Association of gastrointestinal events with quality of life and treatment satisfaction in osteoporosis patients: results from the Medication Use Patterns, Treatment Satisfaction, and Inadequate Control of Osteoporosis Study (MUSIC OS)

The purpose of this study was to assess the association of GI events with HRQoL and treatment satisfaction. The effect of baseline GI events persisted through 1 year of follow-up, as indicated by lower EQ-5D, OPAQ-SV, and treatment satisfaction scores among patients with vs without baseline GI events. The presence of GI events is an independent predictor of decreased HRQoL and treatment satisfaction in patients being treated for osteoporosis.

INTRODUCTION

The goal of this study was to assess the association of gastrointestinal (GI) events with health-related quality of life (HRQoL) and treatment satisfaction in patients being treated for osteoporosis.

METHODS

MUSIC OS was a multinational, prospective, observational study examining the impact of GI events on osteoporosis management in postmenopausal women. In this analysis, HRQoL and treatment satisfaction were assessed at baseline, 6, and 12 months and compared between patients with and without GI events. Covariate-adjusted scores were calculated using multivariate least-squares regression analysis, and differences between the mean scores of patients with and without baseline and post-baseline GI events were determined.

RESULTS

Among the 2959 patients in the analysis, unadjusted scores at each time point were lower (i.e., worse) for patients with GI events than patients without GI events. In adjusted analyses, the effect of baseline GI events persisted through 1 year of follow-up, as indicated by lower EQ-5D and OPAQ-SV scores at 12 months among patients with vs without baseline GI events (-0.04 for the EQ-5D utility score, -5.07 for the EQ-5D visual analog scale, -3.35 for OPAQ physical function, -4.60 for OPAQ emotional status, and -8.50 for OPAQ back pain; P ≤ 0.001 for all values). Decrements in month 12 treatment satisfaction scores were -6.46 for patients with baseline GI events and -7.88 for patients with post-baseline GI events.

CONCLUSIONS

The presence of GI events is an independent predictor of decreased HRQoL and treatment satisfaction in patients being treated for osteoporosis.

The Human Proteome Organization Chromosome 6 Consortium: integrating chromosome-centric and biology/disease driven strategies

The Human Proteome Project (HPP) is designed to generate a comprehensive map of the protein-based molecular architecture of the human body, to provide a resource to help elucidate biological and molecular function, and to advance diagnosis and treatment of diseases. Within this framework, the chromosome-based HPP (C-HPP) has allocated responsibility for mapping individual chromosomes by country or region, while the biology/disease HPP (B/D-HPP) coordinates these teams in cross-functional disease-based groups. Chromosome 6 (Ch6) provides an excellent model for integration of these two tasks. This metacentric chromosome has a complement of 1002-1034 genes that code for known, novel or putative proteins. Ch6 is functionally associated with more than 120 major human diseases, many with high population prevalence, devastating clinical impact and profound societal consequences. The unique combination of genomic, proteomic, metabolomic, phenomic and health services data being drawn together within the Ch6 program has enormous potential to advance personalized medicine by promoting robust biomarkers, subunit vaccines and new drug targets. The strong liaison between the clinical and laboratory teams, and the structured framework for technology transfer and health policy decisions within Canada will increase the speed and efficacy of this transition, and the value of this translational research.

BIOLOGICAL SIGNIFICANCE

Canada has been selected to play a leading role in the international Human Proteome Project, the global counterpart of the Human Genome Project designed to understand the structure and function of the human proteome in health and disease. Canada will lead an international team focusing on chromosome 6, which is functionally associated with more than 120 major human diseases, including immune and inflammatory disorders affecting the brain, skeletal system, heart and blood vessels, lungs, kidney, liver, gastrointestinal tract and endocrine system. Many of these chronic and persistent diseases have a high population prevalence, devastating clinical impact and profound societal consequences. As a result, they impose a multi-billion dollar economic burden on Canada and on all advanced societies through direct costs of patient care, the loss of health and productivity, and extensive caregiver burden. There is no definitive treatment at the present time for any of these disorders. The manuscript outlines the research which will involve a systematic assessment of all chromosome 6 genes, development of a knowledge base, and development of assays and reagents for all chromosome 6 proteins. We feel that the informatic infrastructure and MRM assays developed will place the chromosome 6 consortium in an excellent position to be a leading player in this major international research initiative. This article is part of a Special Issue: Can Proteomics Fill the Gap Between Genomics and Phenotypes?

The use of consensus guidelines for management of cytomegalovirus infection in renal transplantation

Cytomegalovirus (CMV) infection imposes a significant economic burden on susceptible patients after renal transplantation. Our study was conducted to determine the prediction, probability, consequences, and treatment costs of CMV infection under Canadian consensus guidelines in 270 sequential transplant patients. Transplant patients from donors positive (D(+)) for CMV into recipients negative (R(-)) for CMV received antiviral prophylaxis for 14 weeks and all but donor negative (D(-))/R(-) patients were monitored weekly for the CMVpp65 marker expression. Marker-positive patients and patients with CMV infection or disease received antiviral treatment. Within the first 6 months, 27% of the 270 patients tested had incidences of asymptomatic CMV infection, while 9% had CMV syndrome or disease. Only 1% of patients had infection after 6 months. The CMVpp65 marker levels were significantly greater in patients with syndrome or disease; but post-test probabilities and predictive value of the marker assay were low. Mean direct costs for care were $2256 and ranged from $927 for D(-)/R(-) patients to $7069 in the D(+)/R(-) patients. Extension of antiviral prophylaxis to D(+) or D(+)/R(+) patients significantly increased the estimated mean costs for an absolute reduction to 4% in CMV syndrome or disease. Our studies show that current guidelines for treatment enable effective control of CMV infection; however, alternative strategies have different economic impact.

Biomarkers in transplantation: Prospective, blinded measurement of predictive value for the flow cytometry crossmatch after negative antiglobulin crossmatch in kidney transplantation

This prospective, blinded observational study was conducted to measure the predictive value the of flow cytometric crossmatch for biopsy-proven acute rejection, graft loss, or death following kidney transplantation. Patients were selected for renal transplantation on the basis of a conventional antihuman globulin cytotoxic T-cell crossmatch. Flow crossmatch was performed simultaneously, but the results were not disclosed to the transplant team. A total of 257 kidney transplant recipients were enrolled in the study; 78 patients experienced biopsy-proven rejection in the first post-transplant year, and 41 patients lost their graft or died during the period of follow-up (mean: 2046 days). Kaplan-Meier estimates of rejection, graft loss, or patient death did not differ between subjects with a positive or negative flow crossmatch. Cox analyses showed no influence of the flow crossmatch on the risk of biopsy-proven acute rejection (P = 0.987). The sensitivity and specificity of the flow crossmatch for prediction of biopsy-proven rejection were 0.128 and 0.883, and the positive and negative post-test probabilities were 0.323 and 0.301, respectively. The magnitude of the channel shift did not influence the multivariate Cox regression model. The area under the receiver operating characteristic curve of the flow crossmatch was 0.483 (P = 0.71) and 0.572 (P = 0.38), respectively for the living and cadaver transplant recipients, indicating no discriminative value in this study population. Flow crossmatch appears to have no significant incremental value in predicting biopsy-proven acute rejection, graft loss, or death following kidney transplantation in patients who have a negative antihuman globulin cytotoxic T-cell crossmatch against their donor.

