Comparing Plasmapheresis plus IVIg with Plasmapheresis plus IVIg plus Rituximab on the Management of Suspicious Antibody-Mediated Acute Rejection in Kidney Transplant Recipients

BACKGROUND

There is no treatment of choice for the management of acute antibody-mediated rejection (ABMR) in kidney transplant recipients. Plasmapheresis ± intravenous immunoglobulin (IVIg) ± rituximab has been used in different regimens with contradictory results.

OBJECTIVE

To compare three regimens of acute ABMR management including plasmapheresis + IVIg ± rituximab in two different rituximab regimens.

METHODS

In this prospective, observational study kidney transplant recipients with suspicious ABMR were categorized into three groups. Group 1 patients were treated with plasmapheresis + IVIg. Groups 2 and 3 received weekly rituximab at a dosage of 375 mg/m² for either 4 doses (group 2 or high dose) or 2 doses (group 3 or low dose) in addition to plasmapheresis + IVIg.

RESULTS

8, 15, and 9 patients were categorized in groups 1, 2, and 3, respectively. There was no difference among the groups in terms of demographic and clinical characteristics of recipients and donors. Although, 1-year graft (37.5%, 60.0%, and 66.7% for groups 1, 2, and 3, respectively; p=0.308) and patients survival (75.0%, 86.7%, and 77.8% for groups 1, 2, and 3, respectively; p=0.730) were not significantly different among studied groups, graft survival was 22%-30% higher in rituximab-treated groups. Estimated glomerular filtration rate at 12^th month of follow-up did not differ among groups (56.3±19.6, 57.3±20.6, 48.7±16.1 mL/min/1.73 m² for groups 1, 2, and 3, respectively; p=0.683). However, kidney function steadily improved over time in rituximab-treated patients.

CONCLUSION

Adding high or low doses of rituximab to plasmapheresis + IVIg comparably increased graft survival in suspicious acute ABMR kidney recipients and steadily improved kidney function among survived allografts over time.

Plasma Neutrophil Gelatinase-Associated Lipocalin as a Marker for Prediction of 3-Month Graft Survival after Kidney Transplantation

BACKGROUND

Ischemic injury during organ transplantation increases the risk of acute and chronic rejections by promoting alloimmune responses. Measurement of neutrophil gelatinase-associated lipocalin (NGAL) immediately after kidney transplantation may be promising for early detection of ischemic injuries to allograft.

OBJECTIVE

This study assessed possible predictive values of plasma NGAL levels during first hours after kidney transplantation for graft loss within the first 3 months after transplantation.

METHODS

45 kidney transplant recipients were classified into those without graft loss or with graft loss during 3 months after transplantation. Plasma NGAL levels were measured before and at 2, 6, 12, 24 and 96 hours after transplantation. Serum creatinine concentration was assessed daily during hospitalization and at 1, 2, and 3 months post-transplantation.

RESULTS

Serum creatinine and plasma NGAL levels were consistently higher in patients with graft loss compared with those without graft loss. At 2, 24, and 96 hours after transplantation, plasma NGAL concentration was significantly higher in patients who developed allograft loss within 3 months post-transplantation. The cutoff point of plasma NGAL at 2, 24, and 96 hours after transplantation for prediction of graft loss was 304.5 ng/mL (sensitivity of 71.4%, and specificity of 73.7%), 207.8 ng/mL(sensitivity of 85.7%, and specificity of 60.5%), and 184 ng/mL (sensitivity of 85.7%, and specificity of 71.1%), respectively.

CONCLUSION

Plasma NGAL levels at 2, 24, and 96 hours after transplantation can predict 3-month graft loss with fair sensitivity and specificity.

Tacrolimus Dose Requirement in Iranian Kidney Transplant Recipients within the First Three Weeks after Transplantation

BACKGROUND

Tacrolimus is the main immunosuppressive agent in many kidney transplant protocols with an initial recommended daily dose of 0.2 mg/kg of ideal body weight (IBW). However, due to the high inter- and intra-patient variability in its pharmacokinetics, the required tacrolimus doses may differ markedly from patient to patient.

OBJECTIVE

To assess the required tacrolimus dose to achieve the desired whole blood concentration within the first three weeks after kidney transplantation among Iranian patients.

METHODS

This cross-sectional study was performed at kidney transplantation ward of Imam Khomeini Hospital Complex where almost all patients receive thymoglobulin induction therapy and a calcineurin inhibitor, mainly tacrolimus, plus mycophenolate, and prednisolone as maintenance immnosuppressive drugs with the target tacrolimus whole blood concentration of 8-12 ng/mL for the first month after transplantation.

