between 2011 and 2013. Body weight, abdominal circumference and blood testing associated with lipid and glucose metabolism were recorded every 3 months during 1 year of ADT. Computed tomography (CT) was performed to measure areas of subcutaneous and visceral fat before and after 1 year of ADT. ADT was limited to a luteinizing hormone-releasing hormone (LHRH) agonist with or without bicalutamide.

RESULTS

Of 218 patients registered, data were available from 177 patients who completed 1 year of ADT. Of these, CT was performed before and after 1 year of ADT in 88 patients. Median age was 75 years (range, 49-85 years). Median PSA before ADT was 16.7 ng ml(-1) (range, 0.3-3316). Clinical stage was B (54.2%), C (23.2%) and D (20.9%). Mean increases in body weight and abdominal circumference after 1 year of ADT were 2.9 and 3.0%, respectively. Mean increases in total, low-density lipoprotein and high-density lipoprotein cholesterol and triglycerides were 10.6, 14.3, 7.8 and 16.2%, respectively. Mean increases in fasting blood sugar and hemoglobin A1c (HbA1c) were 3.9 and 2.7%, respectively. Lipid alterations were noted in patients without comorbidities, whereas changes in HbA1c were noted in patients with diabetes mellitus at baseline. These lipid and glucose alterations were prominent in the early ADT period. Both visceral and subcutaneous fat, as measured by CT, increased by >20%. The increase in subcutaneous fat was significantly greater than that in visceral fat (P=0.028).

CONCLUSIONS

One year of ADT significantly changed lipid and glucose metabolism in Japanese patients with prostate cancer. Patient characteristics or comorbidities at baseline may be associated with ADT-induced metabolic changes.

Outcome comparison of ABO-incompatible kidney transplantation with low-dose rituximab and ABO-compatible kidney transplantation: a single-center experience

BACKGROUND

The development of immunosuppressive techniques has helped overcome the ABO incompatibility barrier. However, the outcomes of ABO-incompatible (ABOi) kidney transplantation remain a controversial issue with the advent of the anti-CD20 chimeric antibody rituximab. Herein, we report the outcomes of ABOi kidney transplantation with low-dose rituximab.

PATIENTS AND METHODS

Between June 2006 and April 2013, 42 patients underwent living-related kidney transplantation at our hospital. The patients were divided into 2 groups: ABO-compatible (ABOc; n = 29) and ABOi kidney transplants using low-dose rituximab (100 mg/m(2)) without splenectomy (n = 13). The basic immunosuppression regimen (calcineurin inhibitor [CNI], mycophenolate mofetil [MMF], and steroids) was the same for both groups, except for the use of rituximab and therapeutic apheresis in the ABOi group. We compared post-transplantation renal function, incidents of virus infection, episodes of rejection, and graft survival between the 2 groups.

RESULTS

In our hospital, 30% of recipients received ABOi kidney transplants. The estimated glomerular filtration rate (eGFR) did not differ between the groups. Rejection episodes confirmed by biopsy in the ABOc and ABOi groups were 8 (28%) and 4 (31%) patients (P = .833), acute antibody-mediated rejection was observed in 1 (3.5%) and 2 (15%) patients (P = .165), and virus infection was observed in 14 (48%) and 3 (23%) patients (P = .252), respectively. The 5-year patient survival rate was 100% in both groups, and the 5-year graft survival rates were 95% for ABOc and 100% for ABOi transplants (P = .527).

CONCLUSIONS

These results suggest that the outcomes of ABOi kidney transplantation with low-dose rituximab are similar to those of ABOc kidney transplantation. Further study is necessary to address the efficacy and safety of ABOi kidney transplantation.

Post-transplant renal function and cardiovascular events are closely associated with the aortic calcification index in renal transplant recipients

INTRODUCTION

The aortic calcification index (ACI) is reported to be closely associated with renal dysfunction and cardiovascular events; however, its implication in renal transplant recipients has not been well examined. In this study, we investigated the relationship between pretransplant ACI, ACI progression, post-transplant renal function, and post-transplant cardiovascular events in renal transplant recipients.