Two-Hour Post-Dose Cyclosporine Levels in Renal Transplantation in Argentina: A Cost-Effective Strategy for Reducing Acute Rejection

Monitoring of cyclosporine (microemulsion CsA) at 2 hours post-dose (C2), a measure of absorption and exposure, appears superior to trough (C0) monitoring for prediction of rejection risk. The purpose of this study was to determine whether C2 was cost-effective compared to C0 in Argentina.

METHODS

A predictive decision model was adapted to Argentina to predict costs associated with C0 and C2 measurements in the first year after transplantation. Patients were treated with microemulsion CsA, steroids and azathioprine or MMF. Parameter estimates for the C0 strategy were based on event rates observed in published clinical trials. The model was adapted to Argentinean health system through local protocols and expert opinions; costs were valued in Argentinean pesos and converted to US dollars (1 USD = 2.85 ARS).

RESULTS

Incidence of acute rejection was predicted to be 25.0% at 1-year among patients monitored by C0 and 18.0% by C2. Graft survival was predicted to be 1.4% lower in the C0 group. No important differences were identified in co-morbidity, C0 and C2 monitoring costs, and in ambulatory-based adverse events between C0 and C2 cohorts. The model predicted an average cost per patient of $16,269 for C0 and $16,343 for C2 testing (year 1). Sensitivity analyses indicated that the average daily dose of microemulsion CsA was the most important parameter leading to the incremental cost per patient.

CONCLUSIONS

C2 is expected to provide a potentially important reduction in the risk of acute rejection without increasing the estimated cost of care in the first year post-transplant.

Economic analysis of basiliximab in renal transplantation

BACKGROUND

Basiliximab is a chimeric monoclonal directed against the alpha-chain of the interleukin-2 receptor. International studies have shown that it is highly effective in preventing acute rejection in patients receiving Neoral, and causes no measurable incremental toxicity, but its economic value remains unknown.

METHODS

This study employed an economic model to examine the potential economic benefit of basiliximab. Parameter estimates were derived from a randomized, prospective, double-blind study conducted in 21 renal transplant centers in seven countries in which 380 adult primary allograft recipients were randomized within center to receive basiliximab (20 mg i.v.) on days 0 and 4 or placebo in addition to dual immunosuppression with Neoral and steroids. Key clinical events included primary hospitalization, immunosuppressive drug use, patient and graft survival, graft rejection, treatment of rejection, dialysis, and repeat hospitalization. Health resources were valued via a comprehensive electronic cost dictionary, based upon a detailed economic evaluation of renal transplantation in Canada. Medication costs were calculated from hospital pharmacy acquisition costs; basiliximab was assessed a zero cost.

RESULTS

The average estimated cost per patient for the first year after transplant was $55,393 (Canadian dollars) for placebo and $50,839 for basiliximab, rising to $141,690 and $130,592, respectively, after 5 years. A principal component of the cost in both groups was accrued during the initial transplant hospitalization ($14,663 for standard therapy and $14,099 for basiliximab). An additional $15,852 and $14,130 was attributable to continued care, graft loss, and dialysis in the two groups, whereas follow-up hospitalization consumed an additional $15,538 for placebo and $13,916 for basiliximab. The mean incremental cost of dialysis was $5,397 for placebo compared with $3,821 for basiliximab, whereas incremental costs of graft loss were $2,548 compared with $2,295 in the two treatment groups. The principal costs associated with repeat admission to the transplant ward and the general ward were marginally higher for placebo ($7,395 vs. $6,300 and $5,986 vs. $4,625). Treatment of acute rejection and maintenance immunosuppressive drug use were associated with only limited savings as a result of basiliximab (savings <$200 each). Sensitivity analysis indicated that the most influential parameters affecting the savings as a result of using basiliximab were a reduction in the duration of initial and repeat hospitalization followed by the reduced risks of acute rejection and graft loss.

CONCLUSIONS

Before accounting for the cost of the therapy itself, basiliximab produces an estimated economic saving of $4,554 during the first year after transplant, of which $3,344 is attributable to the reduced costs of graft dysfunction, including graft loss and dialysis ($1,722) and follow-up hospitalizations ($1,622). When marketed, basiliximab is expected to cost approximately $3,000 per course (two doses of 20 mg), resulting in a net first-year saving of $1,554. Under these circumstances, basiliximab can be considered a dominant therapy in renal transplantation.

Association between dinucleotide repeat in non-coding region of interferon-gamma gene and susceptibility to, and severity of, rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis ranges from a mild, non-deforming arthropathy with little long-term disability to severe, incapacitating, deforming arthritis which may be refractory to conventional disease-modifying agents. Epidemiological studies show an important genetic influence in rheumatoid arthritis, and MHC region genes and cytokine genes within and outside this region have been considered as candidates. We did a case-control study to test whether polymorphisms in the interferon-gamma gene are associated with severity of rheumatoid arthritis.

METHODS

Interferon gamma dinucleotide repeat polymorphisms were examined with quantitative genescan technology, and HLA-DR alleles were identified by PCR and restriction-fragment-length polymorphism analysis. We studied 60 patients with severe rheumatoid arthritis, 39 with mild disease, and 65 normal controls.

FINDINGS

Susceptibility to, and severity of, rheumatoid arthritis were related to a microsatellite polymorphism within the first intron of the interferon-gamma gene. A 126 bp allele was seen in 44 (73%) of 60 patients with severe rheumatoid arthritis, compared with eight (21%) of 39 with mild disease (odds ratio 10.66 [95% CI 4.1-24.9]), and with eight (12%) of 65 normal controls (19.59 [7.7-49.9]). Conversely, a 122 bp allele at the same locus was found in four (7%) patients with severe disease compared with 25 (64%) of those with mild disease (0.04 [0.01-0.1]) and with 52 (80%) of controls (0.018 [0.005-0.06]).

INTERPRETATION

This association may be valuable for understanding the mechanism of disease progression, for predicting the course of the disease, and for guiding therapy.