RESULTS

The mean±SD administered daily dose of tacrolimus during the first three weeks after transplantation was 0.085±0.024 mg/kg of IBW that resulted in a mean±SD whole blood concentration of 10.34±5.44 ng/mL. The required mean±SD dose of the drug to achieve the desired whole blood level of 8-10 ng/mL was 0.08±0.02 mg/kg. Only 27.4% of the assessed tacrolimus blood levels were within the desired range. Compared with males, females needed 19% more daily dose of tacrolimus to reach similar whole blood levels. Tacrolimus blood levels were significantly correlated with daily tacrolimus doses (r=0.307, p=0.001) and patients' age (r=0.283, p=0.003).

CONCLUSION

It seems that Iranian kidney transplant recipients need lower daily doses of tacrolimus to achieve the desired whole blood levels; compared with males, females need a higher dose.

Antimicrobial resistance pattern of gram-negative bacteria of nosocomial origin at a teaching hospital in the Islamic Republic of Iran

The emergence of antimicrobial resistance is a global problem in the community and in hospitals. Antibiotic resistance of Gram-negative bacteria from nosocomial infections were evaluated during a 6-month period at Shariati teaching hospital, Tehran, Islamic Republic of Iran. Susceptibility tests were performed on 570 Gram-negative isolates obtained from clinical samples of patients infected after at least 72 hours stay in the hospital. Escherichia coli was the most frequently isolated Gram-negative organism (42.6%). The highest rate of resistance in Gram-negative isolates was seen in the intensive care unit, with Acinetobacter spp. as the most resistant organisms. Gentamicin was the most effective antibiotic against E. coli and all other isolates, while ciprofloxacin was also effective against a wide range of other species. Antibiotic resistant Gram-negative nosocomial infection is prevalent in this teaching hospital in Tehran.

Adverse reactions of prophylactic intravenous immunoglobulin; a 13-year experience with 3004 infusions in Iranian patients with primary immunodeficiency diseases

Intravenous immunoglobulin (IVIG) replacement therapy improves health-related quality of life in patients with a primary immunodeficiency disease, although there have been reports of adverse reactions associated with its regular administration. The study population was composed of 99 patients with primary antibody deficiencies. All the patients were diagnosed with a primary immunodeficiency disease and received at least 4 infusions of IVIG at the Children's Medical Center Hospital, Tehran, Iran over a 13-year period (1995-2007). A total of 3004 infusions were recorded, and 216 (7.2%) of these were associated with adverse reactions in 66 patients. Adverse reactions were classified as mild (172 reactions), moderate (41 reactions), and severe (3 reactions). The rate of adverse reaction varied by diagnosis from 3.35% in patients with X-linked agammaglobulinemia to 17.4% in IgG subclass deficiency. There were no age-related differences in the rates of adverse reactions. Adverse reactions to IVIG infusions are occasionally encountered; therefore, physicians and nurses should be aware of these reactions in order to manage and prevent them.

Nutritional status and serum zinc and selenium levels in Iranian HIV infected individuals

BACKGROUND

Human immunodeficiency virus infected individuals are prone to malnutrition due to increased energy requirements, enteropathy and increased catabolism. Trace elements such as zinc and selenium have major role in maintaining a healthy immune system. This study was designed to evaluate the nutritional status of Iranian subjects who were newly diagnosed with human immunodeficiency virus infection and to compare serum level of zinc and selenium in these patients with those of the sex and aged match healthy subjects.

METHODS

After an interview and physical examination, nutritional assessment was done based on clinical and anthropometric parameters. Body mass index (normal range 18.5-27 kg/m2 based on age) of less than 16, 16-16.9 and 17-18.4 kg/m2 were considered as severe, moderate and mild malnutrition respectively. Serum level of zinc and selenium were measured by graphite furnace atomic absorption.

RESULTS

Severe, moderate and mild malnutrition were detected in 15%, 38% and 24% of human immunodeficiency virus infected individuals respectively. Compared with the healthy control group, serum level of zinc and selenium in the human immunodeficiency virus infected subjects were significantly lower (P = 0.01 and P = 0.02 respectively).

CONCLUSION

Malnutrition found to be prevalent in Iranian human immunodeficiency virus infected individuals and low serum zinc and selenium levels are common in this population.