PATIENTS AND METHODS

The study from June 1996 to Jan 2012 included 61 renal transplant recipients (living donors, 47; cadaveric donors, 14). The median follow-up period was 60 months. ACI was quantitatively measured on abdominal computed tomography. The relationship between age, dialysis period, estimated glomerular filtration rate (eGFR), and pre- and post-transplant ACI was longitudinally evaluated. Risk factors for post-transplant ACI progression were determined by logistic regression analysis. Patient background and the incidence of post-transplant cardiovascular events were also assessed.

RESULTS

The pretransplant ACI (median 4.2%) significantly correlated with age at transplant, dialysis period, and diabetes mellitus. ACI gradually increased up to 2.8 times at 10 years after transplantation. Post-transplant eGFR significantly correlated with ACI progression in patients with chronic kidney disease of stage ≥ 3. Logistic regression analyses showed that age at transplantation, post-transplant period, cadaveric donors, and post-transplant chronic kidney disease stage 3 were risk factors for post-transplant ACI progression. The pretransplant ACI was higher (median 66%) in 3 patients who experienced post-transplant cardiovascular events.

CONCLUSIONS

ACI progression closely correlates with age and post-transplant renal function. A high pretransplant ACI is a risk factor for post-transplant cardiovascular events in renal transplant recipients.

Telomerase activity Simplification of assay and detection in bladder tumor and urinary exfoliated cells

Detection of telomerase activity can differentiate malignant from benign cells. However, the original telomeric repeat amplification protocol (TRAP) methods had a number of limitations including a radioisotope labeling [α(32)P] dCTP [α(32)P] dGTP system. We developed digoxigenin labeled CX primer to detect telomerase activity without using radioisotope and attempted to detect telomerase activity of bladder tumor and exfoliated cells in bladder cancer patients. Telomerase activity was detected in 5 (71%) of 7 patients diagnosed with grade 1, 31 (97%) of 32 grade 2, and 11 (100%) of 11 grade 3 bladder tumors. In urinary exfoliated cells, 32 (82%) of 39 grades 1 or 2 bladder tumors were positive for telomerase activity but 20 (51%) of 39 were positive for urinary cytology (P < 0.01). Ten (91%) of 11 of grade 3 tumors were positive for telomerase activity and 11 (100%) of 11 were positive urinary cytology. Three of 100 noncancerous patients were positive for telomerase activity. Sensitivity, specificity, and positive predictive value of telomerase activity assay in urinary exfoliated cells were 84%, 97%, and 93%, respectively. Telomerase activity may be a useful diagnostic marker to detect the existence of immortal cancer cells in the urine.

Minimum incision endoscopic radical prostatectomy: clinical and oncological outcomes at a single institute

AIMS

The objective of this study was to investigate the clinical and oncological outcomes of prostatectomy patients undergoing minimum incision endoscopic radical prostatectomy (MIE-RP).

METHODS

Between September 2005 and May 2010, 541 patients underwent MIE-RP with bilateral lymphadenectomy for clinically localized prostate cancer at Hirosaki University Hospital. The present retrospective study enrolled 375 patients who had not received neoadjuvant or adjuvant therapy. MIE-RP was performed through a 6-cm suprapubic midline incision. A 30° laparoscope was conveniently positioned on the head side of the patient for precise observation and monitoring.

RESULTS

The median operating time was 119 min, and the estimated blood loss was 900 ml. The most frequent perioperative complication was leakage from the vesicourethral anastomosis (6.7%), and rectal injury occurred in 1.0%. Overall, 31.2% of the patients had a positive surgical margin, including 11.1% with pT2, 52.9% with pT3 and 100% with pT4 diseases. The post-operative median follow-up period was 40.5 months (range, 2-56.5 months). The 5-year PSA-free survival rate was 71.6%. In multivariate analysis, high-risk patients (according to the D'Amico risk criteria), pathological T stage and positive surgical margins were identified as independent predictors of PSA-free survival. The limitations of this study included a retrospective study, relatively short follow-up period and single-institution nature of the study.

CONCLUSIONS

MIE-RP is a safe and minimally invasive procedure that may represent a reliable alternative to laparoscopic and robotic-assisted RP.