Development of a biologically distinct EBV-related lymphoproliferative disorder following autologous bone marrow transplantation for an EBV-negative post-renal allograft Burkitt's lymphoma

Post-transplant lymphoproliferative disorder (PTLD) is a known complication of both solid organ transplantation and allogeneic bone marrow transplantation (BMT) but is rarely seen following autologous BMT. We report the case of a 45 year-old female who developed Burkitt's lymphoma eight years after a renal allograft. This PTLD was found to have lambda light chain restriction, contained del(8)(q24) and add(14)(q32), and was negative for EBV on immunohistochemical and DNA-based PCR analyses. Immunoglobulin heavy chain (IgH) PCR studies revealed a prominent clonal rearrangement. She responded to intravenous cyclophosphamide and proceeded to high-dose chemoradiotherapy and mafosfamide-purged autologous BMT. Thirty-nine days post-BMT she presented with cough and fever and developed hepatic dysfunction; abnormal lymphoplasmacytoid cells were noted in the peripheral blood. Investigations revealed kappa light chain restriction, an oligoclonal IgH rearrangement, a normal karyotype and PCR studies for EBV were positive, consistent with a clinically and biologically distinct PTLD. She initially improved following discontinuation of immunosuppression, but then deteriorated abruptly and died 58 days post-BMT. It is likely that the two separate episodes of PTLD in this patient, one of which was atypical, arose as a result of both the chronic use of cyclosporine and the impairment of cell-mediated immunity associated with autologous BMT. The sequence of events in this patient should contribute to a better understanding of late-onset, EBV-negative PTLD.

Effect of gastrointestinal inflammation and age on the pharmacokinetics of oral microemulsion cyclosporin A in the first month after bone marrow transplantation

Cyclosporin A (CsA) absorption is highly variable in BMT patients. Neoral, a new microemulsion formulation of CsA, permits increased absorption with less variable pharmacokinetic parameters in non-BMT patients. We evaluated the pharmacokinetics of CsA after BMT in patients received microemulsion CsA. Two oral doses of 3mg/kg were given 48 h apart between 14 and 28 days after allogeneic BMT in 20 adults, and one dose in seven children, while subjects were receiving a continuous i.v. infusion of CsA. Whole blood samples were taken throughout the dosing interval to calculate the incremental CsA exposure using maximum concentration (Cmax), time to Cmax (tmax), concentration at 12 h after the dose (C12), the area under the concentration-time curve (AUC), and to establish inter- and intra-patient pharmacokinetic variability. Drug exposure was substantially lower in children than adults, with an AUC of 861+/-805 vs 2629+/-1487 micromg x h/l (P = 0.001), respectively, and absorption was delayed and diminished in both groups by comparison with solid organ recipients. Intra-patient variability in adults for AUC was high at 0.59+/-0.34, while inter-patient variability, measured as the coefficient of variation (c.v.), was 0.55 for the first and 0.54 for the second dose. In adults, gastrointestinal (GI) inflammation due to either mucositis or GVHD resulted in a higher AUC of 3077+/-1551 microg x h/l compared to 1795+/-973 microg x h/l (P = 0.02), and a similar trend was observed in children. AUC seemed little affected by the CsA formulation (liquid or capsule), or co-administration with liquids or food. Trough (12 h) CsA levels correlated poorly with incremental AUC. Sparse sample modeling of the AUC using two-point predictors taken at 2.5 and 5 h after dosing accurately approximated AUC in adults (r2 = 0.94), while 1.5 and 5 h was superior in children (r2 = 0.98). These data suggest that 12 h postdose trough measurements of CsA may not be the most appropriate way to evaluate CsA blood concentrations in order to establish therapeutic efficacy in BMT patients. Based on this study, the dose of microemulsion CsA should be adjusted based on recipient age, and the presence of GI inflammation secondary to mucositis or GVHD. These data would suggest that sparse sampling at time points earlier than the trough more accurately reflects the AUC and may correlate more closely with therapeutic efficacy early post-BMT.

Distribution of DRB1 and DQB1 HLA class II alleles in occupational asthma due to western red cedar

Occupational asthma caused by western red cedar is a common problem in sawmill industries. The objective of this study was to examine a possible association of human leukocyte antigen (HLA) class II genetic markers with susceptibility or resistance to western red cedar induced asthma. The distribution of DRB1 and DQB1 HLA class II alleles and DRB1-DQB1 haplotypes was studied in 56 Caucasian patients with proven red cedar asthma and 63 healthy Caucasian control subjects exposed to red cedar dust. DRB1 and DQB1 high resolution typing was performed by the polymerase chain reaction-based method. Patients with red cedar asthma had a higher frequency of HLA DQB1*0603 and DQB1*0302 alleles compared to a group of healthy exposed control subjects and a reduced frequency of DQB1*0501 allele. The frequency of the DRB1*0401-DQB1* 0302 haplotype was increased and the DRB1*0101-DQB1*0501 haplotype was reduced. These findings suggest that genetic factors such as human leukocyte antigen class II antigens may be associated with susceptibility or resistance to development of red cedar asthma.

The role of inflammatory mediators in the mechanism of the host immune response induced by ischemia-reperfusion injury

Our previous study suggested that inflammatory mediators released due to IRI lead to host's immune response by upregulating MHC II in the host's peripheral T lymphocytes. This study hypothesized the role of platelet-activating factor (PAF) in the mechanism of induced MHC II upregulation due to IRI on peripheral T lymphocytes. The objectives of this study were to investigate the role of PAF in the induction of host immune reactivity and the protective effect of PAF-antagonist TCV-309 in combination with prostaglandin E1 (PGE1) against the host's immune response caused by IRI. Thirty female domestic swine were divided into three groups. Group A (6 donors, 6 recipients) had no pharmacological intervention. Group B (6 donors, 6 recipients) was the experimental group treated with TCV-309 + PGE1. Group C underwent sham operation. The ex vivo preservation time for groups A and B was 4 hr at 4 degrees C. To detect the changes in MHC II expression on T cells due to IRI, blood samples were collected before reperfusion (baseline level), 1, 2, and 3 days post-reperfusion. Two-colour flow cytometry analysis (FACS) was used to study MHC II-DR-beta expression in peripheral T lymphocytes. Swine anti-MHC II and anti-CD3 antibodies were used for this purpose. The FACS analyses demonstrated that in group A, there was a significant increase (p < 0.05) in MHC II intensity on peripheral T lymphocytes on day 2 post-reperfusion. By the third day post-reperfusion, MHC intensity had a tendency to decrease but did not reached the baseline level. In group B and C, however, there was no significant change in the level of MHC II in T lymphocytes at any of the post-reperfusion times. In group A, the number of CD3+MHC+ T lymphocytes significantly decreased (p < 0.05) by one day post-reperfusion and remained at this level until the third day post-reperfusion. In groups B and C, no significant change in the number of CD3+MHC+ T cells was observed. The results of this study suggested that the release of inflammatory mediators (e.g. PAF) due to IRI played a role in the mechanism of IRI-induced host's immune response. The results also suggested that the combination of TCV-309 + PGE1 could reduce this immune response.