Inpatient paediatric use of intravenous immunoglobulin at an academic medical centre

INTRODUCTION

Intravenous immunoglobulin (IVIG) is an important research topic because of its efficacy in the management of an increasing number of diseases, its high cost and limited availability. This study was designed to evaluate the paediatric inpatient use of IVIG and identify strategies to reduce the drug expenditures.

METHODS

Over a six-month period, physician and nursing charts, and notes for subjects who were treated with IVIG, were reviewed to gather the required data. This included patient demographics, IVIG, indications, dosage regimen, adverse drug reactions (ADRs) and their management.

RESULTS

58.3 percent of IVIG infusions were ordered for labelled indications. Patients in the labelled group experienced more clinical improvement than subjects in the off-label group. Haematologists and neurologists were the most prevalent prescribers. ADRs were more prevalent in the off-label group. Hypotension, fever, headache and chills were the most common adverse effects. ADRs were managed with drugs in 22.9 percent of IVIG administrations and IVIG infusions were modified in 12.5 percent of infusions.

CONCLUSION

ADRs were more prevalent in this hospital than those reported by other authors. This may be due to nursing negligence of the recommended infusion rate, higher sensitivity of our population or to the brands of IVIG which are used in the hospital. This shows the need for further evaluation of IVIG prescription and administration.

Phenol and menthol in the treatment of chronic skin lesions following mustard gas exposure

INTRODUCTION

Chronic skin lesions are common late complications of sulphur mustard exposure in veterans injured in chemical warfare. Pruritus is the most common complaint in the chronic phase, with significant effects on the patient's quality of life. The current study evaluated the efficacy of a combination of one percent phenol and one percent menthol in the control of pruritus in these affected patients.

METHODS

This randomised, double-blinded clinical trial was performed in chemical warfare-injured veterans with mustard gas-induced pruritus. 80 subjects were selected randomly and divided into two equal groups. One group was treated with a combination of one percent phenol and one percent menthol twice a day, while the other group received a placebo. The therapeutic effects and side effects were evaluated during a six-week treatment course. Pruritus score with a range of 1-48 points was used to calculate the severity of pruritus before and after treatment in both groups.

RESULTS

The final pruritus score in the drug group was significantly different, compared with the placebo group (p-value equals 0.03). There was also a statistically-significant difference between the pre-treatment (19 points) and post-treatment (15.5 points) pruritus scores in the drug group (p-value equals 0.001), but there was no significant difference in the response in the placebo group (p-value equals 0.66). Only a few patients had complaints about the drug, and these were generally minor. The most common complaints were of the greasy nature of the drug and its intolerable odour.

CONCLUSION

A phenol one percent and menthol one percent combination has significant therapeutic effects for mustard gas-induced pruritus in chemical warfare-injured veterans, in comparison with the placebo.

Relationship between erythrocyte lithium concentration and renal concentrating capacity

BACKGROUND

Studies investigating possible correlations between plasma lithium concentration, lithium treatment duration, and frequency of lithium administration, and lithium nephrotoxicity have yielded conflicting results.

OBJECTIVES

Our main objective was to investigate whether there was any relationship between erythrocyte lithium concentration (ELC) and renal side effects. Another objective of our study was to identify a parameter, which could be estimated inexpensively, for assessing possible renal side-effects of lithium.

METHOD

Seventy Iranian inpatients with bipolar disorder entered this case-control study. Medications taken concurrently by the patients were recorded. A direct method of measuring ELC was used in this study. The cases were patients on lithium who had urine specific gravity (SG) of 1.006 or less after 8-10 h water deprivation at night and the controls consisted of patients on lithium with urine SG of 1.011 or more after this period. Blood urea nitrogen, serum creatinine, sodium and potassium and urine SG, sodium, and potassium were measured in all patients during this time. Renal indices were compared by using independent sample t-test at a significance level of a P-value of 0.05 or less. Non-parametric Spearman's rank correlation test was used to investigate the relationship between clinical variables and the indices of renal function.

RESULTS

Results revealed that in case group mean serum sodium concentrations were significantly higher (P = 0.008) and mean urine sodium and potassium were significantly lower than those of controls (P = 0.004 and 0.007 respectively). We found no statistically difference in lithium ratios between the two groups. However, ELCs were significantly higher in the cases (P = 0.026). There were no significant correlation between concomitant use of neuroleptics, benzodiazepines or carbamazepine and ELC or lithium renal side-effects.

CONCLUSION

This study showed that ELC may reflect lithium renal side-effects better than plasma lithium level.