Feasibility and efficacy of gemcitabine and carboplatin neoadjuvant chemotherapy in muscle-invasive bladder cancer

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Background: The neoadjuvant M-VAC followed by radical cystectomy for muscle-invasive bladder cancer has improved survival compared to radical cystectomy alone. Nevertheless, M-VAC has been associated with severe toxicity. The objective of this retrospective study was to evaluate the objective response rate, the impact on overall survival, disease-free survival, disease-free survival and toxicity adverse events of gemcitabine and carboplatin (GC) neoadjuvant chemotherapy in patients with locally advanced bladder cancer. Methods: We reviewed the clinical and pathological data of 140 patients who underwent radical cystectomy and bilateral pelvic lymphadenectomy for T2N0M0 to T4aN0M0 bladder cancer at our institution between January 2001 and August 2008. Seventy patients were treated with neoadjuvant GC followed by cystectomy between March 2005 and August 2008 (GC group), and 70 patients were treated with cystectomy alone between January 2001 and May 2007 (cystectomy alone group). In the GC group, the patients received 2 courses of GC therapy consisted of 800mg/m2 gemcitabine on days 1, 8, and 15 and carboplatin (AUC 4) on day 2. The primary endpoint was the objective response rate, and the secondary endpoints were overall survival, cancer-specific survival, disease free survival, and toxicity. Results: Fifteen patients (23.8%) had a complete response and 26 patients (41.3%) had a partial response in the GC group. At a mean follow-up period of 26.7 months, the overall survival was 85.0% in the GC group and 47.8% in the cystectomy alone group (p = 0.003). The cancer-specific survival was 78.4% in the GC group and 44.6% in the cystectomy alone group (p = 0.0018). The disease-free survival was 82.9% in the GC group and 35.7% in the cystectomy alone group (p = 0.0001). Hematologic toxicities were the main adverse events. Grade 3/4 neutropenia occurred in 26 patients (37.1%) and thrombocytopenia in 15 (21.4%). There was no grade 3/4 gastrointestinal toxicity and no renal function abnormalities. Conclusions: Although this is not a randomized study, the GC neoadjuvant therapy followed by radical cystectomy is feasible and may be associated with improved survival among patients with muscle-invasive bladder cancer. A randomized trial is warranted.

No significant financial relationships to disclose.

Involvement of retinoic acid-inducible gene-I in inflammation of rheumatoid fibroblast-like synoviocytes

Interferon (IFN)-gamma is a major cytokine that regulates T helper 1-type immune reactions and serves as an important mediator in the pathogenesis of autoimmune diseases. Retinoic acid-inducible gene-I (RIG-I) is an IFN-gamma-inducible gene and known to be involved in the inflammatory and immune reactions. In the present study, we found high levels of RIG-I expression in synovial tissues of rheumatoid arthritis (RA), while the expression in osteoarthritis tissues was low. Treatment of cultured fibroblast-like synoviocytes with IFN-gamma markedly induced the expression of RIG-I. Knockdown of RIG-I in fibroblast-like synoviocytes, with specific siRNA, resulted in the inhibition of the IFN-gamma-induced expression of chemokine (C-X-C motif) ligand 10 (CXCL10)/IFN-gamma-inducible protein-10 (IP-10), a chemokine with chemotactic activity towards T cells. These findings suggest that RIG-I may play an important role in the pathogenesis of synovial inflammation in RA, at least in part, by regulating the IFN-gamma-induced expression of CXCL10/IP-10.

Serum sex steroid hormone levels and polymorphisms of CYP17 and SRD5A2: implication for prostate cancer risk

Polymorphism of the steroid hormone-related genes might affect life-long androgen exposure, thus altering a risk of prostate cancer incidence. To evaluate the effect of the polymorphisms of CYP17 and SRD5A2 on serum steroid hormone levels, the 164 male Japanese cohort were tested for serum hormone levels and the genotype of the polymorphisms of CYP17 (T-C base substitution in the promoter region) and SRD5A2 (V89L). The linear trends across the CYP17 genotypes in serum-free testosterone and androstenedione levels were found, suggesting the importance of the polymorphism of CYP17 in determining the circulating androgen levels.