New immunosuppressive strategies

Discovery of novel biological and pharmaceutical agents directed against discrete molecular targets in the lympnocyte activation sequence has enabled the effective control of graft rejection by the use of combinatorial immunosuppressive therapy. Chimeric and humanized monoclonal antibodies against T-cell receptor CD3 complex chains or the IL-2 receptor block T-cell function without inducing activation, and do not cause the cytokine release syndrome of first generation products. Biological blockade of co-stimulatory molecules including CD40L and CD28 produces immunological allograft unresponsiveness in primates, though this effect is not yet proven in humans. Heterogeneity in clinical response to pharmaceutical agents is often explained by pharmacokinetic factors of absorption, metabolism and elimination. The use of microemulsion technology has increased the absorption and efficacy of cyclosporine in all organ transplants, so that there is little difference in efficacy between this agent and tacrolimus. Mycophenolate mofetil is not maximally effective alone, but significantly reduces the relative risk of acute rejection in combination with an immunophilin binding agent. It is also effective when introduced at the time of rejection. Whether it can replace other agents for maintenance immunosuppression is now under investigation. Sirolimus, the latest pharmaceutical agent to complete phase III trials, acts to inhibit IL-2 driven lymphocyte proliferation and reduces the risk of acute rejection to below 20%. Multiple pharmacokinetic interactions occur within and between these agents, so that pharmacokinetic monitoring is increasingly important. At present there are few tools to detect pharmacodynamic interactions, although reporter gene constructs and intracellular cytokine labeling offer exciting possibilities for biological monitoring. Despite these advances, none of these interventions confers demonstrable long-term benefit in graft survival or function. Acute rejection can not therefore be assumed to be a simple surrogate for chronic injury, and research must be re-focused to determine the relevant targets for long-term immunosuppression.

Cyclosporine monitoring in patients with renal transplants: two- or three-point methods that estimate area under the curve are superior to trough levels in predicting drug exposure

The recent introduction of a cyclosporine microemulsion demonstrating less pharmacokinetic variability than the conventional formulation offers the potential for accurately and precisely predicting area under the curve (AUC) with a limited-sampling monitoring strategy. This was studied based on the pharmacokinetic profiles from 55 stable patients with renal transplants who were observed on two occasions at steady state on both formulations. Multiple linear regression analyses were performed on a training dataset from 27 patients, in which combinations of cyclosporine concentrations drawn from 0 to 4 hours postdose were regressed against the full AUC over the dosing interval. Predictor regression equations used concentration combinations ranging from one-point (concentrations at 0, 1, 2, 3, or 4 hours) through five-points (all five concentrations 0 to 4 hours). The predictive performance of these equations was then assessed in the training group with data from a subsequent profiling occasion and in the remaining 28 patients who constituted an independent test group. Prediction bias (mean prediction error) and prediction precision (absolute prediction error) were quantified and compared between formulations. Correlations between predicted and actual AUC were consistently stronger for the microemulsion, suggesting the possibility of more accurate and precise predictions of exposure than from the conventional formulation. For both formulations, the one-point predictors rendered the lowest prediction precision, and predictive performance improved considerably when multiple-point predictors were used. Significantly higher precision and lower variability were observed with the microemulsion for most predictors in the both training and test groups. For the microemulsion, two-point (C0 + C1 or C0 + C2) and three-point (C0 + C1 + C2) predictors yielded relatively unbiased and precise exposure predictions, inasmuch as mean absolute prediction error was less than 10% and 5%, respectively. Hence, a two- or three-point method may provide a clinically important improvement over the use of trough levels in monitoring cyclosporine therapy in patients with renal transplants.

The relationship of ischemia-reperfusion injury of transplanted lung and the up-regulation of major histocompatibility complex II on host peripheral lymphocytes

OBJECTIVES

This study was designed to examine the relationship between ex vivo preservation time of the transplanted lung and the extent of injury and to relate this to the severity of rejection with and without allogenicity.

METHODS

Single lung transplantation was performed on two groups of domestic swine. Group A (n = 7) and group B (n = 6) had ex vivo preservation times of 4 and 15 hours, respectively, at 4 degrees C hypothermia. Group C (n = 6) underwent 2 hours of warm ischemia via dissection and isolation of the left lung with ligation of its bronchial artery and crossclamping of the left pulmonary artery, vein, and bronchus without explantation. Assessment measures included lung function, antioxidant enzyme activities in the plasma and lung tissue, levels of inflammatory mediators in the recipient plasma, and quantification of major histocompatibility complex II HLA-DR-beta on host peripheral lymphocytes.

RESULTS

All groups demonstrated increases in interleukin-10, lung weight, and HLA-DR-1beta expression and decreases in lung-tissue antioxidant enzyme activities, gas exchange, and lung compliance. There was a strong positive correlation between ex vivo preservation time and the expression of HLA-DR-beta and a negative correlation between ischemic time and lung-tissue superoxide dismutase.

CONCLUSIONS

These results suggest that the intensity of the host immunogenic response is related to the severity of ischemia-reperfusion injury and is independent of tissue incompatibility and/or the type of ischemic insult. We conclude that the extension of ex vivo preservation time may predispose the transplanted lung to more severe rejection.

Investigation of a possible interaction between ciprofloxacin and cyclosporine in renal transplant patients

BACKGROUND

Bacterial infection is a common complication during the first few months after renal transplantation. Ciprofloxacin, a fluoroquinolone broad-spectrum antibiotic, is used frequently in treating infections in the early posttransplant period. Evidence from in vitro studies has suggested that ciprofloxacin can antagonize the cyclosporine (CsA)-dependent inhibition of interleukin-2 production. Such an effect in renal transplant patients could antagonize the immunosuppressive activity of CsA and lead to rejection of the graft.

METHODS

To investigate the possibility of a pharmacodynamic interaction between ciprofloxacin and CsA, we conducted a case-control study in 42 patients who had received a kidney transplant and who were prescribed ciprofloxacin in the first 1-6 months after transplantation and in their matched controls (two per case) who did not receive ciprofloxacin during the study period.

RESULTS

There was a twofold greater incidence (P=0.008) of ciprofloxacin use at 1-3 months (65%) than was observed at 4-7 months (35%) after transplantation. The proportion of cases experiencing at least one episode of biopsy-proven rejection 1-3 months posttransplant (45%) was significantly greater (P=0.004) than that of controls (19%). Furthermore, there was a marked increase (P<0.001) in the incidence of rejection temporally associated with ciprofloxacin use among cases (29%) compared with that experienced by the controls (2%).

CONCLUSIONS

The possibility that ciprofloxacin increases rejection rates in renal transplant patients may be of clinical importance and therefore warrants further investigation.

Simple bioequivalence criteria: are they relevant to critical dose drugs? Experience gained from cyclosporine

A critique of the current bioequivalence regulations is presented with reference to critical dose drugs. Using the development of a new cyclosporine formulation as an example, the deficiencies in current bioequivalence testing guidelines are examined and discussed. Based on the experience gained with cyclosporine, recommendations are made on how therapeutic equivalence, rather than just bioequivalence, should be established.

Detection and quantification of cyclosporine in body fluids using an interleukin-2 reporter-gene assay

Different assays are employed to monitor the concentration of immunosuppressive drugs in biological fluids. None of these methods gives direct and precise information on the actual level of immunosuppression in the patient. Here we describe the use of an interleukin-2 (IL-2) reporter-gene assay (IL-2 RGA) to monitor the concentrations of immunosuppressants in body fluids. This assay is based on a chimeric gene construct in which the human IL-2 promoter drives the expression of a reporter gene. Upon mitogenic stimulation the reporter gene is expressed and can be easily quantified. The assay is very sensitive and selective for immunosuppressive compounds inhibiting IL-2 gene expression such as cyclosporine (CsA) and FK506, their active metabolites and derivatives, but not for others such as rapamycin. High reproducibility, fast performance time, and high capacity are additional characteristics of the assay. The assay was developed to monitor immunosuppressive drug levels in human volunteers or in animals receiving CsA analogues as the only immunosuppressive drugs. This assay is sensitive to CsA or ascomycin/FK506 analogues and metabolites, for which there are presently no specific monoclonal antibodies available. The IL-2 reporter-gene assay may be more suitable than other in vitro systems such as MLR or mitogen stimulated PBMC which were previously used to study the immunosuppressive activity of drugs in body fluids.

Late acute rejection occurring in liver allograft recipients

To study the effect of immunosuppressive reduction on the incidence and consequence of late acute rejection (LAR) in liver allograft recipients, mean daily prednisone dose, mean cyclosporine A (CsA) trough and nadir levels were retrospectively reviewed for the nearest 12-week period preceding six episodes of LAR in five liver allograft recipients (group 1). Results were compared with those from a cohort of 12 liver allograft recipients who did not develop LAR (group 2). LAR was defined as acute rejection occurring more than 365 days post-transplantation. Median follow-up for both groups was similar (504 days, range 367 to 1050, versus 511 days, range 365 to 666, not significant). Mean trough CsA levels were lower in patients with LAR compared with those without (224 +/- 66 ng/mL versus 233 +/- 49 ng/mL) but the difference was not statistically significant. In contrast, mean daily prednisone dose (2.5 +/- 1.6 mg/day versus 6.5 +/- 2.9 mg/day, P = 0.007) and CsA nadir values (129 +/- 60 ng/mL versus 186 +/- 40 ng/mL, P = 0.03) were significantly lower in patients who developed LAR compared with those who did not. Five of six episodes (83%) of LAR occurred in patients receiving less than 5 mg/day of prednisone, versus a single LAR episode in only one of 12 patients (8%) receiving prednisone 5 mg/day or more (P = 0.004). In all but one instance, LAR responded to pulse methylprednisolone without discernible affect on long term graft function. The authors conclude that liver allograft recipients remain vulnerable to acute rejection beyond the first post-transplant year; and reduction of immunosuppressive therapy, particularly prednisone, below a critical, albeit low dose, threshold increases the risk of LAR.

Evidence for earlier stabilization of cyclosporine pharmacokinetics in de novo renal transplant patients receiving a microemulsion formulation

Sequential cyclosporine pharmacokinetic assessments were performed at four centres within the context of a double-blind, multicenter clinical trial comparing the safety and tolerability of the conventional formulation with cyclosporine for microemulsion in de novo renal transplant patients. The initial average daily oral dose was 9.3 mg/kg given in two divided doses every 12 hr with subsequent dose reductions individually titrated to maintain trough concentrations within the target therapeutic range. Pharmacokinetic profiles were assessed at week 2, once between weeks 4-6, and at week 12 in 12 patients on the conventional formulation and 9 patients on the microemulsion. Over the study duration, cyclosporine daily doses were comparable in both study arms and were reduced in parallel from 9.2 to 6.9 to 4.7 mg/kg/day at the three successive pharmacokinetic visits. Dose-normalized peak and area-under-the-curve (AUC) increased between the week 2 and week 4-6 assessments for both formulations. Thereafter, these parameters continued to increase for the conventional formulation but exhibited a high degree of within-in patient stability for the microemulsion between week 4-6 and week 12. Between-formulation comparisons indicated that the rate and extent of cyclosporine absorption from the microemulsion were significantly higher over the study duration. Specifically, at week 2, 4-6 and 12, dose-normalized AUC was 49%, 63%, and 32% higher for the microemulsion. Intrasubject coefficients of variability for pharmacokinetic parameters of the conventional formulation ranged from 26.3% to 68.2%. Corresponding values for the microemulsion were reduced by approximately half, ranging from 13.1% to 38.7%. The correlation between predose trough concentration and AUC was stronger for the microemulsion (r(2)0.819 vs. 0.635) over the full range of systemic exposures attained throughout the study. These results provide initial evidence that, as doses are reduced with time posttransplant, the cyclosporine dose-exposure relationship from the microemulsion may stabilize earlier than that from the conventional formulation, allowing increased pharmacokinetic control over cyclosporine use in this critical posttransplant period.

Use of cyclosporine microemulsion (Neoral) in de novo and stable renal transplantation: clinical impact, pharmacokinetic consequences and economic benefits. Canadian and International Neoral Study Groups

Neoral appears to offer substantial pharmacokinetic benefits over previous formulations. It is absorbed more rapidly, completely, and consistently, and may eliminate the need for intravenous administration of CyA in all but the most difficult circumstances. Neoral may reduce the incidence of graft rejection in new renal transplant recipients, although this is not substantiated by all studies to this point. The economic analyses, though limited to cost-minimization studies with reasonably small patient populations, suggest that there may be potential savings in the use of Neoral which evolved from a lower use of health care resources. The more extensive studies now in preparation will be able to examine each of these outcomes in greater detail.

Successful paternity of twins following bone marrow transplantation with busulfan, melphalan and cyclophosphamide conditioning

A 33-year-old man who had received previous chemotherapy with cytarabine, daunorubicin and mitoxantrone followed by an autologous marrow transplant after conditioning with busulfan, melphalan and cyclophosphamide, fathered sex-mismatched fraternal twins approximately 6 years post-transplant. HLA and DNA analyses showed the probability of paternity to be in excess of 99% for each twin. To our knowledge this represents the first documented case of paternity following conditioning with this combination of marrow ablative agents and the first report of twin paternity following autologous marrow transplantation.