Glycolipid composition in bladder tumor: a crucial role of GM3 ganglioside in tumor invasion

Glycolipids were extracted from primary bladder tumors of 14 patients and 2 normal counterparts. Their expression pattern was assessed by thin-layer chromatography (TLC). The most remarkable change was massive accumulation of GM3 in superficial bladder tumors compared with invasive tumors. This change was also confirmed by immunohistochemistry using anti-GM3 monoclonal antibody. The activities of glycosyltransferases responsible for GM3 synthesis (GM3 synthase, Gb3 synthase and GD3 synthase) were consistent with upregulated expression of GM3 in superficial tumors. It was suggested that the marked GM3 accumulation in superficial tumors was caused not only by upregulated GM3 synthase but also by downregulated activities of Gb3 and GD3 synthase. Histopathologic examination revealed an inverse correlation of the amount of GM3 expressed with invasive potential. Exogenously supplemented GM3 suppressed invasion potential in human bladder tumor cell lines (T-24, KK-47). These results indicate that the amount of GM3 expressed may serve as an indicator of the invasion potential of bladder tumor. Furthermore, new antiinvasion therapeutics may be possible by administration of GM3.

Enhanced GM3 expression, associated with decreased invasiveness, is induced by brefeldin A in bladder cancer cells

We reported previously that non-invasive bladder cancer expresses high level of GM3 ganglioside, whereas invasive tumors have low levels. Since glycosphingolipid synthesis in Golgi is modified greatly by a macrocyclic lactone isolated from fungi, brefeldin A (BFA), we studied effects of BFA on expression of glycosphingolipids and on invasiveness of bladder cancer cell lines. Only GM3 synthesis in invasive tumors was greatly enhanced upon treatment with BFA; synthesis of other glycosphingolipids with lacto-series type 2 or globo-series structure in both invasive and non-invasive tumors was not changed. Invasiveness of bladder cancer cells was greatly decreased in association with the great increase of GM3 synthesis induced by BFA treatment. Level of sialyl-Lex expressed in invasive cell line YTS1, which provides the adhesive property of the cells to E-selectin, was unchanged upon BFA treatment. All the bladder cancer cell lines, regardless of invasiveness, highly express tetraspanin CD9. GM3 has been implicated as a co-factor of CD9 in control of tumor cell motility. Down-regulation of CD9 is associated with metastatic properties of tumor cells and survival of patients with colonic cancer. Therefore, enhanced synthesis of GM3 induced by BFA, causing decrease of invasiveness in bladder cancer, is ascribable to the capability of GM3 to interconnect integrin with CD9, in analogy to colonic cancer and perhaps many other types of cancer.

Adenocarcinoma arising from the prostatic duct mimicking transitional cell carcinoma

A 71-year-old man was first diagnosed with primary transitional cell carcinoma of the prostate with a skip lesion on the distal urethra. The patient received three courses of intra-arterial chemotherapy of cisplatin (CDDP) and pirarubicin (THP-ADM) followed by a radical prostatectomy. Histopathologic examination of the prostatectomy specimen revealed adenocarcinoma invasion along the prostatic duct extending to the peripheral acini, which was diagnosed as ductal adenocarcinoma. The clinical and histopathologic features of this case are entirely different from usual adenocarcinomas of the prostate. This rare histopathologic feature should be recognized as 'ductal carcinoma of the prostate', to distinguish it from papillary adenocarcinoma or adenocarcinoma with endometrioid features. The patient has had no sign of recurrence 14 months after the operation. CDDP-based chemotherapy followed by radical prostatectomy may be one of the promising therapeutic modalities for this rare entity.

Trans-urethral whole layer core biopsy for detection of residual tumor after neoadjuvant therapy in invasive bladder cancer

The most essential information necessary for the treatment of bladder cancer is to know its exact staging. We have developed a percutaneous whole layer core biopsy (PC-WLCB) of the bladder tumor and applied it successfully since April 1985 for the staging and evaluation of neoadjuvant therapy in locally invasive bladder cancer. We report here a modified method, the trans-urethral WLCB (TU-WLCB) and present its clinical results. Methods: A 20 F. rigid nephroscope was introduced trans-urethrally and an 18 gauge, 350mm-long biopsy needle or newly developed 450mm-long biopsy needle was advanced to the tumor through the nephroscope. Biopsy was performed under trans-abdominal ultrasound guidance. Results: Specimens of all 20 TU-WLCB cases included the muscle layer and adipose tissue, and demonstrated small focus of residual cancers after neoadjuvant therapy. Serious complications were not observed so far. Conclusion: TU-WLCB may prove to be a reliable method to stage and evaluate neoadjuvant therapy for invasive bladder cancer.