Cytokine profile in acute myelofibrosis associated with aggressive large granular lymphocyte leukemia

We report a patient with acute large granular lymphocyte (LGL) leukemia, presenting as acute myelofibrosis (AMF). The leukemic cells were immature T-cells (CD5+, CD7+, CD16-, CD56-, CD57-, and CD41-), had monosomy 7, and secreted large amounts of Transforming Growth Factor-beta 1(TGF-beta 1). The serum levels of interleukins (IL)-2, -2R, -6 and -8 were elevated, while the IL-1 beta, IL-4, and tumor necrosis factor-alpha were normal.

An introduction to utility measurement in health care

Key decisions regarding the introduction and optimal use of health technologies often are made on an ad hoc basis. Quantitative information on effectiveness, if incorporated into the decision-making process, would establish a reasoned and defensible basis for the introduction and optimal use of therapeutic technologies. Utility measures provide a single summary score of effectiveness which, when combined with cost information, permits the calculation of cost-utility ratios for alternative technologies. A number of techniques have been developed to elicit utilities, including standard gamble, time trade-off, rating scales, the Quality of Well-Being Scale, and the Health Utility Index. No single method has been accepted yet as the gold standard. Selection therefore must be guided by the specific objectives of the assessment.

Standardization of flow cytometric crossmatch (FCXM) for investigation of unexplained habitual abortion

PROBLEM

To define a positive flow cytometric crossmatch (FCXM), in terms of channel shift, for maternal IgG and IgM (n = 28) against paternal T and B lymphocytes.

METHOD

A reference range study. Mononuclear cells were obtained from 28 healthy volunteers using density gradient separation of heparinized blood, followed by pre-incubation with goat immunoglobulin. A total of twelve tubes were prepared for each volunteer. Primary incubation was with negative control serum, positive control sera (either IgG or IgM) and individual AB sera. Secondary incubation was with four combinations of fluorochromes: CD3 PE/IgG-Fc F(ab')2FITC, CD3 PE/IgM F(ab')2FITC, CD20 PE/IgG-Fc F(ab')2FITC and CD20 PE/IgM F(ab')2FITC. The cells were then analyzed with an EPICS Profile flow cytometer, using 256-channels and a four decade log scale.

RESULTS

The linear mean channel fluorescence of the negative control serum was subtracted from the individual AB sera (channel shift) for each of the four combinations of fluorochromes. By determining the 95% one-sided upper reference limits of the negative control serum for each of the four trimmed data sets, we clinically defined a positive FCXM for bound IgG or IgM to T lymphocytes as a shift of 10 or more channels, and for bound IgG or IgM to B lymphocytes as a shift of 25 or more channels, above the linear mean channel shift of the negative control serum.

CONCLUSION

Positive FCXMs were defined for maternal IgG and IgM against T and B lymphocytes, in terms of channel shift above the linear mean channel fluorescence of the negative control serum. By standardizing the dual-color FCXM methodology, the clinical significance of alloantibodies in the maintenance of pregnancy could be addressed in a collaborative manner.

Safety and efficacy of recombinant human erythropoietin in correcting the anemia of patients with chronic renal allograft dysfunction

Recombinant human erythropoietin (rHuEPO) is effective in correcting anemia in hemodialysis, peritoneal dialysis, and predialysis patients. Limited studies in patients with failing renal allografts suggest a similar efficacy but provide little information concerning benefits, dose requirements, or adverse events. This study examined these considerations in a group of 40 patients (18 men; 22 women) aged 40.3 +/- 13.8 yr with stable, chronic renal allograft failure. All patients had a hemoglobin < 95 g/L and a serum creatinine > 250 mumol/L at baseline. Patients received rHuEPO (50 U/kg sc) three times weekly for 24 wk along with iron po if serum ferritin was < 100 micrograms/L. Mean hemoglobin rose from 78.9 +/- 10.4 to 102.6 +/- 18.4 g/L after 24 wk. Mean rHuEPO dose at 24 wk was 129.8 +/- 81.9 U/kg per week. With oral iron supplementation only, serum ferritin fell throughout the 24 wk, whereas serum iron, transferrin saturation, and total iron-binding capacity remained stable. Quality of life was assessed by use of the general Sickness Impact Profile and the disease-specific Transplant Disease Questionnaire measures at baseline and every 8 wk during rHuEPO therapy. Significant improvement was noted in global Sickness Impact Profile scores and in four of five dimensions of the Transplant Disease Questionnaire. Serious adverse events were infrequent. No change in mean systolic or diastolic blood pressure was noted, although there was a significantly increased need for antihypertensive drugs in 18 patients (P = 0.0002). A significant inverse correlation was noted between baseline renal function and maintenance rHuEPO dose (r = -0.45; P < 0.05). Twelve patients returned to dialysis during the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of a 21-aminosteroid, U74006F, on lipid peroxidation and glomerulotubular function following experimental renal ischemia

In order to investigate the capacity of the 21-amino-steroid, U74006F, to mitigate ischemic/reperfusion injury (IRI), we studied lipid peroxidation and glomerulotubular function in a rat model of IRI. U74006F, superoxide dismutase (SOD), and their respective vehicles were administered preischemia and prereperfusion to Brown Norway rats subjected to 45 or 60 min of bilateral normothermic ischemia. Lipid peroxidation was assessed by assay of thiobarbituric acid reactive products (TBA-RP) in a forced peroxidation reaction with t-butylhydroperoxide while renal function was assessed by timed determinations of serum creatinine, creatinine clearance, urine volume, and fractional excretion of sodium (FeNa+). Twenty-four hours following a 60-min ischemic insult and uninephrectomy, the glomerular filtration rate (GFR) was markedly reduced in the IRI + vehicle group compared to controls as reflected by a significant elevation in mean serum creatinine (0.138 +/- 0.018 vs 0.045 +/- 0.002 mumole/liter, P < 0.05) and a significant reduction in mean creatinine clearance (0.200 +/- 0.076 vs 1.130 +/- 0.153 ml/min, P < 0.05). Neither U74006F nor SOD afforded protection against this marked fall in GFR. In contrast, U74006F significantly attenuated both the diuresis (UVol) and the increase in fractional excretion of filtered sodium (FeNa+) seen post-IRI. At 24 hr post-IRI, mean UVol was 22.50 +/- 4.57 ml/day and FeNa+ 1.35 +/- 0.16% in the IRI+vehicle group compared to 11.48 +/- 2.00 ml/day and 0.82 +/- 0.22%, respectively, in the IRI+U74006F group (P < 0.05). While SOD also proved partially protective of tubular function, the effect was not as pronounced as that observed with U74006F.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunocytochemical localization of secreted transforming growth factor-beta 1 to the advancing edges of primary tumors and to lymph node metastases of human mammary carcinoma

The level of expression and localization of transforming growth factor-beta 1 (TGF-beta 1) were analyzed by immunocytochemistry using antibodies that distinguished the sites of intracellular synthesis and extracellular secretion of TGF-beta 1 in 28 cases of infiltrating duct carcinoma of breast, 12 of which had lymph node metastases. Twenty-seven of 28 primary tumors and all 12 lymph node metastases showed extracellular deposition of TGF-beta 1. The extracellular TGF-beta 1 staining was either confined to or more strongly expressed at the advancing edges of the tumor than in the center of the primary tumor. By contrast, 19 of 28 primary tumors and 11 of 12 metastases contained intracellular TGF-beta 1, and no variation in the intensity was seen. The metastatic tumors were significantly more intensely stained for both intra- and extracellular TGF-beta 1 than the primary tumor tissues. The preferential expression of secreted TGF-beta 1 at the advancing tumor edges and in lymph node metastases suggests a role for TGF-beta 1 in the malignant progression of breast carcinoma.

The cost impact of cytomegalovirus disease in renal transplant recipients

A retrospective case controlled study was performed to determine the cost impact of cytomegalovirus disease in the first year following renal transplantation as a basis for the analysis of cost effectiveness of prophylactic and therapeutic regimens directed at CMV infection. Eleven sequential cases of organ-specific CMV disease were matched with 22 controls for age, diabetic status, and donor/recipient CMV serologic status from 119 consecutive first cadaveric renal transplant recipients performed at a single university-affiliated, solid organ transplant unit between January 1, 1988 and March 31, 1990. The groups were comparable for sex, HLA match and mismatch, incidence of initial graft dysfunction, and immunosuppression. Hospitalization data, resource utilization, and costs for all 33 subjects were obtained for a one-year period after transplantation. The mean initial hospitalization time was comparable for both CMV cases and controls (14.5 vs. 15.0 days, P = NS), but patients developing CMV disease averaged 59 hospital days during the first year posttransplant versus 22 days in the control group (P = 0.001). A mean of 31 days hospitalization was directly related to CMV disease. Mean total institutional costs, calculated in 1988 Canadian dollars, were 2.5 times higher for patients with CMV disease than for controls ($42,611 vs. $17,309, P = 0.001), reflecting predominantly a difference in general ward ($19,988 vs. $7484, P = 0.001), hotel ($2508 vs. $927, P = 0.001), clinical laboratory ($5420 vs. $2558, P = 0.0001), radiology ($1581 vs. $640, P = 0.05), and pharmacy ($4916 vs. $1782, P = 0.01) costs and utilization. Operating room, special ward, ancillary, and mean per diem costs ($719 vs. $790, P = NS) were not significantly different between the two groups. Functional graft survival at 1 year was 72% in patients with CMV disease compared with 86% in controls, reducing the mean calculated cost-effectiveness of transplantation by 2.9-fold. These data show that CMV disease has significant economic impact on renal transplantation as a result of extended hospitalization. In order to develop a cost effective management approach to CMV infection, this impact must be considered when assessing therapeutic and prophylactic regimens and protocols of organ allocation.

Rapid DNA typing for class II HLA antigens: subtyping of DRw52-associated DRB1 alleles

Serologic typing for MHC class II antigens is incapable of identifying important subtypes for certain DRB1 alleles and occasionally leads to errors of assignment, particularly with the DR antigens associated with DRw52. To simplify DNA typing of DRw52-associated DRB1 alleles, we have developed a new rapid method using PCR-RFLP. The PCR-RFLP method is based on allele-specific amplification followed by digestion of PCR-amplified DNA with restriction enzymes. Group-specific amplification of the second exon of DR3, DR5, DR6 and DR8 was achieved using a 5' primer specific for the first hypervariable region sequence common to all alleles in this group and generic 3' primers. Human genomic DNA was amplified in a Perkin-Elmer Thermocycler. The presence of a 265 bp fragment was confirmed by agarose gel electrophoresis. Restriction enzyme digestion using Rsa I followed by polyacrylamide gel electrophoresis gave a pattern unique for some alleles and placed the remainder in subgroups. Digestion of the PCR product with one or two of the following enzymes (Asp 700, Hae II, Mnl I, Mbo II, Ksp I and Hph I) permitted the identification of 21 of the 22 alleles. DRB1*1103 and DRB1*1104 are not distinguished by this method and can be distinguished by SSOP or by using a specific 3' primer. For some heterozygous combinations, additional primers are used to provide full subtyping. This method provides a rapid and less costly alternative to PCR-SSOP for DRw52 subtyping in the smaller laboratory as only one amplification is required (two primers) for the majority of samples.(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphoproliferative disorders after renal transplantation in patients receiving triple or quadruple immunosuppression

A retrospective review of 478 renal transplant recipients receiving cyclosporin A (CsA) was conducted to determine the incidence, relative risk, and outcome of lymphoproliferative disease after transplantation. Cases of neoplasm were identified by linking the computerized databases of the British Columbia (B.C.) Transplant Society and the B.C. Cancer Agency. B.C. Cancer Statistics for 1988 were used to determine relative risk. Patients were monitored for a total of 1,054 patient years with a mean follow-up time of 26 months (range, 0.1 to 63 months). A total of 334 patients were treated with triple immunosuppression (CsA), azathioprine, and prednisone), and 144 received adjunctive antilymphocyte globulin as induction immunosuppression. Sixty-nine patients received OKT3 for the treatment of transplant rejection. Twenty-two patients developed 23 malignancies (4.8%) at a mean interval of 16 months (range, 3 to 45 months) after transplantation. Non-Hodgkins lymphoma occurred in five patients, of whom two received triple (0.6%) and three received quadruple (2.1%) therapy. All five patients, in addition, received OKT3 for the treatment of graft rejection. The relative risk of developing a neoplasm among the defined sample adjusted for age and sex was 3.08 overall, increasing to 26.9 (P less than 0.005) for lymphoma. Six of the 22 patients (27%), including all 5 patients with lymphoma, died as a result of their tumor. Renal transplant recipients receiving CsA have a significantly elevated risk of developing a de novo lymphoreticular malignancy, which is comparable to that reported for those receiving azathioprine treatment, and which appears to be increased by the use of quadruple immunosuppression and the administration of OKT3 for the treatment of acute graft rejection.

Immunological monitoring in organ transplantation and autoimmune disease

The clinical manifestations of graft rejection or autoimmune disease represent the terminal phase in a complex sequence of inflammatory events. Although the spectrum of response to injury within each tissue is normally narrowly defined, the immune mechanisms involved may be heterogeneous, influenced by the immune status of the host, the nature of the stimulus (i.e. viral antigen, allostimulation, or aberrant recognition of self), and the use of exogenous immunosuppression. Within this framework, immunological monitoring is employed to distinguish the causative effector mechanisms, to characterize the disease course, to tailor therapeutic intervention, and to monitor treatment impact in individual immunological disorders.

Diffuse anterior scleritis during OKT3 monoclonal antibody therapy for renal transplant rejection

OKT3, a murine monoclonal antibody, is a potent, specific immunosuppressive agent used in solid-organ transplantation both as an adjunct during induction therapy and for treatment of steroid-resistant graft rejection. Minor, self-limiting ocular complications are often seen with this drug, of which conjunctivitis is the most common, occurring in approximately three-quarters of patients. We describe the more serious and previously unreported complication of diffuse anterior scleritis, which developed on the fifth day of OKT3 therapy in a 47-year-old man who had undergone cadaveric renal transplantation. Despite continuation of OKT3 treatment the scleritis resolved rapidly with increased dosages of prednisone.

The influence of long-term morbidity on health status and rehabilitation following paediatric organ transplantation

Driven by the technological and immunological innovations of the past decade, paediatric transplantation has evolved quickly to occupy an important clinical role in the management of vital organ failure. With this success, the focus of clinical attention has moved progressively from an institutional to a more comprehensive community perspective, and the long-term success of transplantation has assumed greater importance in the evaluation of risk and benefit. Five-year patient survival now exceeds 90% after living donor or cadaveric renal transplantation, 70% following heart or liver transplantation, and approaches 60% at 2 years for the more developmental procedures of heart/lung and lung transplantation. Successful transplantation is accompanied by compelling evidence of improved quality of life. The earliest and most prominent gain is in physical capability, with a progressive re-establishment of social and psychological functioning compared to age-appropriate developmental norms. More than 75% of long-term recipients are in school or employed with a high rating of life satisfaction. Rehabilitation is threatened, however, by the complications of long-standing organ failure and long-term immunosuppression. These principally encompass skeletal and developmental disorders, metabolic abnormalities, cardio-vascular disease, renal dysfunction, and chronic infection or malignancy arising as a result of impaired immune surveillance. Prevention or effective management of these debilitating sequelae is a principal goal in the changing paradigm of organ transplantation for the current decade.

The quality of initial function following renal transplantation determined by creatinine elimination kinetics. Comparison of Minnesota antilymphocyte globulin and cyclosporine induction immunosuppression

To compare the effect of type of induction immunosuppression on the quality of initial renal allograft function, we identified 35 cadaver donor kidney pairs in which one recipient of a kidney from a given pair received induction immunosuppression with Minnesota antilymphocyte globulin (MALG group) while the recipient of the contra-lateral kidney received cyclosporine from day zero (CsA group). In the absence of an existing quantitative measure to assess and compare the status of those grafts that function primarily, we defined the half-life of creatinine elimination (t1/2SCr) as such an outcome measure based on a review of creatinine elimination kinetics. All organs were procured with in-situ perfusion and en-bloc removal. Total cold storage times, rewarm times, and perioperative management were comparable for the two groups. In the MALG group, the mean t1/2SCr) was not different from that in the CsA group (1.38 +/- 0.96 days vs 1.35 +/- 1.2 days P = NS). Multiple regression analysis performed on the differences in recipient age, number of DR-B locus matches, total cold ischemia time, rewarm time, and central venous pressure at reperfusion of a given donor pair demonstrated no significant impact of any of these differences on the difference in t1/2SCr for the same pair set in this sample. The nadir of serum creatinine achieved in the first five days posttransplant was somewhat higher in the CsA group (234 +/- 131 mumol/L) as compared with the MALG group (200 +/- 132 mumol/L) but the difference was not significant. A similar nonsignificant trend was observed in the comparison of mean serum creatinine values at 30 days posttransplant (MALG group: 158 +/- 62 mumol/L vs. CsA group: 200 +/- 141 mumol/L). Only one of seventy recipients (CsA group) was dialyzed within the first 5 days posttransplant for an overall incidence of ATN of less than 2%. Fourteen of 35 (40%) recipients in both groups received treatment for acute rejection. The mean time to first treatment for acute rejection episode was shorter in the CsA group than the MALG group (10 +/- 8 days vs 23 +/- 24 days, P = 0.055). Graft survival at one year was not different for the two groups (92% vs. 87% for the MALG and CsA groups respectively, P = NS).(ABSTRACT TRUNCATED AT 400 WORDS)

Cytomegalovirus epididymitis following renal transplantation

Cytomegalovirus infection is an important cause of morbidity and mortality in immunocompromised individuals. The disease is usually systemic in expression although localized infection can occur, particularly in the lung, liver, retina and gastrointestinal tract. We report a case of cytomegalovirus epididymitis with limited systemic manifestations occurring 2 months after renal transplantation in a patient immunosuppressed with azathioprine, prednisone and cyclosporine. Diagnosis was confirmed by observation of typical cytopathic changes in epididymal cells. Clinical resolution occurred with epididymo-orchiectomy and 9-(1,3-dihydroxy-2-proproxymethyl)guanine therapy. To our knowledge this presentation has not been described previously in the transplant literature and it is extremely rare in other forms of inherited or acquired immune deficiency.

Measurement of cyclosporine A by a specific radioimmunoassay with a monoclonal antibody and 125I tracer

We developed a sensitive radioimmunoassay (CYCLO-Trac SP) that specifically measures cyclosporine A in serum, plasma and whole blood of transplant patients. The specific monoclonal antibody was from Sandoz and the tracer was an 125I derivative of cyclosporine C. The assay is performed at room temperature for 1 h followed by a 20 min centrifugation. The sensitivities of the assays are 2.6 ng/mL and 8.7 ng/mL for the serum/plasma assay and the whole blood assay, respectively. Within-run and between-run CVs for both types of assays using cyclosporine concentrations of 80 and 58 ng/mL (serum) and 186 and 199 ng/mL (whole blood) were less than 5% and 9%, respectively. Averaged recovery of serum/plasma and whole blood assays at various levels ranged from 93% to 115%. Interferences by bilirubin, triglyceride, cholesterol, hemoglobin, OKT-3, azathioprine, methylprednisolone and 20 other drugs were insignificant. Multicenter proficiency studies showed an excellent correlation between the CYCLO-Trac SP and the specific 3H-Sandimmune assay from Sandoz: whole blood assay (r = 0.998) and serum assay (r = 0.997).

Quality assessment of cyclosporine monitoring by 32 Canadian laboratories

The Canadian Quality Assurance Program was initiated in June 1989, and is a voluntary program which currently encompasses all 32 laboratories involved in the measurement of cyclosporine (CsA) across Canada. Two whole blood samples from control or clinical patients (kidney, liver and heart) containing unknown concentrations of CsA are circulated to each participating laboratory monthly, and analyzed by all techniques employed within that laboratory. Four analytical methods are currently employed: HPLC (n = 4). Sandimmun SP (n = 3), CycloTrac SP (n = 27) and TDx (n = 3). Four laboratories reported survey results in more than one methodology. Results from all participating centers are analyzed monthly. The mean, SD, standard deviation index and range are reported to each laboratory with information coded to preserve confidentiality. Accuracy, precision, recovery, analytical specificity, linearity and blank studies have been performed. This report covers the period from June 1989 to April 1990.